Following discharge from inpatient rehabilitation unit patients with moderate to severe brain injury typically receive ongoing therapy at a lesser intensity. While most patients move back to their former living environment with therapy intervention provided for them in the home or community, some go on to other facilities that may provide longer duration treatment for those that are slow-to-recover. The effectiveness of these interventions is reviewed in this section.
There are numerous models of care within community-based rehabilitation. In regards to social re-entry, Martelli (2012) argues that peer support interventions are effective in reintegrating individuals and should be incorporated into community rehabilitation models. Avocational and vocational reintegration are also important factors as the former can improve functionality, strength and endurance, while the latter improves productivity, self-worth and life satisfaction. Vocational reintegration can be facilitated through the case coordination model whereby the patient collaborates with a case coordinator who assesses the services needed and makes appropriate referrals on the patient’s behalf (Martelli et al. 2012). Lack of services could be an issue, thus a supported employment program or a program-based model could also be utilized.
Ashley et al. (2012) proposed a new community-based interventional model that focuses on cognitive attributes. The proposed model incorporates tasks that assist with attention, perceptual processing and categorization. The authors point out that previous research has found re-establishing neuronal connections that become damaged after a TBI leads to greater cognitive functioning in patients. For the model to be successful, Ashley et al. (2012) state that the tasks need to be errorless, with high levels of repetition and redundancy in order for the intervention to be successful. As this model of care can be extremely time-consuming, it is therefore suggested that this be utilized in a community-based rehabilitation center.
For continuity of rehabilitation community-based programs are needed following inpatient rehabilitation and should be tailored to individuals’ needs in order to maximize their recovery. It is unacceptable to allow patients to be discharged from a rehabilitation setting without adequate follow through on the issues that they continue to face in the course of their recovery. In examining the long-term follow-up after discharge from a comprehensive rehabilitation program, Olver et al. (1996) found that strong recoveries were made in terms of mobility and physical functioning; however, many issues were still present years later. More specifically, cognitive issues were still present in two-thirds of the sample, behavioural concerns such as irritability and aggression still existed, as well as persistent fatigue. This study emphasizes the need for continued support. Given that most patients will continue to make gains for two or more years, it is reasonable to ensure that they continue to receive therapeutic intervention for this period of time.
One of the main targets for community-based rehabilitation is to assist the patient in their transition into independent living. Independence is a key component of self-efficacy and allows us to live an autonomous life. Powell et al. (2002) randomly assigned patients with TBI to an outpatient support program where patients received two to six hours of therapy a week at home or in another community setting, or to a control group that received an information session at home. Patients in the intervention group showed improvements in cognitive functioning, mobility, and personal wellbeing. Areas such as socializing and competitive employment rates showed no relative difference between groups, the authors suggest that this reflects external influences beyond the control of the rehabilitation team. The authors recommend that this type of outpatient approach be applied to a broader range of patients with ABI in a larger trial to confirm their results.
Wood et al. (1999) found that rehabilitation of at least six months led to greater independence, higher social activity levels, and less need for care support. To accomplish independence and reintegration back into community settings, patients are encouraged to set goals in order to assist their transition. When examining involvement in goal-setting in neurorehabilitation, Webb and Glueckauf (1994) found that patients who had greater involvement in goal-setting maintained their improvements at study follow-up; contrarily, those with low involvement in their goal setting showed a decline in the number of goals attained. Not surprisingly, it is beneficial to have the patients highly involved in the goal setting as it ensures the goals are meaningful and thus, the motivation of the patient is increased. Ownsworth et al. (2008) performed an RCT to compare individual occupation-based support, group-based support, and a combination of the interventions for goal attainment and psychosocial functioning. The individual occupation-based support contributed to gains in performance in goal-specific areas. The combined intervention was associated with maintained gains in satisfaction and performance, while the group and individual interventions were more likely to result in gains in behavioural competency and psychological well-being.
Hassett et al. (2009) randomized patients to a supervised fitness center-based exercise program or an unsupervised home-based program and found that both groups at follow-up made comparable gains in terms of psychosocial and physical functioning. Although, the fitness group achieved more goals post intervention, the difference was not significant at follow-up. This study highlights that these programs are equally as effective which is positive for individuals who cannot access or prefer not to attend community center fitness programs. In an RCT conducted by Peirone et al. (2014), while all patients received physiotherapy to target balance impairments, those in the intervention group also received a dual-task home-based program. The program was provided six days a week over seven weeks and resulted in this group making significantly greater gains in terms of balance then the control group. While improvements were also shown on the goal attainment scale and a balance confidence scale, the between groups differences were not significant. Unfortunately, the results are hard to interpret due to being underpowered and the inability to distinguish whether the improvements are based on the program itself or just the intensity of the additional therapy. A study by Eicher et al. (2012) investigated the intensity of rehabilitation programs and how they influence adjustment and adaptability. More intensive programs provided more functional benefits, whereas supported living programs resulted in relatively stable scores on the Mayo-Portland Adaptability Inventory.
Participation has also been an area of interest in regards to how patients reintegrate themselves into societal and occupational environments. With regards to societal participation, Malec (2001) found that one year after participation in a comprehensive day treatment program 72% were living independently, 39% were working independently, 10% were in transitional placements, and 18% were involved in supported or volunteer work. Malec and Moessner (2000) reported that after participation in a comprehensive day treatment program, patients experienced reduced impaired self-awareness and distress, both of which were significant predictors of goal attainment. In this sense, focusing on psychosocial factors can assist patients to achieve their goals and independence; however, neither were related to employment.
Two studies used the Mayo-Portland Adaptability Inventory-Fourth Addition (MAPI-4) to determine the significance of community rehabilitation in three reintegration issues following brain injury: functional ability, emotional adjustment and community participation (Curran et al. 2015; Duchnick et al. 2015). Duchnick et al. (2015) utilized the MAPI-4 to test the significance of a transitional community rehabilitation program for veterans who suffered an ABI across four rehabilitation sites. Following treatment all components of the MAPI-4 showed significant improvement; functional abilities improved the most, followed by emotional adjustment and community participation (Duchnick et al. 2015). Similarly, Curran et al. (2015) determined that a community rehabilitation program for patients with TBI significantly improved all three components of the MAPI-4 as rated by the participant, program staff and significant others.
Despite the services offered to patients, and the recommendations made, compliance is essential to each patient’s success. For example, Blackerby and Baumgarten (1990) patients with substance addictions who followed recommendations for additional rehabilitation or psychiatric treatment at discharge from the program remained drug-free. On the other hand, only one of the five clients who did not follow recommendations remained drug-free at follow-up. Overall, the program was relatively unsuccessful due to an inability to keep clients participating in the program for the six-month period desired and the clients’ failure to follow discharge treatment recommendations.
There is Level 1b evidence that a supervised fitness center-based program is equally as effective as an unsupervised home-based program for improving cardio-respiratory fitness.
There is Level 1b evidence that structured multidisciplinary community-based rehabilitation is more effective in improving functional ability, as well as activity, participation, and psychological aspects of functioning in the community compared to educational booklets.
There is Level 2 evidence that a high-level of involvement in neurorehabilitation goal setting results in a greater number of attained goals being maintained at follow-up (two months), whereas patients with low-involvement show a decline in the number of goals attained.
There is Level 4 evidence that a transitional community rehabilitation program improves functional abilities, emotional adjustment and participation post ABI.
There is Level 4 evidence that patients with a dual-diagnosis of TBI and substance abuse often do not benefit from community-based treatment programs to become chemical-free due to lack of compliance on the part of the patient.
There is Level 4 evidence that participation in a comprehensive day treatment program reduces impaired self-awareness and distress, as well as improves societal participation at one-year follow-up.
Community-based programs for patients with ABI are associated with greater independence, higher social activity levels, and less need for care support when they can be sustained for at least six months.
Programs targeted towards participants with a dual-diagnosis of TBI and substance abuse are challenging due to lack of compliance and an inability to keep them in the program for an extended period of time.
When direct patient involvement in goal setting is employed, there is a significant improvement in achieving patients’ goals.
Comprehensive day treatment programs can reduce impaired self-awareness and distress, and improve societal participation.
There remains a need to provide ongoing outpatient or community care and rehabilitation years post injury.
Cognitive, behavioural, and employment issues can still exist years after discharge from a comprehensive rehabilitation program.