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

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

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

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

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

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 www.hchcmd.org

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)

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

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

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

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

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?

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

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

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

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

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

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

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

Outcomes of Evaluation: Example

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

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

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

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

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

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

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

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

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

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