The Clinical and Cost Benefits of Investing in Neurobehavioural RehabilitationMichael OddyDirector of Clinical ServicesSara d S RamosResearch Fellow

Bridgend13th November 2013

OverviewWhat is neurobehavioural rehabilitation?Is it clinically effective?Is it cost-effective?

Impact of brain injuryCognitionBehaviour and personalityEmotional experiencePhysical and sensory abilities

Impact of brain injuryEmploymentPersonal relationshipsSocial lifeStress on relatives

What is neurobehavioural rehabilitation? Types of evidence: Supporting principles

Neuro evidence concerning changes in abilities following a brain injury especially changes in the abilities to learn and remember but also executive function Behavioural theory and evidence from behavioural psychology Rehabilitation evidence based practice and broadly accepted principles

Neurobehavioural RehabilitationInformed by an understanding of the cognitive, emotional and behavioural effects of acquired brain injuryEspecially the effects of brain injury on memory and learning, motivation, emotional regulation and social behaviour - these affect the ability to participate in and profit from rehabilitation

Neurobehavioural Rehabilitation Evidence concerning the learning abilities of those with acquired brain injuries

Implicit learning Procedural learning skills or routinesErrorless learning and vanishing cuesClassical and operant conditioningEvidence for lack of generalisation of learning e. g. learned to use a washing machine but unable to use a new one

Neurobehavioural RehabilitationEffects of brain injury on motivationidea generation, goal selection, goal formulation (planning), initiation, monitoring behaviour, review and reinforcement (Oddy, Worthington and Frances 2009)

Neurobehavioural RehabilitationDisinhibited behaviourEmotional regulationImpulsivity Social perception and behaviour

Neurobehavioural Rehabilitation

Vast area dating back to Pavlov and Skinner includes comparative psychology, evidence from a wide range of clinical populations including LD, MH, child health includes operant and classical conditioning and it includes learning and training protocols.

Neurobehavioural RehabilitationBehaviour and skills are learnedBehaviour has a function or purposeBehaviours may have an observable antecedentThe likelihood of the behaviour recurring is determined by the consequences Behaviour is described and recorded objectively: what you see, not what you infer observed behaviour can be measured

Neurobehavioural Rehabilitation

Shaping Skills trainingBreaking down into the elementsChaining elements together Short bursts

How to do neurobehavioural rehabilitationSet a small number of core goalsFocus on increasing positive behaviours rather than to reduce behaviours seen as negativeEnsure the teams and familys aims are aligned with those of the individual

How to do neurobehavioural rehabilitation (cont.)Try to understand the context of behaviourTry to understand the personUnderstand frustrationAvoid confrontationBuild relationships

We are what we repeatedly do. Excellence is not an art but a habit.

Aristotle

Neurobehavioural RehabilitationHolistic approach including psychological adjustmentInterdisciplinary team approachFunctional approachCommunity basedCompensatory strategiesSMART goal setting specific, measurable, achievable, relevant (rather than realistic) and time-boundGoal Attainment ScalingWorking with the familyProsthetic environment (structure etc.) including assistive technology for cognitive deficitsSystematic reviews by: Cicerone et al. 2000, Cicerone et al.,2005 Carney et al. 1999; Chesnut et al. 1999

Neurobehavioural RehabilitationThe neurobehavioural approach is not just about challenging behaviour but informs the way all aspects of rehabilitation are delivered i.e. physical and sensory, functional ADLs, cognitive deficits and challenging behaviourIt addresses how those with a brain injury best learn and can benefit most from their rehabilitationCognitive deficits and challenging behaviour can stand in the way of learning after acquired brain injury and need to be addressed before any rehabilitation can be effective

Clinical and Cost Benefits

The people we serve (I)

The people we serve (II)Glasgow Coma Scale (GCS)Severe TBI GCS 8 Moderate TBIGCS 9 -12 Mild TBIGCS 13 -15

MeanRangeAge at injury40.93-76Injury severity (GCS)6.73-15Time since injury (weeks)102.61-2325Length of stay (weeks)25.60-223

What we achieve (I)Bars represent percent (%) Service Users (SRS Scores)

What we achieve (II)Bars represent percent (%) Service Users CDR-A

What we achieve (III)Bars represent percent (%) Service Users CDR-O

What we achieve (IV)Bars represent hours of care SRS

What we achieve (V)Bars represent hundreds of pounds Hours of care x per hour

Savings over timeCalculated based on care costsAssuming level of support at follow-up is maintained or reduced over lifetimeAssuming life-expectancy same as general population (approx. = 79.6 years, but McMillan et al., 2011)Correcting for the effects of inflation on value of money over time

Wood et al. (1999). BI, 13, 69-88Worthington et al. (2006). BI, 20, 947-957

Savings todayB = Daily care costs before rehabilitationA = Daily care costs after rehabilitationR = Total cost of rehabilitation

Cost savings = (B-A)-R

Cost savings per yearB = 165.95 ( 60,571.75 per year)A = 51.67 ( 18,859.55 per year)R = 54,080.56

1st year Cost savings = (B-A)-R = - 12,368.36 BUTA annual cost saving of 41,712.20

B = 135.84 ( 49,581.60 per year)A = 85.60 ( 31,244.00 per year)R = 85,810.71

1st year Cost savings = (B-A)-R = - 67,473.11BUTA annual cost saving of 18,337.60

0-12 months> 1 year

Individual cost savings in a lifetime...Cost of rehabilitation recovered in 1 to 5 years, depending on Time Since Injury

Given a mean cohort age of 43.4 at discharge, and a mean lifespan of 79.6.

Lifetime savings0 12 months> 1 yearDiscounted at 1.5%1,134,799.42858,056.63Discounted at 3%891,682.70653,101.87Discounted at 5%671,217.01465,580.63

Individual cost savings in a lifetime...McMillan et al. (2011). JNNP, 82, 931-935

Conclusions

Neurobehavioural rehabilitation contributes to achieving greater independence and more participation in societyNeurobehavioural rehabilitation contributes to significantly reducing the costs of long-term careOddy & Ramos (2013). Brain Injury, Open Access

... And Users views of the processWe as a family felt nothing was too much trouble to the staff. Family of Kerwin Court Service UserThe most important and evident thing for me was the level of care and helpfulness of all the staff. I cannot thank them all enough. Service User of Daniel Yorath HouseEach client and family treated with a very warm and personal approach.Opportunity for pre-referral discussion. Referrer to York House

Thank you

Q&A

michael.oddy@thedtgroup.orgsara.dasilvaramos@thedtgroup.org

*Claparde (1911, Swiss neurologist) hid a pin in his hand before shaking hands with a patient with amnesia, after this she was reluctant to shake hands, but was embarrassed that she could not explain her reluctance. ****Note. The sample is not the same as that reported in BIRTs Annual Outcome Reports*Although these are the average characteristics of our service users in the past, that is not to say that we do not admit individuals who have different characteristics. Always contact the referral unit for discussion.Em*As measured with the Supervision Rating Scale*As measured with the Community Disposition Ratings - Accommodation*As measured with the Community Disposition Ratings OccupationNote. The samples at admission, discharge and follow-up are not exactly the same due to attrition. The increase on the number of people with no productive activity at follow-up compared to discharge may reflect these differences. Nevertheless, the number of people with no productive activity at follow-up is significantly lower than before rehabilitation.Majority of people do continue on some sort of productive activity.*Hours of care estimated from the SRS*Cost of care estimated from hours of care needed multiplied by the hourly cost of care (i. e. support worker).*I was extremely happy the way as I was treated. You also saw people who really got better, which was very encouraging. People were helped according their individual abilities.

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