1. Post-deployment Rehabilitation & Evaluation Program -PREP-
Inpatient program
Mild TBI / Post-deployment stress
Evaluations
Treatment
Multi- and Inter-disciplinary
The program I will be focsuing on today is the ………
Provides – in my opinion – an alternative treatment option – at least for some individuals within this complex population
BRIEFLY – PREP (as we refer to it) – b/c we consdier what we do as preparing the veteran or service members for Life AFTER COMbat
So that they can return to work (military or otherwise), school, life, function…
To resume, engage in a productive and fullfilling life after serving our country so well.
Inpt program for primarily mild TBI / post-deployment stress pts
Evals, tx within a multi and inter disc paradigm
There is really two parts to what I would like to share with you today
Our outcomes of course
But also the evolution of this program which began in 2006
We went from a almost purely evaluative program, through a slow progression of providing more and more treamtent – but primarily within rehab therapies, given the short nature of their stays
Despite our early desires and awareness, being able to integrate intensive mental health therapy within a rehab program has been a challenge, but one that is well worth it…as I hope I am able to highlight today
INTIALLY our program was 3 weeks in length – doing head to toe evals, providing dx clarity based on referrals (is this TBI behavior or something else), we would create a tx plan and send them back
We quickly learned that those tx plans were not always being excuted – no over sight, limited resources, pt would not follow through, travel, etc, so we began to provide brief rehab tx and psychoeducation

2. PM&R Physical Therapy Neurology Psychiatry Optometry Visual Rehab
Occupational Therapy
Psychiatry
TBI
PTSD/Mood
Pain
Physical Injuries
Substance Abuse
Family Issues
Vocational
Optometry
Neuro-psychology
Visual Rehab
Psychology
Pooling resources….
Audiology
Speech Therapy
Vocational Rehab
Recreational Therapy

3. PREP Team Approach Integrated evaluations & treatment
“1-stop shop”…efficient
Inpatient setting allows:
direct and indirect assessment
Inter / multidisciplinary team support
contextual evaluations
functional observations
Flexible: not one size fits all
(vs. discrete & independent evaluations/treatment)
Multifaceted needs require an integrated tx – it is not sufficient to merely concurrently tx an individual’s disorders independently and discretely
Care must be coordinated across domains
This is in line with what the mTBI/concussion treatment guidelines reccommend
Inpt setting: rapport, consistency in presentation = what day-to-day activities/interactions make symptoms get worse vs. better
Stable environment = reduced distractions from external stressors (family, work, etc)
KEY to program: FLEXIBLE

4. Management of symptoms -not necessarily a quick fix
Education
Explain WHY symptoms are occurring, prognosis
Consistent information
Symptom Management
Teach techniques for symptom reduction/prevention, stress reduction, compensatory strategies, coping skills
Seeking Safety Group, Neurocognitive Group, Cog-Balance Group, Headache Management Group, Tinnitus Group, Sleep Hygiene Group
Specific Symptoms
Headache, Vestibular, Cognition, Mood
NEED TO KNOW WHAT WE ARE DEALING WITH FIRST….
Consistent information provided across providers
recovery expectations, symptoms, diagnoses, treatment goals, importance of compliance, prognosis, compensatory strategies
Symptom Education
mTBI course/expectations, overlap of symptoms, factors contributing to cognitive difficulties, appropriate psychotherapy paradigms
Management of symptoms -not necessarily a quick fix
Will require consistent effort, practice and time
“how long have you had these symptoms….”
Goal of symptom mgt/tx
By decreasing core symptom intensity or frequency, patients are better able to utilize resources to more effectively engage in other more intensive treatment activities

5. PREP: Extended Treatment Arm

6. TBI Step-Care Treatment Model
EDUCATION: Expectation of Recovery
BEHAVIORAL HEALTH ISSUES (Comorbidities)
COGNITIVE ISSUES
IRRITABILITY / IMPULSIVITY
SELF-CARE ROUTINES *
(Sleep Hygiene)
SOMATIC COMPLAINTS
(Pain Management)
† Begin each encounter at the bottom of the pyramid and progress upward
* Includes Sleep Hygiene, diet, exercise, and avoiding further TBI
Terrio, 2009 6

7. Extended Treatment Arm
Individualized, with additional 1-12 weeks LOS
Intensive rehabilitation
Vestibular, vision, cognitive, physical rehab, Yoga, Cog-Balance group, multi-sensory team, HardCORE, Tinnitus Group, Headache Group, Sleep Hygiene Group
Intensive mental health treatment
Individual & group formats
Medication changes
Prolonged exposure (PTSD) (+outings)
Education
Depression, chronic pain, somatization, motivational interviewing, problem solving, acceptance, support
OVERALL -
We seek to bridge gaps in continuity of care by combining physical rehabilitation programming with evidence-based mental health treatment.
Our team is interdisciplinary, with a shared patient-centered, holistic philosophy of care that tailors treatment plans to the needs of the individual.

8. Inpatient TBI Rehabilitation and PE outcomes

9. Outcomes
100% rated their EMOTIONAL FUNCTIONING as improved as compared to admission
100% rated their SLEEP as improved as compared to admission
100% rated their COGNITIVE ABILITIES as improved as compared to admission
100% rated their PHYSICAL ABILITIES as improved as compared to admission
LOGISTICS

17. Questions ???