1. Addressing Brain Injury Within Settings Serving Homeless Adults:
Addressing Cognitive and Executive Functioning In Primary Care Settings by Integrating Occupational Therapy with Primary and Behavioral Health Care
Brain Injury Association of Maryland Annual Conference
March 24th, 2017
Jan Caughlan, LCSW-C
Caitlin Synovec, MS, OTR/L

2. Background Jan Caughlan – Caitlin Synovec –
Social Worker at Health Care for the Homeless
Long journey of learning about brain injury and thinking about ways to be more helpful and effective
Caitlin Synovec –
Occupational Therapist at Health Care for the Homeless, Baltimore
First began working as an OT in mental health – has transitioned to integrated care within HCH, and focusing on the impact of brain injury on individuals who are homeless

3. Objectives
Understand methods to screen and identify history of traumatic brain injury within primary and integrated care settings
Understand incidence and prevalence of TBI within the population as well as co- morbidities of TBI
Understand effective approaches and interventions for clients with a history of TBI within primary and integrated care settings

4. Integrated Care Encompasses “whole person” care
Medical/physical health care
Behavioral/mental health care
Case management and supportive services
Within the low-income and homeless population, there are often many needs within each of these services
Clear histories are often not available

5. Integrated Care
Recent shift for true “team based” care to increase communication and clarity of needs among providers
Streamlines the needs of the clients served
Typically includes medical, behavioral health, and case management services
Often does not include rehabilitation services

6. Health Care for the Homeless
Mission: "...to prevent and end homelessness for vulnerable individuals and families by providing quality, integrated health care and promoting access to affordable housing and sustainable incomes through direct service, advocacy and community engagement.“
In partnership with caregivers, advocates, donors and our neighbors without homes, HCH
provide comprehensive health care services and supportive services to people experiencing homelessness
apply a whole-person approach to care, considering all aspects of life and health in an individual's treatment
advocate for affordable housing and livable incomes for all

7. Brain Injury, Integrated Care, and Homelessness
“Whole person care” means addressing all factors impacting a client’s life
Brain injury is often under-recognized especially within the homeless population
TBI screenings among individuals who are homeless have indicated 8-53% of those experiencing homelessness have sustained a TBI, which is up to 5 times greater than the general population [Hwang et al., 2008.; Topolovec-Vranic et al., 2012]
87% of adults with a reported hx of TBI sustained TBI PRIOR to becoming homeless [Topolovec-Vranic et al., 2014]
Indicates TBI as a risk factor for homelessness, not just a result of
In one meta-analysis, the frequency of cognitive impairment in homeless adults was 25%
The authors note significant gaps and limitations in understanding the true impact of cognitive impairment in this population
(Depp, Vella, Orff, & Twamley, 2015)

8. Behavioral Health Context
Homelessness has always been connected to:
Serious mental illness
Serious substance use disorders
Increasing awareness that additionally, many have cognitive problems that are rooted in examples like:
Developmental delay
Lead poisoning
Brain injuries
Co-occurring is prevalent
Impacts of previous brain injuries may be addressed separately among providers, lack of continuity in care

9. Challenges Associated with Existing Rehabilitation Programs
Programs tend to target immediate post-acute
Referral streams are mostly from hospitals
Focus is on more severe injuries
Not always accessible more than 6 months post-injury if client is not directly admitted after injury
Often requires documentation of injury
Programs that target later issues can be very intensive
Concussion program in Maryland requires several hours 5 days/week
Difficult to access for homeless and unstably housed adults, especially those with several immediate health and housing needs

10. Challenges with Standard Health Care Approaches
Questions of:
Cognitive ability
Functional ability
Ability to learn and adapt?
Medical and most behavioral providers are not trained to assess or address these problems

11. Where is the Sweet Spot?
If cognitive rehabilitation programs are out of reach, how can those approaches be adapted?

12. Is there a space for a marriage of both approaches?
What are the foundational approaches for people experiencing homelessness?
Low-demand
Brief
Motivational
Is there a space for a marriage of both approaches?

13. The Grand Experiment
Implement an Occupational Therapy Program within Health Care for the Homeless

14. Occupational Therapy Model at HCH
Screening for BI
Evaluation
Cognitive ability
Functional skills
Intervention
Adaptation and Compensation
Remediation

15. Outcomes of Screening 52 % of clients screened had at least one TBI.
44% of clients had sustained a TBI with LOC

16. Outcomes: Problem list vs. Screening
Per the problem list, 20% of clients had a reported history of brain injury
OSU TBI Screening indicated 52% of clients had experienced a TBI (44% with LOC)
Crosstabulation indicated that there was a statistically significant relationship between the OSU TBI ID results and the problem list, supporting the need to implement TBI screens to gather a full medical history and problem list
*All clients within this study had a MH diagnosis

17. Evaluation
Includes cognitive screening and more in- depth functional assessment
Evaluation documentation includes:
Standardized report of scores
Interpretation into functional context
Recommendations for providers and clients

18. Evaluation Cognitive screening: Functional assessments serve to:
Establishes a baseline or picture of current cognitive abilities
Functional assessments serve to:
Highlight skill areas already possessed by clients
Identify areas of need for supports or more skill building
Assists in determining and accessing various support services

19. Outcomes of Evaluation
Cognitive screening results:
Average score is well below standard range for a “typical” adult
The recommendations that accompany these scores often include supervised living arrangements and a lot of community support
Functional assessment results:
Scores are incredibly varied
Performance on these assessments is often NOT correlated with cognitive screen

20. Outcomes of Evaluation: Example

21. Outcomes of Evaluation
Despite some previous research in the literature, lower cognitive scores do not always indicate lower functional skills as related to independent living
Functional needs are not predictable
Supports need for continued individualized and client-centered interventions
Interventions may include supportive housing and case management services, in-home supports or modifications, and/or ongoing OT

22. Intervention Intervention Model:
Adaptation and compensation, then
Remediation
Client-centered, goals are based on client preferences
At beginning of intervention, clients rate their performance and satisfaction with each of the goal areas identified

23. Intervention “Adapt and compensate”
Developing strategies to meet immediate needs
How to get something done “now”
Involves adaptive equipment, modifying routines, and external strategies

24. Intervention
Clients continue to rate performance and revise goals as needed
“Remediate”
Focuses on underlying areas that impact skills (e.g. memory)
Introduces more traditional cognitive rehabilitation practices
Often occurs when individual has more routine stability and/or housing

25. Outcomes of Intervention
Canadian Occupational
Performance Measure
The client rates the performance and satisfaction on each of the goal areas on a scale of 1-10 (1 is low, 10 is best)
A change in score of at least 2 points is significant
Participation Improvement: 2.8
Satisfaction Improvement: 3.4

26. Provider Perspective on OT
Providers from all service teams routinely refer to occupational therapy
Purpose of referrals often varies based on the provider’s role
Providers value access to information regarding the client’s cognition and function

27. Themes: Provider Perspective of Occupational Therapy Consultation
Consultative Occupational Therapy provides an important, unique alternative view
OT has different view of function
Complex clients require multiple viewpoints
Value of team perspective
Consultative Occupational Therapy enriches client services
Results influence subsequent treatment decisions
Results lead to different ways of engaging clients
Results influence overall care and QOL
Need for more occupational therapy services
Providers pre-screen to prioritize referrals
Desire 100% referral for supported housing
Desire expanded interventions—individual in home/community and group

28. Summary of Outcomes
Higher incidence of BI than reported to providers and part of problem list
Cognitive impairment does not indicate functional skills and performance
Individuals show ability to learn and develop adaptations at varying time intervals after injury with ongoing intervention
Providers in varying roles value the information added by referring to occupational therapy

29. What We’ve Learned
Providers are open and willing to learn more to better engage their clients
Ongoing OT not always the “answer” but evaluation can help providers determine what support services might be beneficial
Higher self-ratings for performance and satisfaction occur throughout the process, and may be impacted by external circumstances

30. Areas for Growth Validated approaches
Growing awareness regarding brain injury beyond a few specific providers
Piloting a training for behavioral health providers to better engage and meet the needs of individuals with brain injury