Rehabilitation to support community reintegration for individuals following traumatic brain injury (TBI) should be a coordinated process.  Timely access to specialized outpatient or community-based rehabilitation has shown to be beneficial.  It has also been shown that gains can be made over longer periods of time, highlighting the value of rehabilitation at later stages of recovery.  Several factors are associated with poor reintegration, and efforts should be taken to mitigate these.   Approaches to promote reintegration and participation can reduce isolation, provide opportunities to develop and practice new skills, and optimize the individual’s performance in tasks of daily living.  Daily living tasks have more benefit when practiced in realistic/naturalistic environments.  Leisure activities should also be facilitated through identifying what is meaningful and productive for the individual.  Increased independence can be facilitated by a return to driving, though assessment and retraining is required to confirm an individual’s ability to safely operate a vehicle.   Assessment and case coordination are important facilitators in vocational rehabilitation. 

Reintegration to community for an individual with moderate to severe TBI is not a linear process.  System planners and clinical leads should recognize that supports and specialized services may be required long-term to ensure continued progress and gains.  Follow-up with individuals and their families/caregivers in the form of appointments or telephone interviews should be made by referring programs to ensure continuity of services.   Outpatient and community-based programs should plan for a new client’s entry into their service in a timely manner through coordination, intake and assessment.  Outpatient programs require sufficient staffing to ensure that skills can be practiced in a realistic and meaningful environment to the individual with TBI.  Rehabilitation programs should build a partnership with peer support organizations within the community (e.g. local brain injury association). Programs should put in place a mechanism allowing for individuals to re-access services, if required, in periods of life transition that demand new skills to be developed.  Rehabilitation teams should establish a mechanism for referral to appropriate physicians to enable assessments for driving capacity to be made. Vocational rehabilitation should be offered to individuals with TBI who require support and training to assist their return to work or to school, or for entering the workforce for those not previously employed.

Indicators examples

• Average time between referral and admission to outpatient/community-based rehabilitation services.

• Proportion of individuals with ongoing disability following TBI who have access to a specialized outpatient / community based rehabilitation service.

• Proportion of individuals with TBI with a documented assessment of daily living and instrumental activities of daily living (ADL/IADL) in the person’s chart.

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Clinical tools:

• Mayo-Portland Adaptability Inventory – 4 (MPAI-4)
• LIFE-H (RIPPH)
• Work-Ability Support Scale
• Work Role Functioning Questionnaire (in French only)
• How to Conduct a Post-discharge Follow-up Phone Call Toolkit – Agency for Healthcare Research and Quality (AHRQ)
• Goal Attainment Scaling
• Activity Card Sort
• Activity Measure for Post Acute Care
• Components of the Vocational Evaluation following mTBI (Appendix 12.1) from the ONF Adult mTBI guidelines Return to Work Considerations (adapted from Stergiou-Kita 2012)
• Identification des meilleures pratiques de remédiation des fonctions cognitives reliées à la conduite automobile chez les personnes ayant subi un traumatisme craniocérébral modéré ou grave (Identification of Best Practices for Remediation of Cognitive Functions Related to Driving for People with Moderate to Severe Traumatic Brain Injury) – IRDPQ, CIUSSS CN (in French only)
• L'évaluation des capacités reliées au travail pour une clientèle présentant une déficience physique – Guide de pratique à l'intention des ergothérapeutes (Assessment of work-related abilities for people with physical disabilities – Practice Guide for Occupational Therapists) – IRSST (in French only)

Patient and Family Resources:

• Guide en soutien à la famille (Guide to Family Support – For The Parents of a Child or an Adult with a disability) – OPHQ (in French only)
• Factsheet for Driving After Traumatic Brain Injury – TBI Model Systems KT Center
• Survivor Life Skills Tool Kit: Workbooks help survivors rebuild their lives after brain injury Bell KR, Fraser RT., Johnson KL, Leonhardt D., Stahura B., Webster B. 2011
• Medical Review Section – Ontario Ministry of Transportation Fact
• Fatigue au volant – Guide de gestion de la fatigue (Fatigue while driving) – SAAQ (in French only)
• For Ontario:
  Ontario Brain Injury Association (OBIA) – Directory of Services
  Peer Support Programs offered through local brain injury associations
• For Quebec:
  Regroupement des associations de personnes traumatisées craniocérébrales du Québec (RAPTCCQ)
  Office des personnes handicapées – Gouvernement du Québec
• Kéroul – Tourisme et culture pour les personnes à capacité physique restreinte

Other Resource:

• Canadian council of Motor transport Administrators: CCMTA Medical Standards 2009

Community reintegration is challenging. A study by Fleming et al. (2014) found that 47% of participants reported physical barriers and 54% reported service barriers in their attempts to reintegrate into society. Service barriers and physical/structural barriers (Pappadis, 2012), as well as financial strain are associated with poor community reintegration (Nalder et al., 2012).

In terms of outpatient care or community care there are several similarities to inpatient rehabilitation. A multidisciplinary approach is still favourable for outpatient services, and timely rehabilitation is imperative as patients are often sent home too early and referred to outpatient services too late (Jeyaraj et al., 2013).  However, a longer duration of rehabilitation is suggested but with less intensity to allow patients to integrate back into daily life. Jeyaraj et al. (2013) noted that there is a need to train clinicians who provide community services about how best to assist individuals with acquired brain injury (ABI) and increase the amount of community resources. Cusick (2003) compared individuals enrolled in a Medicaid Waiver Program to those receiving no outpatient Medicaid support. Although patients in the Medicaid waiver program showed higher levels of resource use, as well as improved mental health status and less substance abuse, the control groups scored better on independence based measures (i.e. physical, cognitive, and mobility). Given all the confounding variables that were not controlled for, firm conclusions cannot be drawn from this study; however, such programs seem promising in terms of helping patients with ABI access appropriate services. In terms of services, it is important to highlight the findings of Turner et al. (2009) that showed stress and depression significantly increased over time after rehabilitation. Although the focus is often on functional status, it is crucial that the psychological wellbeing of individuals with brain injury is remembered during this transitional phase.

Braunling-McMorrow et al. (2010) looked at the benefits of participation in a weekly program that included both behavioural and cognitive therapies that would teach participants to respond to various life events appropriately and allow for greater independence. Those in the neurobehavioural group admitted within the first six months of injury showed greater improvement than those admitted later. The study authors suggest that injury severity may have been a factor, with more severe cases being admitted sooner. As well, for those admitted later, gains had already been made and this may have made the gains in the program appear less significant (Braunling-McMorrow et al., 2010).

At home follow-up for patients with traumatic brain injury (TBI) have proven benefits. Bell et al. (2005) found that scheduled telephone counselling and education was beneficial in comparison to usual outpatient care. Those who received the intervention were significantly better, at 1-year follow up, in terms of functional status and quality of well-being. However, these findings were not replicated in a later study (Bell et al., 2011). Matching individuals with community participants or mentors has been shown to be a simple yet effective strategy in improving perceived levels of social support (Hibbard et al., 2002; Johnson & Davis, 1998; Struchen et al., 2011).

Another study by Ponsford et al. (2006) compared outpatients treated in the community to those who returned to the hospital for outpatient care. The findings indicate that patients who received outpatient care were significantly less dependent on support from close others, more independent in mobility, displayed fewer inappropriate social behaviours and had less difficulty with motor speech and following conversations than those receiving community based-rehabilitation. No significant differences were shown in terms of employment outcomes.

Bender et al. (2014) evaluated an inpatient interval rehabilitation program compared to an early rehabilitation program. Bender et al. (2014) reported that patients who entered the interval rehabilitation program demonstrated improvement-rate increases comparable to initial rehabilitation levels, where the greatest gains are said to be made, highlighting the benefit for additional rehabilitation at later stages of recovery. The study found an improvement in FIM scores during early rehabilitation, community care, and inpatient interval rehabilitation, with benefits that lasted up to one and a half years, despite the therapy only lasting six to seven weeks (Bender et al., 2014).

As suggested in the following cohort studies, daily living tasks show improvements when practiced in a realistic setting. Lamontagne et al. (2013) reported that individuals living in a structured institutionalized setting experienced greater difficulty, with social role-related life habits being performed more easily by patients living in group homes or with foster families. Similar findings were reported by Sloan et al. (2012) in that patients living in a disability-specific setting required higher levels of support than those in home-like settings. The authors argue that due to time-constraints, caregivers may provide more assistance than is needed, thus reducing the patients’ autonomy and independence.

Brain injury negatively affects participation in leisure activities (Fleming et al., 2011; Wise et al., 2010). Therapeutic recreational activities and leisure education can improve participation. Mitchell et al. (2014) studied 12 adults with brain injury admitted to a week-long residential leisure intervention program called “Pushing the Boundaries” in an attempt to trial leisure intervention through groups. The program included leisure awareness, leisure resources, social interaction skills and leisure activity skills finding improvements in leisure satisfaction, self-esteem and QOL following the program.

For many individuals in our society, driving represents a significant marker of independence. In the literature, return to driving rates ranged from 36.5% to 75% (Fleming et al., 2014; Hawley, 2001; Leon-Carrion et al., 2005; Liddle et al., 2012; Pietrapiana et al., 2005). Of concern, at admission to rehabilitation, one study found 30.5% of the patients were driving despite not being fit to do so (Leon-Carrion et al., 2005). It is imperative that thorough evaluations are conducted prior to the return to driving. Schanke et al. (2008) found that patients who had sustained a TBI had twice as many accidents post-injury then they did pre-injury. The authors felt this may be the result of a lack of adequate compensation for the patients cognitive deficits post-injury, particularly deficits relating to executive function.

In terms of returning patients back to work or educational settings, 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). This is further discussed by Thomas and Menz (1996) who suggest the process should involve an assessment of functional skills, as well as knowledge of pre-injury skills, as well as a vocational plan, with continual access to resources (Stergiou-Kita et al., 2011). Malec and Degiorgio (2002) reported that patients in three different rehabilitation pathways, who differed in terms of cognitive functioning and disability, were able to succeed in terms of community-based employment. The study highlights the need for an individualized approach to ensure successful integration into the community. The intensity of therapy and the resources and interventions offered must match the individual’s needs, severity of injury, and goals, among other factors (Malec & Degiorgio, 2002). Radford et al. (2013) evaluated a TBI specialist vocational rehabilitation (VR) intervention in  those with TBI requiring > 48 hours acute hospitalization in a non-randomized trial. The primary outcome was return to work at follow-up by postal questionnaire at 3, 6 and 12 months post-hospital discharge. At 12 months, 15% more TBI-VR participants (27% more with moderate/severe TBI) were working than Usual Care (27/36, 75% vs. 27/45, 60%). Mean TBI-VR health costs per person (consultant, GP, therapy, medication) were only £75 greater at 1 year. People with moderate/severe TBI benefitted most. This positive trend was achieved without greatly increased health costs, suggesting cost-effectiveness. There is a need for definitive Randomized Controlled Trials (RCT) in this group.

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