1. Primary Care for Patients with Brain Injury Courage Center Physicians Clinic Teresa Kiresuk, DNP Michelle Ullery, FNP Korinne Novak, ANP

2. 2 Brain Injury Incidence MN TBI: 154,933 –Estimated that 10,00 progress to long term disability (MN, Department of health, 2010) Nationwide TBI: 1.4 million annually –100,000 develop long term sequale (CDC, 2010) Currently estimates of 5.3 million individuals have disability due to TBI (CDC, 2009) cdc.gov/traumaticbraininjury/tbi_report_to_congress.html#6 health.state.mn.us/injury/midas/ub92/index.cfm

3. 3 Post Brain Injury Problems Physical Symptoms Psychological Symptoms Social Symptoms

4. 4 Physical Symptoms HeadacheDizziness TinnitusVisual Disturbances InsomniaFatigue Chronic PainImpaired Cognition Neurogenic Bladder Neurogenic Bowel Spasticity and Dystonias

5. 5 Psychological Symptoms Personality Changes Mood Disorders Depression Mania Anxiety Substance Abuse

6. 6 Social Symptoms Relationship Difficulties Vocational Concerns Sexuality Issues Driving Safety

7. 7 Health Maintenance Needs USPSTF Preventive healthcare and health maintenance General recommendations based on age and gender for -Screening, -Immunization - Counseling -Chemoprophylaxis

8. 8 Health Maintenance Needs Following TBI Screening: Headache, fatigue, dizziness, visual changes, bowel and bladder management, spasticity, mood disorders, personality changes, vocational concerns and status, relationship concerns, and substance use Counseling: injury prevention, family planning, health concerns Immunization: pneumovax, influenza, hep b, TD, Chemoprophylaxis: asa, vit d, calcium, bisphosphonates Secondary Prevention Measures: injury, skin integrity,

9. 9 Health Maintenance Challenges Inadequate comprehensive primary care and preventive health services Appointment time limitations Physical access to clinic and exam techniques Provider knowledge regarding Post TBI needs Provider knowledge regarding Health Maintenance Needs Focus on a Few Chronic Problems

10. 10 Interdisciplinary Approach Primary Care, Psychiatry and PM&R in same clinic HCH Model Co-Visits, Back to Back Visits Specialty Services within Clinic Organization Rehabilitative Services in Organization Specialty Referrals Available Adaptive Clinic Equipment

11. 11 References Bockenek, W., Currie, D. (1994). Physical medicine and rehabilitation as a primary care specialty, Commentary. American Journal of Physical Medicine and Rehabilitation. 73(1) 58-60. Bushnik, T., Englander, J., & Wright, J. (2008). The experience of fatigue in the first 2 years after moderate-to-severe traumatic brain injury: a preliminary report. Journal of Head Trauma Rehabilitation. 23(1)17-2 Castriotta, R,& Murthy, J. (2011). Sleep disorders in patients with traumatic brain injury: a review. CNS Drugs 25(3): 175-85. Hoffman, J., Lucan, S., Dikmen, S., Braden, C., Brown, A., Brunner, R., Diaz-Arrastia, R., Walker, W., Watanabe, T., and Bell, K. (2011). Natural history of headache after traumatic brain injury. Journal of Neurotrauma, 28(9) 1719-1725. Iverson, G., Zasler, N., & Lange, R. (2007). Post-concussive disorder. In Zasler, N., Katz, D., & Zafonte, R. (Eds.), Brain Injury Medicine (pp373-406). New York: Demos Medical Publishing Klein, M., (2011). Sexuality and Dysfunction. Medscape Reference: Drugs, Diseases, and Procedures. Retrieved from http://emedicine.medscape.com/article/319119- overview#a30. Kroll, T., Jones, G., Kehn, M., and Neri, M. (2006). Barriers and strategies affecting the utilization of primary preventive services for people with physical disabilities: a qualitative inquiry. Health and Social Care in the Community, 144284-293.

12. 12 References Morrison, E., George, V., & Mosqueda, L., (2008). Primary care for adults with physical disabilities: perceptions from consumer and provider focus groups. Family Medicine, 40(9)645-651. Orff, H, Ayalon, L., & Drummond, S. (2009). Traumatic brain injury and sleep disturbance: a review of current research. Journal of Head Trauma Rehabilitation, 24(3): 155-65. Radice-Neumann D, Zupan B, Tomita M, Willer B (2009). Training emotional processing in persons with brain injury. Journal of Head Trauma and Rehabilitation, 24(5): 313– 323. Slomine, B., McCarthy, M., Ding, R., MacKenzie, E., Jaffe, K., Aitken, M., Durbin, D., Christensen, J., Dorsch, A., and Paidas, C.(2006). Health care utilization and needs after pediatric traumatic brain injury. Pediatrics, 117(4)663-674. Sutton, J., and DeJong, G. (1998). Managed care and people with disabilities. Archives of Physical Medicine and Rehabilitation, 79: 1312-1316. US Department of Health and Human Services (2010). Agency for Heath Care Research and Quality. The guide to clinical preventive services 2010-2011. Electronic Publication of the US Preventive Ser