Traumatic Brain InjuryAnd

Best Doctors

Sherri Hickey, Director of Medical ManagementSafety National

Bev Covert, Associate Director – CatCareBest Doctors

Regions of the Human Brain

Levels of Brain Injury Mild, Moderate and Severe

Mild—aka Concussion• May not have LOC or if so, very

brief.• Testing and scans appear normal• May be dazed, confused or some

alteration to brain function.Treatment– a little time off work,

may or may not limit driving for short time, nothing further.

Levels of Brain Injury Mild, Moderate and Severe

Claims Management Recommendations:

• May want to assign a TCM/NCM to monitor their status, watch for complications and assure a timely RTW.

• Does not need to be reported to SNCC

Levels of Brain Injury Mild, Moderate and Severe

Moderate Brain Injury:• Usually have LOC from a few min. to

a few hours.• Confusion lasts from days to weeks• Physical, cognitive, and/or

behavioral impairments last for months or are possibly permanent.

• These persons usually make a good recovery or learn to compensate for their deficit.

Levels of Brain Injury Mild, Moderate and Severe

Treatment—• Admission to neuro rehab facility may

be needed for short period of time w/ ST, OT, PT both in-pt. and out-pt.

• May need supervision (or a/c) for a period of time.

• Driving us usually limited for a while.

Levels of Brain Injury Mild, Moderate and Severe

Claims Management Recommendations:• Recommend a field NCM be assigned to

manage the care and attend team conferences at rehab facility.

• Obtain a copy of job description for physician to evaluate for RTW plan.

• Work w/ NCM to determine any DME or A/C needs.

• Make Safety National aware of claim. May involve CatCare.

Levels of Brain Injury Mild, Moderate and Severe

Severe Brain Injury – • Often involves prolonged unconscious

state or coma which could last for days, weeks, or months.

• May be either:Open Head Injury w/ probable external wounds and skull fx(s) or a Closed Head Injury -- impact from outside force, the skull surface is intact, but there can still be severe damage or bleeding of the brain.

Levels of Brain Injury Mild, Moderate and Severe

Claims Management Recommendations—

• Notify Safety National within 3 business days of the injury for assignment of Best Doctors CatCare program

• Best Doctors will assign a field NCM• Participate on the BD conference

calls

Types of Skull Fractures

• Depressed Skull Fx—the broken piece of skull bone moves in towards the brain.

Types of Skull Fractures

• Compound Skull Fx—The scalp is cut and the skull is fractured and possibly protruding

Types of Skull Fractures

Basilar Skull Fx—the fracture is located at the base of the skull and may include the opening at the base of the skull.

Usually have CSF leaking from nose or ears, + Battle Sign, and raccoon eyes.

Types of Skull Fractures

• Linear Skull Fx—a non-displaced fracture line

Types of Skull Fractures

• Comminuted Skull Fx– is a skull that is broken into several pieces.

Closed Head Injury

• With a CHI, the brain swells, if it has no place to expand, this can cause an increase in intracranial pressure (ICP) and causes brain tissues to compress, causing further injury.

• As it swells, it may expand through any available opening in the skull, including eye sockets. This is one reason why they monitor a person's pupil size and ICP.

• Treatment may include a skull flap.

Intracranial Bleeds

The brain may bleed because of tears from skull fractures, or due to trauma when ‘slamming’ against the skull.

Epidural—bleeding between the skull and the dura mater

Intracranial Bleeds

• Subdural Hematoma—between the dura and arachnoid membranes

Intracranial Bleeds

• Subarachnoid—between the middle membrane (arachnoid) and the brain where CSF is.

Intracerebral—bleeding within the substance of the brain

Treatment for TBI

Acute treatment:• Treatment for a TBI can vary with each

case, but almost always involve extended ICU stays.

• Surgery may occur to remove blood clots or relieve pressure on the brain, including skull flap.

• Usually on a vent for some period of time, and may later have a trach placed.

Treatment for TBI (con’t)

• Have Intracranial Pressure (ICP)Monitor placed to indicate amount of pressure on the brain.

• NG Tube and later PEG• Acute treatment will always include

multiple CT scan evaluations, and may include MRI

• EEG studies may be done to determine if the patient is brain dead.

Glasgow Coma Scale An Assessment of a person’s state of consciousness

• A score of 8 or below—usually in a coma and indicate severe brain injury that is life threatening, w/ permanent residual impairment.

• A score of 9-11 – is moderate severity, may have had LOC greater than 30 min. and will have cognitive impairment that may resolve to some degree or fully.

• A score of 12 or above – is usually a minor injury, may have had brief LOC and should have a full recovery.

Rehabilitation Post TBI

Acute Rehab – Make sure it is CARF Accredited….When someone is medically stable and has reached a point in recovery where they are able to participate in therapy. (LOS-3-6 wks)– Speech Therapy– Occupational Therapy– Physical Therapy

Rehabilitation Post TBI

• Sub-acute Rehabfor those who need a less intensive level of rehab for a longer period of time.

• Day Treatmentstructured setting during the day, and go home or to an apt / hotel at night.

• Out-patient

Rehabilitation Post TBI

• Community Re-entryfocus on higher level motor, social and cognitive skills so they can learn to live independently or fit into society.

• Independent Living ProgramsProvides housing and minimal supervision

Questions???

So what happens with the Best Doctors referral……

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Best Doctors Mission

Right Treatment

Right Diagnosis

Optimal Outcome

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• A medical organization specializing in high risk, complex medical cases

• Providing direct and immediate impact through efficient access to world class experts

• 20% Change in diagnosis

• 60% Change in treatment plan

Best Doctors Overview

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• Founded in 1989 by Harvard Medical School physicians

• Improves quality of care by ensuring patients get the right diagnosis and treatment

• Who are the Best Doctors in America?

• Unique Medical Analytical Process that provides an in-depth patient review

About Best Doctors

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The medical analytical process developed by Best Doctors

is the cornerstone of efficient access to the world class

medical expert

Intensive Review and Consultation

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Best Doctors – Cat Care - TBI

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Catastrophic Team

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• The earlier – the better~ 3 business days from Date of Injury for Safety National program

• Best Doctor Experts – address entire patient

• Field NCM

• Explain Best Doctors role to all parties

• Schedule/host conference call(s) with the Best Doctor Experts –

Best Doctors Referral & CatCare Process

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• Provide recommendations for facilities and/or providers to best meet the need of the patient. Model Centers

• Provide a conference call summary and action plan

• Facilitate MD to MD communication between the treating physician and the Best Doctor Expert

Best Doctors CatCare Process (cont)

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• Provide ongoing evaluation of the patient’s status and progress – providing recommendations to enhance care for best outcome

• Re-conference as suggested by Expert at the end of the 30 day period – re-evaluate with all parties to see if Best Doctors ongoing involvement is recommended/beneficial.

• Outcome report at the end of each quarter – provided to Safety National

Best Doctors CatCare (cont)

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• 42 year old forklift driver – tried to steady a load of tractor tires – hit him in the head

• Initial Diagnoses: TBI, Multiple skull fractures, bilateral lower extremity fractures

• Best Doctor Experts – Neurosurgeon, Orthopedic Surgeon, PM&R – TBI Expert and Neuro-ophthalmologist

• Recommendations to assure he did not have CSF leak, medication management to optimize cognitive function, neuro-ophthalmology evaluation, his ability to work, and his visual impairments resulting in a cost savings of $60,000.

TBI – Sample case #1

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• 30 year old – electrocuted by 277 volts – found slumped over a ladder – CPR performed at the scene. Hx: seizure disorder

• Initial Diagnosis: Anoxic Brain Injury Best Doctors additional Diagnosis: traumatic brain injury and Heterotrophic ossification – left hip. He presented to us in minimally conscious state at Model TBI center

• Best Doctor Experts – Intensivist, Neurosurgeon, Orthopedic Surgeon, and PM&R – TBI Expert

• Recommendations: Medication management to facilitate his cognitive function and then control his maladaptive behavior, spasticity, heterotypic ossification treatment, neuro-endocrine testing, evaluation and treatment for hydrocephalus, etc. for a savings of $261,000.

TBI – Sample case - #2

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• 42 year old – fell down steps at work with a questionable loss of consciousness – all scans were negative

• Initial Diagnosis: lumbar strain. Eventually the diagnosis of TBI was added. Best Doctors revised diagnoses – Psychotic depression, somatoform disorder, pseudoseizures – none of which were related to the initial mechanism of injury

• When this case was referred – it was 3 years post injury – he was in a locked neurobehavioral unit and the plan was to move him to locked psychiatric unit for life.

• Best Doctor Experts – Neurologist – Behavioral Medicine and Psychiatrist

• Recommendations: Needed inpatient psychiatric admission with skilled experts in Somatoform disorder, depression and seizures to wean him off all the medication – see where he is and then add the appropriate medications – potential cost savings $196,500

TBI – Sample case - #3

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•

Ask Best Doctors

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• Request for 2nd or 3rd spinal surgery

• Request for SCS or morphine pump implant

• Early Onset of Complex Regional Pain Syndrome

• Pharmacy Review

• Validation of treatment

• Chronic Pain

Ask Best Doctors – what type of cases?

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• Contact Safety National

• These are very limited cases – a few questions which are submitted at the time of referral

• 50 pages or less of medical records

• One Expert specialty – One conference call

Ask Best Doctors – Referral

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• Best Doctors reviews/summarizes medicals

• Secure appropriate Expert to review the case

• If radiology studies are needed – we will let you know

• Best Doctors will Host a conference call with the Expert with the claims manager/adjustor, Safety National analyst and Medical Management Nurse, and Best Doctors AD. The NCM can be invited at the discretion of the carrier.

Ask Best Doctors – Process

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• 42 year old guard in a jail that was assaulted by an inmate. He had a + LOC at the scene.

• Initial Diagnoses: Concussion, nasal fractures, lacerations, finger sprain, HNP C6-7

• When the case was referred he was 11 months post injury and had not returned to work due to various complaints – headaches, dizziness, loss of balance, anxiety, depression, etc. Questions at referral were what is related, is there anything else that can be done for him, are medications appropriate, etc.

• Best Doctors Expert: PM&R – TBI Expert

• Recommendations: Expert review indicated he was actually functioning at a very high level but had a lot of subjective complaints. Recommendation was to move forward to counseling for adjustment and mood disorder, vocational counseling, medication specifically to treat his headache complaints and evaluation of his neck to make sure the headaches were not coming from there. Outcome report savings: $86,305

Ask Best Doctors – Sample #1

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• 54 year old truck driver – felt sharp pain in waist, L inguinal/hip area after attempting to close a curtain on his truck. PMH: hernia repair 10+ years prior

• Initial Diagnosis: Left labral tear

• When the case was referred he was 12 months post injury

• Best Doctors Expert: Hernia Specialist and then Plastic Surgeon who specializes in nerve entrapment

• Best Doctors Diagnosis: left ilioinguinal nerve and left iliohypogastric nerve entrapment

• Recommendations: 3 Physicians in the Country that do this type of work – Carrier agreed to send him to a Best Doctor Expert – he had evaluation and block of the nerve which relieved his pain – next day – outpatient surgery to reimplant the nerves into appropriate tissue – pain relief 100% - return to work full duty at 6 weeks post op – Savings: $600,000 + indemnity savings (provided by carrier) $414,000 for a total savings of $1,014,000.

Ask Best Doctors – Sample #2

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Best Doctors – working with Safety National and CRL to assure:

Right Treatment

Right Diagnosis

Optimal Outcome

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Thank you~