Traumatic Brain Injury A Roadmap for Accelerating Progress (2022) / Chapter Skim
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3 Understanding Patients with Traumatic Brain Injury
3 Understanding Patients with Traumatic Brain Injury
Pages 47-70
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One of the essential features of quality health care is patient- or person-centeredness (IOM, 2001) , a key feature of the optimized traumatic brain injury (TBI)
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RECOGNITION Awareness of the signs and symptoms of TBI, and the ecological identification of an individual who needs care following a brain injury. FIGURE 3-1 Illustrative stages of a person's journey through recognition of, treatment for, and recovery after TBI.
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A FRAMEWORK FOR UNDERSTANDING TBI: THE BIO-PSYCHO-SOCIO-ECOLOGICAL MODEL Understanding the medical course of TBI is important, but to fully address effective TBI prevention and care requires a framework that is broader than a medical model of injury, given the multiple personal and social/environmental factors that affect the experience of and recovery from such an injury. Models that recognize the interactions among such factors have been applied to a variety of prevention and disease contexts and are required to understand TBI.
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Chronic pain, diabetes, asthma, cardiovascular disease, various cancers, stroke, and Alzheimer's disease and other dementias are among the many chronic health conditions that share this range of influence. In fact, one could argue that no significant survivable injury, illness, or combat-related wound is free of the influence of BPSE factors.
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Panel discussion during virtual workshop for the Committee on Accelerating Progress in Traumatic Brain Injury Research and Care, March 18, 2021. P B E S FIGURE 3-2 The BPSE prism.
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Challenges include the heterogeneity of TBI; the need for further research; gaps in the handoffs and transitions that occur along the continuum of care; the need for involvement of multiple types of care providers; the variety of data and payment systems involved in TBI care and research; and the diversity of organizations and communities in which people live, learn, work, and play. INTERSECTION OF TBI WITH OTHER CONDITIONS Confounding both acute and long-term diagnosis and management of TBI is the frequent coexistence of posttraumatic stress disorder (PTSD)
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. Systemic inequities exist in the risk of sustaining a brain injury; access to timely and definitive treatment and recovery; and access to work, family, and community infrastructures that support long-term quality of life.
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identifies injury severity as the major contributing factor in a higher TBI mortality rate among Black relative to White children, with insurance status making only a small contribution. Lack of attention to social drivers -- including structural racism, inequities, and bias -- plays a role in poor access to quality TBI care and in particular, to rehabilitation and longer-term follow-up across the lifespan (Moore et al., 2019; NASEM, 2017)
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. In 2019, PINK Concussions launched the Partner-Inflicted Brain Injury Task Force4 to foster collaboration between brain injury professionals and domestic violence/intimate partner violence professionals.
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Panel discussion during virtual workshop for the Committee on Accelerating Progress in Traumatic Brain Injury Research and Care, March 16, 2021.
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Panel discussion during virtual workshop for the Committee on Accelerating Progress in Traumatic Brain Injury Research and Care, March 16, 2021. 8 See Figure 3 from Brown and colleagues (2019)
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Presentations and panel discussion during virtual workshop on Accelerating Progress in Traumatic Brain Injury Research and Care, March 16, 2021.
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Numerous studies have identified relationships of race and ethnicity to rehabilitation outcomes after TBI, including utilization of posthospital care, access to rehabilitation, functional status, community reintegration, and employment. This research has shown that survivors from racial and ethnic minority groups are significantly less likely to utilize posthospital health care after brain injury (Gao et al., 2018; Odonkor et al., 2021)
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Presentation and panel discussion during virtual workshop on Accelerating Progress in Traumatic Brain Injury Research and Care, March 16, 2021.
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These reflections and recommendations span a range of areas, including improving workforce education and performance monitoring, building interdisciplinary care teams, increasing access to care, forging institutional partnerships beyond health systems, reforming payment systems, and leveraging digital health technology and implementation science (see Box 3-1)
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Improve Workforce Education and Performance Monitoring • Educate TBI care providers on the impacts of diversity, equity, and inclusion on health care outcomes for their TBI patients, including the distinctions between equality and equity and privilege and oppression.a • Provide cultural competency training for health care workers seeing TBI patients, including training in communication processes that reduce implicit bias.b • Train providers to acknowledge the historical and current experiences of vulnerable popu lations that impact patient careb and to advocate for patients who need to address ob stacles outside of health care that impact their health.b • Train TBI clinicians in community settings (such as schools, workplaces, prisons, home health care, and public clinics) alongside nonphysician care providers.c • Use diverse, team-based approaches to leadership development that include community health workers.d • Establish incentives for TBI clinicians to receive training in how to communicate about seri ous conditions, such as TBI, to patients.b • Teach and implement trauma-informed care practices so that TBI clinicians can address individual-, family-, and community-level trauma underlying disparities in risk factors for TBI and in health outcomes for TBI survivors.b • Train TBI clinicians to deliver care that is consistent with patient preferences.b • Stratify clinical performance measures by such factors as race/ethnicity, socioeconomic status, disability status, and serious illness status.b • Conduct performance monitoring and quality improvement based on updated content of care.d • Address organizational culture when implementing measures to improve care equity.b Build Interdisciplinary Care Teams • Promote integrated care systems, interdisciplinary care, whole-person care, family-centered care, and team-based care for people with TBI along with their caregivers and families.b,d • Include nontraditional health care workers, such as community health workers and peer navigators, in health care teams.
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• Connect health care delivery systems to expertise in other domains that contribute to health inequity, such as housing, employment, and education.b,d,f • Partner with the people and institutions in the community where patients have daily inter actions outside of health care systems.b • Institutionalize equity in the infrastructure of organizations and their community partnerships.d Reform Payment Systems • Where appropriate, consider alternatives to the standard fee-for-service payment model in favor of performance-based payment models that reward clinicians for better patient outcomes.d • Consider payment models that give health care organizations the flexibility to address patients' social needs and social determinants of health.c • Address payment structures and incentives as an essential component of advancing equity; seek input from severely affected and vulnerable populations.b • Design funding mechanisms to sustain data-driven equity programs that are working.b Leverage Digital Health Technology and Implementation Science • Expand the use of digital health technology,c electronic health records,c telehealth,e and virtual health assistants in TBI care. For example, these tools could be used to refer TBI patients to social services and public benefits via a technology platform that was two-way and integrated electronic health records.f Leverage implementation science when rolling out new interventions for TBI in health systems.b a NASEM, 2016b.
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Assessment, reporting, and rest protocols are an important component of early phases of TBI management for active duty service members.15 TBI is considered a potential risk for all service members deployed to war zones, engaged in training, or participating in sports programs, as well as for athletes in high-risk professional and university sports programs.16 As a consequence, potential TBIs in combat or on the playing field are treated aggressively, particularly given the attention to TBI resulting from the past two decades of war in Southwest Asia and increased focus on the long-term effects of concussions in athletics. After acute TBI care, mid- and long-term management of the consequences of TBI is affected by access to and the nature of specialty care and institutional, community, and educational rehabilitation.
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2007a. Traumatic brain injury and functional outcomes: Does minority status matter?
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2021. Health phenotypes and neurobehavioral symptom severity among post-9/11 veterans with mild traumatic brain injury: A chronic effects of neurotrauma consortium study.
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2014. Racial/ethnic and insurance status disparities in discharge to posthospitalization care for patients with traumatic brain injury.
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2015. Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury.
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2002. Traumatic brain injury in the elderly: Increased mortality and worse functional outcome at discharge despite lower injury severity.
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