RAINBOWVISIONS - Brain Injury Rehabilitation Centers · address ethical questions and allow for...

THE LESSER OF TWO EVILS

RAINBOWVISIONSFor and about the brain injury and spinal cord injury community. Rainbow Rehabilitation Centers, Inc.

WINTER 2018 Volume XV No. 1

rainbowrehab.com

Ethical Challenges for Clinicians

• PLUS Understanding Grief

A Look at Skin and Wound Care

Success Stories

• PRESIDENT'S CORNER

Decades of Stewardship By Bill Buccalo, President & CEORainbow Rehabilitation Centers

In this issue, Lynn Brouwers, Director of Program Development, does an exceptional job of discussing

the ethical challenges clinicians face in the health care industry and provides some practical guidance on how they and their organizations might go about dealing with those issues. These ethical questions can be some of the most challenging issues to address and can also reveal much about the character and define the culture of the organization.

Rainbow strives to set a positive culture. We are aware of the impact of decisions and how they impact patients, employees, clinicians, the organization, and ultimately our industry. As a result, we have forums to address ethical questions and allow for open dialog and consultation, with the goal of maintaining a longstanding track record of doing the right thing.

Not only do clinicians face ethical dilemmas, but managers and administrators do as well. Organizations and industries need to establish a culture of dealing with these issues in a professional manner by holding each other accountable and aiming for doing the right thing, even though that may sometimes be painful in the short term.

We face difficult ethical questions frequently and we work hard to resolve them by including the use of a broad-based employee committee. If needed, we consult with health care law experts, licensing consultants, or other professionals who can shed light on a situation. We want to ensure we are making sound decisions and considering all sides.

Rainbow also participates in a variety of industry advocacy and trade associations, including the Brain Injury Association of America’s Business and Professional Council, the Brain Injury Association of Michigan, the Michigan Brain Injury Providers Council (MBIPC), and several discipline specific associations. As members, we

feel a strong sense of stewardship towards the industry and its character.

Several Rainbow employees have volunteered for committee and board positions with these organizations, including Lynn who served on the MBIPC Board of Directors in a variety of leadership roles. The MBIPC has focused for decades on raising the bar on the quality of care in Michigan and the access to care for people living with the consequences of brain injury. The Council has done this by providing clinical educational opportunities for members and the community, workshops for business practice improvement, advocacy work to protect and expand the rights of patients, and through the establishment of business and ethical standards for member organizations.

Rainbow and member organizations invest heavily to satisfy third-party certification and accreditation requirements such as those of CARF, Joint Commission, and other standards setting agencies. These agencies focus on program quality, ethical practices, safety, and promoting the rights of patients. In addition, through member participation in the MBIPC and other national industry groups, organizations are able to continuously improve through benchmarking activities, tours of similar programs around the nation, and the dynamics of pure competition pushing for higher quality.

The article on ethical challenges does a wonderful job of framing an important issue. I am proud to lead an organization and serve MBIPC, as each values having a forum for debate on these serious matters. Although investing in these practices can be hard work, it is the right thing to do. In the words of Henry David Thoreau, “You cannot dream yourself into character; you must hammer and forge yourself one.” Progressive management of challenging ethical issues can help define that character. ❚

In this article, we review dilemmas commonly seen in brain injury rehabilitation that can place the client and others at risk.

Page 10

Copyright January 2018—Rainbow Rehabilitation Centers, Inc. All rights reserved. Published in the United States of America. No part of this publication may be reproduced in any manner whatsoever without written permission from Rainbow Rehabilitation Centers, Inc. Contact the editor: [email protected].

Our mission is to inspire the people we serve

to realize their greatest potential

Features 2 Therapy Corner Understanding Grief Mariann Young, Ph.D., CBIST

6 Success Story Standing Tall Abby Dull, PT, DPT, CBIS

10 Clinical News The Lesser of Two Evils: Ethical Challenges for Clinicians Lynn Brouwers, MS, CRC, CBIST

20 Success Story Here Comes the Bride Chelsea Lupone

24 TBI Topics Concussion: The Expectations for Recovery Carolyn Scott, Ph.D., CBIST

28 Medical Corner A Look at Skin and Wound Care Kathleen Sobczak, BSN, RN, CBIS, WCC, CRRN

36 Conferences & Events

News at Rainbow 38 Haunted House | Holiday Charity Project | Instagram | Blood Drive and more!

40 Pillar of Excellence Awards | Buzz Wilson and Leadership Awards Employees of the Season

42 New Professionals at Rainbow

Editor Barry Marshall

Associate Editor/Designer Jill Hamilton-Krawczyk

Contributor Valerie Kolesar

Email questions or comments to: [email protected]

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• ON THE COVER

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Loss, Hope and Healing

• THERAPY CORNER

2 | RAINBOWVISIONS • WINTER 2018

Understanding GriefLoss, Hope and Healing

By Mariann Young, Ph.D., CBIST Director of Pediatric and Young Adult Services, Rainbow Rehabilitation Centers

WHAT IS GRIEF?There has been a great deal written about grief, but in general it is a complex emotion that

may not be easily understood. It is the internal or personal response to loss and one of the most common experiences of everyday life.

To grieve means to acknowledge in your heart and to others that your loss meant something to you, and that you must honor the importance and pain of your loss.

There is a wide range of grief, from mild sadness to overwhelming suffering. Grief may lead to depression, anger or disruptive behaviors if it is not acknowledged and addressed. The sadness, the tears, the fatigue, the changes in how we feel physically and emotionally and how we relate to friends and family can all be confusing.1

American culture does not always make it easy to express grief. As a society, we tend to glorify youth, beauty and health. This does not lead us to be able to handle the reality of grief or death. We can be expected to hide our emotions or to handle them within a certain time frame.2 We discourage the direct expression of grief and at times feel so uncomfortable in allowing the grief to be expressed that we try to stop it. We describe people who are crying or expressing pain as “not doing well” and try to cheer those who are sad. We advise grieving individuals to be brave when it is better to allow them the ability to express their emotions.3

AMBIGUOUS LOSSAfter a person has a traumatic brain injury, the family is overwhelmed by emotions.

There is the initial fear, depression, anxiety and guilt—to name just a few. The immediate concern is: Will they survive? There is joy and relief once it is known that the person will live. However, if the person has had a severe or moderate brain injury, the realization sets in that the person who survived is not the same person that they were before the accident.

Emotions may be in turmoil because of the conflict experienced when you are grateful that the person has lived yet grieve the person who is no longer there. The relationship that you had with the injured person, whether parent/child, partner, family member or close friend, is forever altered.

Continued on page 4

RAINBOWREHAB.COM WINTER 2018 • RAINBOWVISIONS | 3

• THERAPY CORNER UNDERSTANDING GRIEF

There are situations in which the family becomes so involved in providing care that they do not recognize the effects the injury has on all members of the family. Even the strongest families grieve the loss. Furthermore, there is not any ritual to assist in this type of grief, because the loss is ambiguous.

Ambiguous loss is unresolved. There is no closure to it, and it becomes the new reality.

Some features of ambiguous loss include:• The loss is always about relationships.

• The loss is stressful.

• There is the frustration of not knowing a “final outcome” of the accident—how long therapy will last, how severe the deficits will be, when will the person be back to their pre-accident self, what will the new normal be like, and how can a person cope?

• Ambiguous loss is not depression but can contribute to depression, anxiety, conflict, illness or explosive emotions if not addressed.

• Ambiguous loss may not be easily resolved.4

CHILDREN WHO EXPERIENCE LOSSNo child is too young to be affected by loss. An infant

recognizes the change in feedings and care-giving routines after loss. They miss the presence of the family member who has been injured, and they are able to sense the powerful emotions expressed by others around them.

Young children grieve deeply but for shorter periods of time than adults. They are easily overwhelmed by strong emotions, and a shorter emoting of grief serves as a protection for them. This does not mean that they are not sad or that their emotions have been addressed—it just means that it is all they are able to handle at that particular time. Older children may focus their attention on school, friends, or helping out when they can.

No matter the age of the child, they will likely not react in the way an adult expects them to react. In fact, children may find it easier to express their feelings through play, art or journaling. Although you may get an indication of what a child is thinking, it is unrealistic to interpret their thoughts exactly.

A child may not be ready to deal with the loss they have experienced, and their lack of emotion may be their inability to grieve at that time. Also, when children are stressed they may behave like a much younger child. They may become whiny and clingy. Younger children could have bowel or bladder accidents or become demanding.

It is important to meet the needs of a child who has experienced loss so that they can care more about others.5

WHAT IS HOPE?Hope is an optimistic attitude based on an expectation

of positive outcomes. People who possess hope and think optimistically have a greater sense of well-being in addition to improved health outcomes. The impact that hope can have on a patient’s recovery is strongly supported through empirical research and theoretical approaches. A person can live with ambiguous loss without becoming hopeless.

According to Janet Cromer, RN, MA, LMHC, these are some of the key points:

1. Recognize what’s going on. Underneath the confusion is a list of losses, changes, thoughts and feelings. Write down your thoughts without censoring them. Talk to other family members about their observations and talk to the individual about what bothers him or her. Talking about an issue does not make it worse.

2. Find a safe and supportive connection. Talk to a therapist, counselor or spiritual leader who is experienced in dealing with ambiguous loss. Inquire in advance if they understand the issue. Join a support group that can assist in your finding meaning and hope in the loss.

3. Come to a shared understanding of the situation over time. Learn what has been lost for each family member and focus on where to build. Mourn whenever you feel the need and understand that this act is not disloyal to the person.

4. Get to know the person for who they are after the accident. Rebuild roles, rituals, and rules to live by.

5. Incorporate humor and fun whenever possible.6. Accept that all or nothing will likely not work. There

will be many situations in which there can be anger and concern about a deficit (e.g., memory issues).

7. Hope is in the knowledge that there are new strategies to try and new options for solving a problem. Explore these as your life moves in a new direction—one small step at a time.

HOW TO HELP FAMILIES WHO HAVE EXPERIENCED LOSS

One of the most important things you can do for families who are grieving is to offer help. Following are some suggestions:

Spend time with the family. Offer your company. Help out around the house if you can. Fix something that is

Continued from page 3


broken. Do laundry or make a meal. Help the children with homework.

Don’t try to take away the grief. Let the family express powerful feelings. Trying to take away the grief or finding something positive in the situation is usually not helpful. Listen more and talk less.

Keep in touch. Grieving takes a long time. Offer support over the coming weeks and months, paying special attention to birthdays, holidays and anniversaries. ❚

References1. The Essential Guide to Grief and Grieving. Holland, Debra, M.S. Ph.D. New

York: Alpha Books, 2011. 2. http://www.tneel.uic.edu/tneel-ss/demo/grief/outline1.asp (Accessed

July 5, 2017)3. http://www.deathreference.com/Gi-Ho/Grief-and-Mourning-in-Cross-

Cultural-Perspective (Accessed July 5, 2017)4. http://www.lapublishing.com/blog/2011/brain-injury-blog-ambiguous-

loss/ (Accessed Oct. 30, 2017)5. After a Loved One Dies-How Children Grieve. Schonfeld, David, MD

& Quackenbush, Marcia, MS,MFT,CHES. New York: The New York Life Foundation, 2009.

About the author

Mariann Young, Ph.D., CBIST Director of Pediatric and Young Adult Services

Dr. Young is a licensed clinical psychologist and Director of Pediatric and Young Adult Services at Rainbow. She oversees all therapeutic programs and services provided to Rainbow’s pediatric and young adult population. She has more than 35 years of experience in individual and group psychotherapy, family therapy, staff training and supervision. In addition, she has significant experience in assessments, intervention and care of behaviorally challenged youths.

Dr. Young has administered the development and coordination of outpatient, day treatment and residential programming for children, adolescents and young adults with TBI. She presents locally, nationally and internationally on topics related to the treatment of young individuals and is a regular contributor to RainbowVisions, a publication for brain and spinal cord injury professionals, survivors and their families.

Dr. Young received a Bachelor of Arts from the University of Michigan in Ann Arbor, MI and a Master of Arts and a Ph.D. from Wayne State University in Detroit.

FAMILY SUPPORT GROUP Rainbow offers a Family Support Group on the first Wednesday of every month from 4-5 p.m. at Rainbow’s NeuroRehab Campus® in Farmington Hills, MI. For more information, send an email to [email protected] or call 734-482-1200 and speak with Dr. Mariann Young.

“I think perhaps I will always hold a candle for you—even until it burns my hand. And when the light has long since gone... I will be there in the darkness holding what remains, quite simply because I cannot let go.“

Ranata Suzuki, writer and poet


• SUCCESS STORY

STANDING TALL


When Will Quarles walks into a room, his presence demands attention. Everyone takes notice, given his impressive height of six feet seven inches.

However, you quickly recognize his reserved demeanor is one of calm and determination.

Will has made significant improvements, both physically and mentally, in the relatively short time that he has been treating at Rainbow. However, at the beginning of his rehabilitation, Will wasn’t always the motivated and confident man that he is now. This is Will’s success story.

On January 19, 2017, Will was involved in a motor vehicle accident in which his legs were trapped inside the crushed vehicle. He sustained severe fractures to both lower extremities as well as burns to 43 percent of his body.

He was rushed to Detroit Receiving Hospital where the majority of his skin that was still intact was used as grafts. He remained trached and in a coma until the end of March. At that time, Will was transferred to a rehabilitation facility where he began therapies daily for one month to regain enough strength to be able to transfer himself from his bed to his wheelchair and sit up for prolonged periods of time.

Will said of this time, “It felt good to be off machines, but my quality of life was still a guessing situation.”

On May 9, Will was admitted into Rainbow’s rehabilitation program. This was a very difficult transition for Will.

“I didn’t want to move to Rainbow. I never had to live like that before—in a house full of strangers, not being able to do anything myself. I didn’t care about meeting people, and I didn’t want to leave my room,” Will shared.

Initially, he was unable to leave the facility because both of his legs were fixed in full extension—Will was unable

to fit into a specialized lift van! Over the next few weeks, the main goal became: Bend his knees

through an intense stretching program. “My physical and occupational therapists came out to the house every

day to see me,” he said.Rainbow modified the lift van

to meet his needs which allowed Will to travel to the therapy center for his physical therapy, occupational therapy, recreational

therapy, speech-language pathology, counseling, and for meetings with the

dietitian. With getting out of the house more and a

beneficial surgery in the near future, Will knew that he should be looking on the positive side, but

something just wasn’t right. Not only was he having severe pain throughout his body with every movement, but just the thought of movement and pain would set him into a downward spiral of not getting out of bed, not interacting, not attending therapies, and just not moving.

Then the diagnosis came: an infection. “I was mad that it pushed everything back, and I couldn’t

get the surgery,” Will stated.

By Abby Dull, PT, DPT, CBIS Rainbow Rehabilitation Centers

Continued on page 8

STANDING TALLTEAMWORK and DETERMINATION

GOT WILL BACK ON TWO FEET

I’ve got a real team here at Rainbow, with coaches and

cheerleaders.


• SUCCESS STORY STANDING TALL

But what was seen as a setback turned into a blessing in disguise. Once Will was put on the proper antibiotics, he was no longer the fearful and apathetic man he had become.

“I began feeling better and working harder,” said Will.He started attending therapy every day. He was motivated to

push himself and to progress quickly. It wasn’t long until Will began standing and then walking, first with a walker, then with crutches, and now with a cane. He was able to have the surgery to bend his knees and can now transport into a standard vehicle, which means he is able to go out with friends and is quickly progressing to complete independence with all mobility. Will is now looking forward to moving home with his sister in the near future.

“My life was put on pause. I feel good, and I want to continue with my original life,” he said.

“I’ve got a real team here at Rainbow, with coaches and cheerleaders. My physical therapist woke me up every morning and got me to do stuff I didn’t want to do. She showed me ways to make life worth living by taking me from living on four wheels to living on two feet.”

Will continued, “My occupational therapist helped me get my strength back in my upper body and taught me the steps for basic everyday living skills. My nurse worked tirelessly to help me heal by changing my dressings and training staff how to best care for me.

“The house staff was my major support. My Rehabilitation Assistant Renisha gave me examples of situations that were similar to mine with positive outcomes and gave me pointers of things to do outside the doors of therapy. She gave me advice and extra support through my time of depression,” he said.

Will was admitted to Rainbow with an emotional and painful recovery ahead of him. Soon he will walk out with a positive experience and a new outlook on life:

“Your body can do whatever your mind tells it to do,” Will said with a smile. ❚


Rainbow Rehabilitation Centers’ Young Adult Program is specially designed to assist individuals

with traumatic brain or spinal cord injury in gaining meaningful employment, developing the skills

necessary to initiate and maintain long-term relationships and solidify their identity.

To register or for more information, call

800.968.6644

It’s about reaching your potential

About the authors

Abby Dull, PT, DPT, CBIS Physical Therapist

Abby is a physical therapist at Rainbow’s Oakland Treatment Center, serving the pediatric and young adult population. She earned her Doctorate of Physical Therapy from Grand Valley State University in Allendale, MI and has worked at Rainbow for the past three years. Abby is a specialist in Brain Injury and has received advanced training in pediatrics, sports therapy, interactive metronome, and neuro-developmental treatment.


Email

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nbowrehab.com for information or to schedule a tour.

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• CLINICAL NEWS


Most people who choose to work in health care do so to help people. But how to best help is not always easy to identify. Scattered

throughout this article are familiar dilemmas, some ethical and some legal, experienced by professionals working in brain injury rehabilitation. We experience distress when placed in complex situations where no clear answers are obvious.

In this article, we review dilemmas commonly seen in brain injury rehabilitation relating to areas such as unclear prognosis, restricted resources, major life role changes, and cognitive/behavioral disability that can place the client and others at risk. We are forced to clarify our own values and beliefs as professionals, as part of an interdisciplinary health care team, and part of a rehabilitation organization.

The first objective of this article is to describe ethical issues and their intersection with regulatory and legal compliance. This will lead to better discernment of those scenarios where there is a clear right or wrong or black or white answer, from those scenarios where the answer is gray.

The second objective is to outline the importance of training in understanding ethics, to establish policies, and outline codes of conduct in clinical, business, and marketing work, and to define courses of action when something falls into the gray area.

In addition to impacting the patient, ethical dilemmas can impact employees and the organization by presenting potential conflicts of interest as well as

engendering moral distress and raising legal issues. The importance of a method for ethics consultation and addressing employees’ feelings will be reviewed.

WHAT IS THE DEFINITION OF ETHICS? “The branch of philosophy that deals with morality.

Ethics is concerned with distinguishing between good and evil in the world, between right and wrong human actions…”1

WHAT DEFINES AN ETHICAL ISSUE?In the complex world of health care and

rehabilitation, ethical choices are not always a simple distinction between right and wrong. An ethical dilemma occurs when a professional is forced to choose between “the lesser of two evils.” The professional then must live with the fact that all such choices have consequences, positive, negative, or a combination of both.2

WHAT THE HEALTH PROFESSIONAL EXPERIENCES WHEN FACED WITH ETHICAL SITUATIONS

Clinicians in rehabilitation settings cited these top three ethical concern areas:

1. Pressures resulting from health care reimbursement changes

2. Conflicts among patients, physicians, team members, or families around goal setting

3. Difficulty assessing decision making capacity3

Continued on page 12

THE LESSER OF TWO EVILS

Ethical Challenges for CliniciansBy Lynn Brouwers, MS, CRC, CBIST

Rainbow Rehabilitation Centers


�e Front Page Test • Volume 1, Number 2 • SPECIAL EDITION

BEFORE YOU MAKE A DECISIONPICTURE IT SHOWING UP ON THE FRONT PAGE

• CLINICAL NEWS ETHICAL CHALLENGES

Moral distress was first defined in 1984 as a phenomena that occurs when nurses cannot carry out what they believe to be ethically appropriate actions because of institutional constraints. Subsequent studies showed that moral distress is experienced by other health care disciplines as well. Examples include “a lack of resources,” “inability to provide necessary treatments,” “prolonged aggressive treatment that the professional believes is unlikely to have a positive outcome,” and “giving up too soon.” The experience of moral distress may dissipate after the provocative situation has resolved, but the residual feelings afterwards, referred to as moral residue, can have a negative impact on an employee’s sense of well-being and morale, especially when there is no avenue to engage in an ethical discussion.

Moral distress may be the driving force that leads to a request for an ethics consultation. But, in addition, when engaging in a discussion of a clinical ethical issue, there may also be the need to support the team of professionals to discuss a particular case, listen to the employee’s input and concern, and to review the action plans. This is a recommended strategy to minimize moral residue experienced by professionals, since it is doubtful that moral distress can ever be eradicated from health care settings.⁴

ETHICAL DECISION-MAKING STRATEGIESPersons working in clinical settings will encounter

involvement in ethical situations, especially in the complex field of brain injury rehabilitation. Understanding that this is a component of professional/client interaction academic programs for health care providers include training in ethics. Clinicians are exposed to a variety of tools. Two simple considerations along with a more thorough model are listed:

THE FRONT PAGE TESTAmerican investor Warren Buffet proposes “The Front

Page of the Newspaper Test.” Buffett elaborates on this strategy:

Contemplating any business act, an employee should ask whether he/she would be willing to see it immediately described by an informed and critical reporter on the front page of the local paper, there to be read by his/her spouse, children, and friends.⁵This method doesn’t guarantee a resolution that is

correct but can act as an intuition pump—a way to question the public defensibility of an action or decision.⁶

THE GOLDEN RULEThe Ethics of Reciprocity—often called the Golden

Rule—states that all of us are to treat other people as we would wish other people to treat us. Almost all organized

religions, philosophical systems, and secular systems of morality include such an ethic. It is intended to have universal application.

However, studies in stroke rehabilitation show that there are problems when health professionals try to use this philosophy of “putting ourselves in the patient’s place.” Predictions by health professionals of what a disabled person would want related to life-sustaining therapies or how a person with a severe disability judge their quality of life were inaccurate of the patient’s wishes or beliefs.⁷



THE CELIBATE MODELA model used in therapy programs is CELIBATE.⁸

The word Celibate is an acronym to remember that Clinical Ethics and Legal Issues Bait All Therapists Equally.

The CELIBATE model guides a therapist through a series of 10 steps:

1. What is the problem?2. What are the facts of the situation?3. Who are the interested parties?4. What is the nature of their interest?5. Does it violate a professional code of ethics?6. Is there a legal issue?7. Do I need more information?8. Brainstorm possible action steps9. Analyze the action steps

10. Choose a course of action

STEPS TO MAKING AN ETHICAL DECISIONUNDERSTAND AND FOLLOW YOUR PROFESSIONAL CODE OF ETHICS

Health care professions have Codes of Ethics developed by leadership in their field. Regularly updated, codes of ethics assist professionals in making decisions. Often, continuing licensure or certification of the professional includes a requirement to receive continuing education training in ethics. See table on page 15 for links.

CREATE AN ETHICAL ENVIRONMENTCreating an ethical environment requires having

structure to help guide employees. The structure should include:

• A mission and values statement tells everyone what the organization intends to do and values that the organization lives by to uphold the mission

• Policies define action• Orientation and ongoing training

programs inform employees • Supervision provides daily

direction and support• Consultation and committees

provide an avenue for discussion, support, and direction when ethical issues arise

CARF International gives guidance in establishing an ethical environment through corporate responsibility standards for all rehabilitation providers.

Mohammed was 27 when he was involved in a high-speed crash resulting in a severe TBI. He and his wife had moved to the U.S. several years earlier from Saudi Arabia so he could study for an advanced degree. Deeply religious and culturally connected to their homeland, his wife spoke only Arabic and did not leave the home for environments where other men are present. The medical team was anxious to obtain consent for treatment but was unable to establish contact with the wife.

Should the doctors proceed with treatment?

John, after three years in a residential facility for treatment of a spinal cord and brain injury from a slip and fall, recently won his negligence lawsuit. Relieved that the family’s dire financial situation was now resolved and anxious to be home with his wife and children, he was elated. His wife (and legal guardian after the injury) was not willing to set a discharge date and expressed satisfaction with his existing living arrangement. John’s caregivers are aware that she is involved in another relationship.

What should John be told? Should she continue to be his guardian?

John and Ronny are living in the same small residential facility. Ronny has been impulsive and threatening to John, creating anxiety and concern for John’s family. In an effort to increase the family’s empathy, the caregiver relays details of Ronny’s background and injury. Ronny’s mother is livid.

Should the caregiver share another patient’s personal information for therapeutic purposes?


ETHICAL SCENARIOS



At minimum, each rehabilitation organization should develop an organizational ethical code of conduct that addresses laws and regulations with a “no-reprisal” approach to reporting.

For providers who receive federal funding, CARF has added corporate compliance standards covering exclusion of certain providers, designation of a corporate compliance officer, training of all personnel, and auditing.⁹

COMPLY WITH LAWS AND REGULATIONS To be in compliance, the rehabilitation organization

and all employees must follow all applicable laws and regulations. Certain elements of a compliance program are only required when a rehabilitation provider accepts payment from a federal health care program, such as Medicare, Medicaid or Tricare. Other elements are universally required.10 A compliance program is composed of regular training in the laws, regulations, organization’s policies, and code of conduct. Laws and regulations include:• The Stark Law generally dictates that if a certain type of

practice or medical facility has a financial relationship with a physician or family member of a physician, then that facility may not bill Medicare for “designated health services” that result from a referral from that physician. There are exceptions to the Stark Law for certain types of relationships. This prevents the physician from receiving money for referring patients, reducing incentives for the physician to act in his/her own interest rather than the patient’s best interest.

• The Anti-Kickback Statute provides that a person may not knowingly offer, pay, seek, or receive anything of value in return for, or to induce the referral of items or services. This means that a provider may not give or receive anything of value in exchange for referrals.

There are safe harbors that describe certain arrangements that will not be considered to violate the anti-kickback law.• Beneficiary Inducement. Federal law

generally prohibits providers of health care from providing an inducement (such

as a gift or a discount) to a Medicare or Medicaid beneficiary to influence the beneficiary’s choice of where

to receive health care. Examples can include providing a service for free or at a rate below fair market value, waiving deductibles or copayments, or giving away services.

Martin, at two years post TBI injury, still complained of discomfort because of increased spasticity. He tried a number of medications but could not tolerate the side effects. Friends suggested he try medical marijuana, for which he would qualify in his state. Martin’s caregivers were concerned that they would test positive if Martin smoked around them. They were also concerned that smoking would lead to other drug use and safety problems. They recommended a guardian.

To what extent do the employee’s or programs have the authority to restrict Martin’s personal choice about marijuana use? Does this choice rise to a level to trigger a competency assessment?

Jenny was a star athlete before her fall while working on a construction site. Physical therapy with the goal of walking is of utmost importance to her parents who are also her guardians. At 2 years post injury, her treatment team does not expect her to make substantial gains and wishes to discharge her with a home program to be carried out at a local gym. Her parents object and obtain a documented physician order to continue physical therapy.

Should the physician order be followed when the therapist is not in agreement? Should it be covered by Workers’ Compensation?

Jenny’s mother tells her case manager that her attorney has counseled her to demand therapy to continue to enhance the potential for a large legal award.

What actions should the case manager take?



• False Claims Act requires that a provider must submit a claim for payment by a federal health care program that is accurate, does not misrepresent the services or care provided, and that is supported by accurate and complete documentation.

• Various laws and regulations address fraud, waste, and abuse to reduce unnecessary costs to the provider and payer. Waste can result from improper management practices and controls. Abuse is excessive or improper use of resources. Fraud is obtaining something of value through intentional misrepresentation or hiding of facts.

• HIPAA laws safeguard the privacy and security of patients’ protected health information.

SAFEGUARD CLIENT’S RIGHTSClient rights include a Bills of Rights for licensed

treatment settings along with the rights of self-determination and the right to live as independently as possible.

Achieving client satisfaction, safeguarding client rights, in balance with assuring safety of the clients and others can become an area of ethical discussion. When severe cognitive/behavioral disability persists and the courts determine the need for an added decision maker, guardian or conservator, the issue becomes complex. The degree of mutual decision-making capability may be different for each person with cognitive disability. Clients do not always agree with the medical or placement decisions of their

guardian or conservator or the recommendations of their treatment providers.

All people have the right to request, receive, and refuse care. Lack of self-awareness secondary to frontal lobe injury complicates the ability of the individual to exercise this right of self-determination. Others, such as a guardian, conservator or patient advocate, may need to make decisions for the individual who is not competent to make decisions for himself. The treatment team may express what it deems to be in the best interest of the client but the decision rests with the client and the client may disagree. Ethical discussion may be indicated when there are differences of opinion, especially when there is risk to the client or others. It must be reinforced that people without cognitive disability also do not always make decisions in their best interest. Just consider the number of people who engage in risky behaviors like smoking or drinking and driving.

A provocative and classical ethical care dilemma is lifesaving when the prognosis for recovery to consciousness is guarded after severe brain injury. Ethics committees often struggle with “doing the right thing.”11

The Supreme Court Olmstead Decision determined that everyone has the right to live in the least restrictive environment,12 regardless of their degree of disability. This right can be difficult to actualize as the funding for long-term living settings and supports are subject to insurance

DISCIPLINE LINK TO CODE OF ETHICS

Rehabilitation Nursing http://www.rehabnurse.org/uploads/files/pdf/ARN_Statement_on_Ethics_Issues_Final.pdf

Case management https://ccmcertification.org/sites/default/files/docs/2017/code_of_professional_conduct.pdf

Psychology http://www.apa.org/ethics/code/index.aspx

Occupational Therapy https://ajot.aota.org/article.aspx?articleid=2442685

Physical Therapy http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Ethics/CodeofEthics.pdf

Speech-Language Pathology https://www.asha.org/Code-of-Ethics/

Rehabilitation Counseling https://www.crccertification.com/filebin/pdf/ethics/CodeOfEthics_01-01-2017.pdf

Recreation Therapy https://www.atra-online.com/welcome/about-atra/ethics

Certified Brain Injury Specialists http://www.biausa.org/acbis/content/AACBISCODEOFETHICS.pdf



or personal/financial limitations. The ethics of resource conservation can be in direct opposition.13 Consider the person who wants to receive care at home but relies on two paid caregivers for transfers.

Brain injury programs should have clearly defined Client Rights statements and regular training on client rights for all employees. Clients should have clear avenues to complain when they view that their rights have been violated.

ASSURE STRONG PROGRAMMING RELATED TO MANAGING AGITATED OR RISK BEHAVIORS

Post-acute brain injury programs typically serve some individuals who are at risk for agitated or unsafe behaviors. Behaviors such as verbal aggression, physical aggression, reduced initiation of activities of daily living (adynamia), social and sexual disinhibition, repetitive thoughts or actions (perseveration), and wandering can lead to risk of injury to the client, caregivers, other clients and their visitors and facilities. Constant vigilance to the potential for agitation/risk can lead to stress and moral dilemmas for caregivers.14

When programs specialize in neurobehavioral rehabilitation and have admission criteria that includes serving this higher-risk patient population, strong clinical leadership is required. The addition of Board Certified Behavioral Analysts to the brain injury programs is a relatively recent addition.

Organizational policies and training programs such as Crisis Prevention Institute15 training or Handle with Care training16 offer teams clear strategies for managing acute episodes. In these programs, attention is also given to the moral distress and moral residue that occurs when care givers must manage people during episodes of risk.

CREATE STRUCTURE TO PROMPTLY REVIEW ETHICAL CONCERNS

Ethics CommitteeApproximately two thirds of health care

organizations maintain an internal committee dedicated to compliance and ethics.17 There is often a close relationship

between the ethics/compliance leader and the legal advisors for the organization.The establishment of a standing

committee to assist employees in reviewing ethical concerns allows for the thorough review of concerning


Martin and Jenny meet in outpatient therapy and have made plans to date. Neither have guardians. Martin’s background as a prior perpetrator of assault and his lifestyle make the team worry that Jenny may be getting into more problems than she is aware of.

Should Martin’s background and lifestyle be shared with Jenny or her parents?

After 10 years of life with a debilitating TBI, Loren reported that she had little left in her life that made her happy. Confronted with breast cancer, for which her physician said she has a good prognosis with treatment, she rejects her physician’s recommendation. She requests that this not be discussed with her husband, children, or parents.

Does she have the right to make a decision that may shorten her life without discussing it with her family? Can her providers discuss this with her immediate family, given her lack of consent?

After 12 months of inpatient/residential rehabilitation, David’s insurance plan will no longer cover this form of treatment, and he is scheduled to be discharged home. Although David’s wife has been very supportive, he has been sexually inappropriate and verbally abusive to her in front of their children. The team is concerned about her well-being as well as that of the children. There are no other identifiable discharge options.

Should he be discharged home? Does the facility or the staff have an obligation to report his abuse to a government agency?



situations, using CELIBATE or another model. The committee may include representatives with clinical, legal/regulatory, and ethical backgrounds.

The committee can also benefit employees who encounter ethical dilemmas.

Ethics Consultation A trained medical ethicist can assist a professional or

organization in reviewing an ethical dilemma. The ethicist, typically not employed by the organization, may be able to see the dilemma in a more objective manner.18

Utilization Review Committee In 1985, when the concept of managed care was

changing our insurance institutions, Norman Daniels published Just Health Care, which articulated the first ethical principle for distributing health care resources. Daniels claimed that health care was important because it helped ensure “normal human functioning,” which in turn enhances people’s opportunities to pursue their life plans. In Daniel’s view, “a just health care system tries to make sure that individuals maintain normal functioning where possible.” He viewed this as a valuable way to ensure “equality of opportunity”. When resources are limited, he suggests:

1. That patients have the right to know the rationale for limits

2. The rationale for limits should be based on evidence

3. An appeal process should exist

4. That regulations should codify these rights13,19

Trauma such as severe brain injury challenges professionals in the area of resource utilization. Neurological plasticity, now acknowledged by most in the neurorehabilitation field, can lead to functional restoration when an injured person has access to intense treatment. Ongoing treatment can maximize their daily functioning and prevent complications. Access to such necessary treatment, however, may be limited depending on the type of insurance associated with the injury (e.g. motor vehicle accident, work injury, sports injury, or assault). Prior authorization and Independent Medical Evaluations allow third party payers to have input into treatment utilization.

Interdisciplinary teams, along with external stakeholders, may differ in their recommendations related to intensity and duration of treatment. A utilization review committee, chaired by experts in neurorehabilitation, is especially helpful in reviewing cases where underutilization or over utilization of resources is of concern.

APPLY ETHICS IN PRE-ADMISSIONS AND MARKETING AS WELL

It is challenging to establish a prognosis early in recovery from brain injury. Early in the development of the post-acute brain injury rehabilitation field, providers, enthused by the value of their services, may have unrealistically raised patient/family expectations with some subsequent disappointments.

CARF thus added a standard for programs seeking accreditation as a Brain Injury Specialty Program (BISP) that addresses the need to monitor the information that is given to patients and their families thereby assuring that people receive accurate pre-admission/marketing information about the program and what range of outcomes can be expected.

Ethical Marketing Practices were established by the Brain Injury Association of America (BIAA)20 and Ethical Principals and Business Practice Guidelines by the Michigan Brain Injury Provider Council (MBIPC).21 These guidelines reinforce laws supporting patient choice and fair competition between providers as well as ethical practice in marketing for referrals.

CONCLUSIONEthical dilemmas are common occurrences in brain

injury rehabilitation. Programs and professionals can prepare through leadership, preparation, training, and communication. Ethical clinical and business practice, if managed well, can positively impact patient outcomes, increase trust between the person served, family, teams, and external stakeholders, reduce involvement with the legal or regulatory parties, lower incidences of risk, and enhanced reputation within the healthcare community. ❚

MBIPC BUSINESS PRACTICE GUIDELINESThe provider adheres to and regularly addresses the

Equal Opportunity Employer Act (EOE), Americans with Disabilities Act (ADA), and the Health Insurance Portability and Accountability Act (HIPAA), as appropriate.

The provider maintains licensure, certification, education, and qualification appropriate for that profession. Examples include:

• CARF and / or The Joint Commission accreditation in the brain injury programs and services that are provided.

• Current and appropriate licensure for the programs and services provided through the local and/or state agency, as required (i.e., Adult Foster Care).



• The provider employs licensed, certified, qualified and competent staff members who demonstrate an awareness of, and conformance to, the ethical principles and practices promulgated by their individual professional governing bodies, groups, and/or associations.

• If not accredited or licensed, the provider demonstrates through its policies, procedures and day to day practices how it assures clients rights, safety, protection, advocacy and quality treatment and care.

The provider has developed and uses internal mechanisms for identifying and resolving ethical issues with persons served, their families, staff members, and other stakeholders. Examples include:

• Complaint Handling and/or Grievance policies• No Reprisal and/or Retaliation policies• Conflict of Interest policies• Code of Ethics statement; or identification of existing

code of ethics as determined by professional trade association, licensure, certification, etc.

The provider operates with a reasonable measure of transparency including but not limited to:**

• Accessible statement of the code of ethics to which the provider adheres.

• Accessible indicators of service efficacy. • Accessible evidence of licensures, certifications, and/or

qualifications.• Accessible statement of services available.

• The provider makes available and/or encourages education and training for its staff in ethical principles and practices.

• The provider actively participates in national, state and/or local organizations that increase knowledge and awareness of brain injury treatment and prevention.

• The provider seeks opportunities to collaborate and cooperate with other providers for the benefit of the persons they serve.

• Providers are proactive, positive, timely and direct in their efforts to resolve conflicts and ethical issues with each other.

• The provider produces indicators and evidence of service efficacy.***

• The provider actively participates in efforts relating to research, public policy, advocacy, education, prevention, and/or support of traumatic brain injury.

• The provider is expected to remain current and actively pursue improvements in service delivery, business practices, professional standing, quality, and accessibility.

** Transparency can be accomplished through reports to stakeholders including but not limited to postings in facility/office, on a website, and/or in marketing materials.

*** Service Efficacy demonstrates the ability to produce the desired results. Examples may include financial (i.e. cost-effectiveness), clinical outcomes, functional outcomes, number of persons served with TBI, stakeholder satisfaction, reduction of barriers, input from stakeholders, quality, community access, etc.


References1. http://www.dictionary.com/browse/ethics Accessed Nov. 20172. Kornblau, B. L., & Starling, S.P., (2000) Ethics in Rehabilitation; A Clinical

Perspective. Thorofare, NJ: Slack3. Kirschner K, Stocking C, Wagner L Foye S: , (2001) Ethical Issues

identified by rehabilitation clinicians; Archives of Physical Medicine and Rehabilitation

4. Jameton A, (1984) Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ Prentice Hall

5. http://sites.tufts.edu/amas/controls-compliance/ethical-business-conduct Accessed Nov. 2017

6. https://businessethicsblog.com/2010/12/08/business-ethics-and-the-New-York_Times-rule Accessed Nov. 2017

7. Kothari, S. & Kirschner, K., (2014) Pages 68-73, Abandoning the Golden Rule: The Problem with “Putting Ourselves in the Patient’s Place” Topics in Stroke Rehabilitation Volume 13, 2006 Issue 4 Ethical Issues in Stroke Rehabilitation

8. Jonsen, Seigler, Winslade, 1998 CELEBATE (Clinical Ethics and Legal Issues Bait All Therapists Equally)

9. Medical Rehabilitation Standards Manual (2017); Commission on Accreditation of Rehabilitation Facilities

10. https://www.cms.gov/regulations-and-Guidance/Regulations-and-guidance.html Accessed Nov. 2017

11. Kitzinger J, Kitzinger C, (2012) The “window of opportunity” for death after severe brain injury: family experiences. Sociology of Health and Illness

12. https://www.ada.gov/olmstead/olmstead_about.htm Accessed Nov. 2017

13. Daniels N & Sabin J, (2002) Setting Limits Fairly; Can We Learn to Share Medical Resources? Oxford University Press

14. Verharghe, S., Defloor, T., & Grypdonk, M.G., (2005) Stress and coping among families of patients with traumatic brain injury: a review of the literature. Journal of Clinical Nursing, 14, 1004-1012

15. https://www.crisisprevention.com/ Accessed Nov. 201716. http://handlewithcare.com/ Accessed Nov. 201717. https://www.beckershospitalreview.com/legal-regulatory-issues/10-

statistics-on-healthcare-compliance-and-ethics-programs.html Accessed Nov. 2017

18. Ozar D, The Value of an Ethics Consultation Lahey Clinic Medical Ethics 2003

19. Daniels N, Just Health Care Cambridge University Press 198520. BIAA Ethical Marketing Practices ; Ethics and Standards Committee Paula

Sundance, MD, Co-chair John Banja, PhD, Co-chair Adopted by the Brain Injury Association Board of Directors September 10, 1992 Revised June 11, 1993, March 14, 1997 © Copyright 1997

21. http://www.mbipc.org/about -us/ Accessed Nov. 2017



About the author

Lynn Brouwers, MS, CRC, CBIST Director of Program Development

Lynn Brouwers holds a Master of Science in Rehabilitation Services from the University of Wisconsin-Stout in Menomonie, WI. She has more than 35 years of leadership experience in medical rehabilitation with a specialty in programs for persons with traumatic brain injury and other neurologic injury. She has managed neurological rehabilitation programs in hospitals, skilled nursing facilities, residential and outpatient facilities, and in the home and community. She is a Certified Brain Injury Specialist Trainer and a surveyor for CARF International.

Further ReadingBernat JL1 Ethical issues in the treatment of severe brain injury: the impact of new technologies. Ann N Y Acad Sci. 2009 Mar;1157:117-30. doi: 10.1111/j.1749-6632.2008.04124.x.

Bergman, A. legal and ethical issues; The Essential Brain Injury Guide. 5th ed. Brain Injury Association of America 2016: 252-26

Caplan A; Ethical and Policy Issues in Rehabilitation Medicine, A Hastings Center Report 1987

Godwin E, Kreutzer J, Ethical Issues in Brain Injury Rehabilitation: Challenges and Practice Principals, Virginia Commonwealth University Medical Center. 2014 www.bifi.us

Malec J., Ethics in brain injury rehabilitation: existential choices among western cultural beliefs. Brain Injury, 1993; 7:383-400

McGrath J C, Ethical Practice in Brain Injury Rehabilitation 2007 Oxford University Press, Oxford

Tarvydas V, Shaw L, Interdisciplinary team member perceptions of ethical issues in traumatic brain injury rehabilitation. Neurorehabilitation 1996; 6:97-111

Willer B, Corrigan J, (1994) Whatever it takes: a model for community based services Brain Injury, 8(7), 647-659

RESIDENTIAL Rainbow Rehabilitation provides specialized residential and therapy services for individuals recovering from spinal cord injury. Residential services include beautiful wheelchair accessible homes with 24-hour supervision and assistance available. The living environment can be equipped with voice-activated environmental control systems. Our goal is to facilitate the independence of our clients and design individualized treatment plans to meet their specific needs. Services can range from assisted living level of care through intense rehabilitation services.

OUTPATIENT We have comprehensive outpatient therapies with special emphasis on recreation and community re-entry. Our facilities are equipped with all necessary equipment to meet the rehabilitation needs of the individual with a spinal cord injury and the family.

No finer promise of achievement

800.968.6644

SPINAL CORD INJURY PROGRAM


• SUCCESS STORY


Oh, to be eight years old again! The days of summer vacation are filled with swimming or running through sprinklers while waiting to hear the music

coming from the ice cream truck around the block. It was 1995 on a typical summer day in her hometown of Wyandotte, MI. Samantha Cable was your typical eight-year-old kid, riding her bicycle home from the park, when suddenly she was struck by a vehicle.

“Everything about my accident is a story,” she recalls. “I don’t remember anything, and every story that I hear conflicts with the others.”

Samantha was pronounced dead at the scene and was revived on the way to the hospital. She suffered a traumatic brain injury (TBI) and had severe internal brain bleeding. She was in a coma for six and a half weeks. When she awoke, she had lost the use of the entire left side of her body.

After Samantha was released from the hospital, she began intensive therapies. She slowly got back into her normal routines and, against her therapists suggestions of going to a special needs school, Samantha returned to Monroe Elementary School. She completed third grade that year and was very close to making the honor roll, despite the challenges she faced.

Samantha continued her education in Wyandotte through the Special Education Program until she graduated from Roosevelt High School in 2005. When I asked her to tell me her story, she told me that she appreciates all of the efforts that her mother had made throughout the years to keep her in public schools. Between cheer practice, as well as her therapies and

appointments, her mother was always there for her. She was her rock.

After graduating high school, Samantha attended community college to pursue a degree in Special Education. She felt, that because she had been in that position before, she could really help children understand what they can achieve.

“If I can do it, anyone can do it,” she said. Unfortunately, recurring seizures interfered with her

ability to pursue a career in Special Education.In and out of jobs for several years, Samantha was at

a loss about what to do next until her mother decided to call her former case manager to seek advice. The case manager suggested Rainbow Rehabilitation’s vocational program, and the Vocational Rehab Campus (VRC) seemed to be the perfect fit. Working at the VRC helped Samantha maintain a routine and build work skills as well as social skills, all while giving her more self-confidence. She took a liking to some of the boutique opportunities of the vocational program, learning skills such as weaving and knitting, and even designing and assembling jewelry such as earrings, necklaces, and bracelets.

Anybody who spends time on social media has seen the term “#throwbackthursday” on a photo’s caption—a fun excuse each Thursday to relive old memories and share photos from times long forgotten.

One such Thursday, Samantha posted a throwback photo of herself with some old classmates in pre-school. She had tagged one of her friends in the photo who then tagged three other friends which Samantha did not remember. One of the males who was tagged sent

HERE COMES THE

BrideBy Chelsea Lupone




• SUCCESS STORY HERE COMES THE BRIDE


Samantha a private message asking how she was doing. She didn’t know who this guy was, but soon realized that he was one of the people her friend tagged in the photo.

If you ever find yourself in Wyandotte for any reason, Frank’s Pizza is a must! It also happens to be where Samantha had her first date with the man that messaged her—her old pre-school classmate, Brian. The two had instant chemistry. This soon progressed to love and a proposal.

One evening in 2015, Brian asked Samantha to get dressed to go out. They got frozen yogurt and went for a walk around Bishop Park in Wyandotte. The two of them sat on a bench while eating their yogurt.

Brian began reminiscing about the good times that they have spent together thus far. “So, I was thinking…” he said, getting down on one knee. Nervously, he fell over

and fumbled for the ring, but quickly recovered and asked Samantha to marry him. “Yes! Of course!” she said.

She was so excited. Samantha said that the evening was such a blur. She recalls gloating to passersby that she was engaged, and later calling her mother. Brian had already asked Samantha’s parents for permission to marry their daughter.

When the time came to plan the wedding, they made a deal that she would pick a color and he would pick a color. She picked lime green, while he picked navy blue. Like any bride, Samantha was excited to plan her dream wedding. She knew that she wanted it to be different, and she wanted it to have splashes of her personality.

One day, while working at the VRC, she came up with the idea to create her own custom jewelry for her wedding. She turned to Char Sobieski-Greco, Rainbow’s Product


About the author

Chelsea Lupone Job Coach

Chelsea Lupone is a Job Coach at Rainbow Rehabilitation’s Vocational Rehab Campus in Ypsilanti, MI. She was a full time hair stylist looking for a career change when she began working at Rainbow as a Rehabilitation Assistant in November of 2014. With an empathetic heart, she quickly became passionate about working with individuals with traumatic brain injuries and in November of 2016, she began working as a Job Coach. She is looking forward to pursuing a degree in Occupational Therapy.

Manager with the Vocational Program, for help. When Char was asked about her part in Samantha’s wedding project, she simply replied, “Oh, I just ordered everything for her. Samantha designed all of it.”

“Samantha worked hard putting together prototypes of bracelets and necklaces for herself as well as her bridesmaids,” said Char. “The handmade jewelry would double as the jewelry worn at the wedding as well as a ‘thank you’ gift for being a part of her special day. She chose to use lime green, navy blue, and white pearls in the end. The jewelry was the special splash of her that she was looking for, made right here at Rainbow’s VRC.”

After having her dream wedding, she said that she would do it all over again in a heartbeat. To her, it was the perfect day, and it was everything that she wanted it to be. The newlyweds went on a two-week honeymoon camping all over the Upper Peninsula in a ten-person tent. Since then, they rescued a red heeler/pit bull mix puppy named Bo (after Bo Schembechler) who has undoubtedly become their “fur child.”

Samantha continues to grow within Rainbow’s Vocational Program. She recently began an enclave group working at Goodwill and has plans to transfer to the new Goodwill closer to her home. Samantha has come a long way since that summer day in 1995, and her treatment team is excited to see what the future holds for the new “Mrs. Glatz.” ❚


• TBI TOPICS

By Carolyn Scott, Ph.D., CBISTRainbow Rehabilitation Centers

In the last issue of Rainbow Vision’s magazine, Tom Constand, President and CEO of The Brain Injury Association of Michigan, wrote the article Good News,

Fake News, and New News on the Concussion Front. His article was a great summary of the current controversies in the field. This article serves as a follow-up to reassure those that have experienced their first concussion and are looking for guidance. We will discuss concussion or mild TBI (the terms are used interchangeably) briefly and what steps you might want to take after your concussion to help in your return to “normal” life.

A concussion is caused by biomechanical forces acting on the brain. There may or may not be a brief loss of consciousness as well as a period of post-traumatic

confusion. Common complaints after concussion include headache, nausea/vomiting, balance problems, dizziness, sensitivity to light and noise, difficulty with attention

and memory, and not “feeling right.” Independent observers may report that the individual had a brief loss of consciousness or appeared dazed, had difficulty recalling events prior to or after the concussion, and demonstrated changes in mood and behavior.

Fortunately, the vast majority of people recover fully from a

concussion or mild TBI (mTBI). In a critical review of 120 best-evidence studies, the World Health Organization’s Collaborating Centre Task Force on Mild Traumatic Brain Injury found that most symptoms resolve in the first one to two weeks and at most one to three months after being hurt.1 A meta-analysis of 39 studies examining cognitive

THE EXPECTATIONS FOR RECOVERY

The vast majority of people recover fully from a concussion or mild TBI (mTBI)


functioning after traumatic brain injury found similar recovery periods among individuals with mTBI.2 Those with mTBI demonstrated rapid recovery in the first weeks after their injury and returned to baseline cognitive status within one to three months.2

Resolution of symptoms may be influenced by a number of factors. For example, The Centers for Disease Control and Prevention states that history of previous concussion or brain injury, neurological or mental health disorders, learning difficulties, and/or family and social stressors may slow recovery from mTBI in children.3 Among adults, these same factors as well as substance misuse and litigation factors,1,4 may contribute to a poor recovery.

Evidence of a bleed on neuroimaging may also predict a longer recovery. Prolonged experiencing of symptoms related to concussion may also be explained by psychosocial models. For example, often after a negative event people may attribute all symptoms to that event and ignore any prior history of these same symptoms or

other factors that may be contributing to their appearance/maintanence.5 As many concussion symptoms are non-specific, over time, individuals with a history of mTBI may ascribe them to their concussion rather than more benign and typical experiences.

Fortunately, literature exists and is continuing to develop (particularly related to sports concussion) that helps individuals with a history of concussion recover more completely and quickly from their symptoms.

REST AND RETURNResting for the first 24-48 hours after a concussion may

be beneficial as it reduces brain energy demands and may reduce some post-concussion symptoms.6 However, prolonged rest and avoidance of activity may lead to difficulties itself. Deconditioning and time to focus on experienced symptoms are two examples of this. As such, a return to typical levels of functioning is important.



• TBI TOPICS CONCUSSION

Return to sport, work, or school demands can occur in a gradual manner. Typically, the recommendation is to take on reduced demands. If these can be achieved without exacerbating symptoms, then additional demands can be resumed.3,5

SLEEPDifficulty with sleep related to pain or distress can

complicate recovery. Initially after a concussion, naps to reduce fatigue and experienced symptoms may be beneficial. However, napping is not helpful if it interferes with night time sleep. With time, resumption of a sleep schedule is beneficial. Individuals should go to sleep and wake at the same time each day. It is useful to limit caffeine intake later in the day and choose quieter activities before bed. Creating a bedtime routine may also be useful.

PAINBehavioral pain management strategies can be taught by

a psychologist. Learning relaxation skills and mindfulness techniques have been found effective in addressing chronic pain. Additionally, the appropriate use of medications as prescribed by your physician, massage, and exercise may all help address pain.

MOOD ISSUESDepression and anxiety can affect cognition and sleep.

Therefore, addressing underlying mood issues can help reduce concussion symptoms. Additionally, depending on how you were injured, there may be ongoing distress related to that experience.

Working with a neuropsychologist or rehabilitation psychologist who has experience with mTBI can help tease apart the many issues that can be contributing to your current experience and help you to find symptom relief.

EXPECT RECOVERYIt can be frightening to have a big fall, accident, or

injury. These events may take you away from your normal routine, and change can be scary. It may also be frightening to hear the word “concussion” as reports in the media suggest a series of negative and long-term consequences. I encourage you to look back at our last magazine (Fall 2017, tinyurl.com/RainbowVisions) and remember that we need more research in the field of multiple concussions and their long-term effects. If you have ongoing concerns about your symptoms, speak


PEDIATRIC • ADOLESCENT • YOUNG ADULT • ADULTRainbow provides outpatient and day treatment services to clients living in their own homes who wish to participate in rehabilitation programs at one of our state-of-the-art treatment centers.

Our in-house staff of highly trained and experienced professionals provide individual and group therapies at all of our centers. Programs feature individualized care plans and treatment, regularly scheduled progress meetings and peer grouping to promote socialization and skill building.

Outpatient and Day Treatment Programs

No better place to healNo greater hope of recovery

No finer promise of achievement

800.968.6644


About the author

Carolyn A. Scott, Ph.D., CBIST Neuropsychologist

Dr. Scott earned her Ph.D. in Clinical Psychology at Wayne State University in Detroit MI. After an internship at the John D. Dingell VA Medical Center, she completed specialized post-doctoral training in neuropsychology and rehabilitation psychology at the Rehabilitation Institute of Michigan. While there, Dr. Scott worked with individuals who had experienced traumatic brain injuries, stroke, spinal cord injuries, and other neurological and orthopedic conditions on both an inpatient and outpatient basis. In addition to other responsibilities, Dr. Scott provides client and team consultation services and brief and expanded neuropsychological evaluations at Rainbow Rehabilitation Centers.

TherapeuticTake steps to boost

academic and social successEducation and structure for children pre-school age

through adolescence who have experienced a traumatic brain injury. Discover the program developed by pediatric rehabilitation specialists to be therapeutic, safe and fun.

Now offered in Oakland and Genesee Counties

800.968.6644

with your physician or someone knowledgeable about concussion.

The overwhelming research supports that you will recover fully from your concussion. Ease back into your routine and do this sooner rather than later. Remember that many of the symptoms experienced after concussion are normal (we all forget where we put our keys!) and not necessarily indicative of mTBI. Address symptoms that may lead to a prolonged recovery and rest easy in knowing that the data is on your side.

For additional materials that you can review at your leisure, the Michigan TBI Services and Prevention Council put together the guide “Recovery from Mild Traumatic Brain Injury/Concussion” that you can find here rainbowrehab.com/wp-content/uploads/2017/12/mTBI_Recovery_Guide_10.8.08.pdf. ❚

References1. Carroll LJ, Cassidy DJ, Peloso PM, et al. Prognosis for mild traumatic

brain injury: Results of the WHO Collaborating Centre Task Force on mild traumatic brain injury. J Rehabil Med. 2004; Suppl 43:84-105.

2. Schretlen DJ, Shapiro AM. A quantitative review of the effects of traumatic brain injury on cognitive functioning. Int Rev Psychiatry. 2003; 15(4):341-9.

3. Recovery from concussion. Centers for Disease Control and Prevention website. https://www.cdc.gov/headsup/basics/concussion_recovery.html. Updated on June 26, 2017. Accessed November 22, 2017.

4. McCrea MA. Functional outcome after mTBI. In: Mild Traumatic Brain Injury and Postconcussion Syndrome. New York, NY: 2008. 129-33.

5. Gunstad J, Suhr JA. “Expectation as etiology” versus “the good old days”: postconcussion syndrome symptoms reporting in athletes, headache sufferers, and depressed individuals. J Int Neuropsychol Soc. 2001; 7:323-33.

6. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport – the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838-47.


• MEDICAL CORNER

Skin is the largest organ of the body and plays an important role to ensure our health. The skin functions as a protective barrier from the outside

environment to prevent invasion from illness and germs. It serves to keep bodily fluids and nutrients inside the body, while assisting in controlling body temperature during cold and hot weather.

People in health care settings are particularly susceptible to health complications when skin integrity is compromised because they are exposed to a lot of other people during the recovery process. Caregivers, therapists, staff, patients and family all potentially share germs. The body is already stressed and busy healing bones and muscles, leaving the skin more vulnerable to infection.

The potential for skin problems increases when someone has sustained a brain or spinal cord injury, particularly when movement, sensation (feeling), or cognition (thinking) are altered.

Working with the entire treatment team provides the client with the expertise to intervene to heal and decrease complications of skin problems. Early intervention is the primary goal, and compliance with established skin care practices is essential to effectively treat and manage wounds if and when they do occur.

KEEPING SKIN HEALTHYWhen skin is healthy, it is intact and well lubricated with

natural oils and nourished with a good blood supply. There are several ways to maintain healthy skin through good hygiene.

Keep the skin clean and dry. After bathing, dry the skin well without rubbing too hard, as it may increase irritation. Do not bathe daily unless needed. Bathing every day washes away natural oils that lubricate the skin. Use a gentle lotion on a regular basis.

NUTRITIONMake sure to eat a well-balanced diet. Include protein,

vitamins and iron (note: using a blender or chopping food does not change the nutritional value of the food). Try to drink eight cups of water daily. Hydration is essential for healthy skin, but needs vary by individual.

INSPECTING SKINDaily skin inspection will provide early detection and

minimize the effects of any skin tissue damage. Inspect the entire body, focusing on the bony areas which are more susceptible to break down. When using new medical equipment and devices, check the skin frequently to monitor for irritation or damage. Pay special attention to areas that were previously injured and healed areas. Scar tissue breaks down more quickly than unharmed skin tissue.

Look for redness, blisters, rashes and any openings in the skin. If a reddened area is identified, use the back of the hand to feel for heat. The groin area is particularly susceptible to skin problems, particularly in men who wear external catheters.

A LOOK AT SKIN and WOUND CARE

AFTER BRAIN OR SPINAL CORD INJURYBy Kathleen Sobczak, BSN, RN, CBIS, WCC, CRRN




A LOOK AT SKIN and WOUND CARE

AFTER BRAIN OR SPINAL CORD INJURY

THE SKIN is comprised of several layers of tissue, some of which are filled with small blood vessels for the purposes of moving oxygen and nutrients to the skin. There are also specialized nerves that communicate with the brain to create the awareness of pain, heat, cold, touch, pressure and vibration. Other nerves assist to inform the conscious brain about its body parts, such as how legs and arms are positioned in space, and whether you are lying on an object.


COMMON SKIN CONDITIONSSpecific skin conditions that may arise include:• Pressure ulcers/pressure sores develop when someone

cannot re-position themselves and lie or sit in the same position for long periods of time.

• Cuts or burns, due to the decrease in ability to feel something sharp or hot.

• Cuts and bruising may occur as a result of bumping objects due to impulsive or quick movements.

• Skin irritation/rashes are often related to restlessness and constant rubbing of a body part against an object (such as rug burn).

• Skin breakdown due to bladder and/or bowel accidents causing irritation.

• Generalized unhealthy skin care practices due to cognition deficits and forgetfulness to perform daily care activities. Examples include insufficient bathing and washing.

RELIEVING PRESSUREWhen a patient is lying down,

avoid any pressure to the heels. Bony areas of skin, including heels, are especially susceptible to breakdown. It is common to position pillows beneath heels when in bed to help this. While not as common as heels, ankles and hips are also more susceptible to breakdown.

While lying on the side, do not rest one leg on top of the other. The top leg should be forward while the bottom leg is behind. Place a pillow between the knees to help relieve pressure.

Lying on the stomach can be done by lying completely on the stomach or at a tilt. If a patient has a feeding tube or tracheotomy, he or she should not be positioned on the stomach as this could cause complications.

When sitting in a wheelchair, pressure should be relieved every 30 minutes by having the client lean from one side to the other.

Pressure can also be relieved while sitting by having the client bend at the waist to lift the pressure off the bottom. This technique should only be used with someone assisting the client.

As the largest organ of the body, it is essential to take good care of the skin and maintain good hygiene.

Remember to inspect skin daily, practice good hygiene and maintain a balanced diet. Doing so helps to ensure that the skin functions properly as a protective barrier from illness and germs.

ASSESSING WOUNDSBy definition, a wound is a physical injury that results in

an opening or breaking of the skin. It is important to assess the type of wound, it’s cause, and its severity. The nurse should include any potential environmental influences, size, location and presence/absence of infection to develop the most appropriate treatment interventions. In addition, when deciding a comprehensive treatment plan, it is also

important to consider the patient’s vascular, nutritional and medical status.

TYPES OF WOUNDSThere are several types of wounds:

surgical, traumatic, and chronic wounds. Traumatic wounds, the most common type of wound, may be caused by mechanical, traumatic or thermal injury, including contusions, abrasions, punctures, fractures, burns, and frostbite.

The surgical wound, induced by surgery, is usually clean and easiest to heal.

By definition, chronic wounds may be more difficult to heal, and include pressure sores, diabetic ulcers, arterial ulcers and venous ulcers.

CATEGORIES AND STAGES OF WOUNDSTwo categories of wounds exist: partial and full

thickness. Partial thickness wounds involve the upper or top two layers of the skin. Full-thickness wounds involve a loss of deeper layers of skin and fat and disrupt the blood vessels and produce a scar when healed.

Wounds are further classified by stage. Stage I wounds are characterized by redness or discoloration, warmth, and swelling or hardness.

Stage II wounds partially penetrate the skin. Stage III wounds are characterized by the deeper full-

thickness wounds that do not extend past a tough white membrane (fascia) that separates the skin and fat layer from the deeper tissues.

• MEDICAL CORNER SKIN AND WOUND CARE


Early intervention is the primary goal,

and compliance with established skin care practices is essential

to effectively treat and manage wounds if and

when they do occur.


Stage IV wounds involve damage to muscle or bone and undermining of adjacent tissue.

Once the stage of a wound is classified, it will always remain classified as such. For example, a Stage IV wound cannot heal to become a Stage II or Stage III wound. Instead, it would be called a healing or healed Stage IV wound.

Two new wound categories, unstageable pressure injury and deep tissue pressure injury, have been added in recent years.

An unstageable pressure injury is an obscured full thickness skin and tissue loss. It is obscured by either slough or eschar which will need to be removed to determine staging. If eschar is stable, meaning it is dry, adherent, and intact without erythema or fluctuance, it should not be softened or removed.

Deep tissue pressure injury is the persistent non-blanchable deep red, maroon or purple discoloration of an area. This type of wound is caused by prolonged pressure or sheer forces.

FOUR PRINCIPLES OF BASIC WOUND CAREThe following are common principles that need to

be performed when caring for any type of wound:1. Debride (remove dead tissue) and cleanse2. Maintain a moist environment3. Prevent further injury4. Provide supportive dietary nutrients for healing

THE HEALING PROCESSThe wound healing process consists of an orderly progression of events that are designed to reestablish the integrity of the damaged tissue. Most wounds respond to the body’s innate ability to heal; however, some wounds do not heal easily usually due to the severity of the wounds themselves or because of the poor state of the individual’s health.

INFLAMMATORY PHASE: The inflammatory phase begins with the injury itself. Here you have bleeding, immediate narrowing of the blood vessels, clot formation, and release of various chemical substances into the wound that will begin the healing process. Specialized cells clear the wound of debris over the course of several days.

PROLIFERATIVE PHASE: A matrix or latticework of cells forms supporting new skin cells and blood vessels. It is the new small blood vessels that give a healing wound its pink or purple-red appearance. These new blood vessels will supply the rebuilding cells with oxygen and nutrients to sustain the growth of the new cells and support the production of proteins (primarily collagen). Collagen acts as the framework upon which the new tissues build and is the dominant substance in scar formation.

EPITHELIALIZATION: This is the process of laying down new skin or epithelial cells forming a protective barrier to protect against excessive water loss and bacteria. This layer begins to form within a few hours of the injury and is complete within 24-48 hours in a clean, sutured (stitched) wound. Open wounds may take seven to 10 days because the inflammatory process is prolonged, which contributes to scarring. Scarring occurs when the injury extends beyond the deep layer of the skin.

REMODELING PHASE: This begins after two to three weeks. The framework made of collagen makes the tissue stronger. Blood vessel density becomes less, and the wound begins to lose its pinkish color. Over the course of six months, the area increases in strength, eventually reaching 70 percent of the strength of uninjured skin.




WHEN A WOUND IS NOT HEALINGThere are signs when a wound is not healing properly. They include:

• Redness, excessive swelling, or tenderness in the wound area

• Throbbing pain and/or tenderness in the wound area or surrounding tissues

• Red streaks in the skin around the wound or moving away from the wound

• Pus or watery fluid beneath the skin or draining from the wound

• Tender or swollen lymph nodes or lumps in the armpit, groin, or neck

• Foul odor from the wound• Chills with or without fever

WOUND CARE OPTIONSThe primary objective in caring for a wound is to heal

the wound in the shortest time possible, with the least pain and discomfort and to minimize the potential of scarring. In order to accomplish this, early intervention is vital and encompasses various strategies for healing.

Once a wound is identified and causes have been established, a specialized treatment plan is developed with physicians, nurses and other members of the treatment team. Complicated wounds can incorporate alternative wound care treatments including:

• Debridement • Alleviation of weight-

bearing wounds• Compression therapy• Antibiotics• Hyperbaric oxygen

therapy• Whirlpool therapy• Ultrasound treatment

• Electrical stimulation• Magnetic therapy• Therapeutic touch• Bio-engineered

skin grafting • Edema management • Non-invasive vascular

assessment• Surgery

In addition to the techniques listed above, patients also benefit from certain whole body wound healing approaches, such as:

• Nutritional assessment and counseling • Diabetes education and blood sugar control• Patient and caregiver counseling • Physical and/or occupational therapy• Pain management

HYPERBARIC OXYGEN THERAPYApproximately 20 percent of wound care patients

become ideal candidates for hyperbaric oxygen therapy (HBOT), a medical treatment that uses pure oxygen to accelerate and enhance the body’s natural ability to heal.

During HBOT, the patient is placed in a pressurized chamber where he or she breathes 100 percent oxygen for an extended period of time. (The air we normally breathe contains only 19 to 21 percent oxygen.) As a result, high concentrations of oxygen are quickly delivered to the bloodstream. This hastens wound healing, helps fight infections, stimulates the growth of new blood vessels and improves circulation.

VACUUM-ASSISTED CLOSURE (V.A.C.®) THERAPY V.A.C.® Therapy promotes wound healing through

Negative Pressure Wound Therapy (NPWT) and is a therapeutic technique used to promote healing in acute or chronic wounds, fight infection and enhance healing of burns. A vacuum source is used to create sub-atmospheric pressure in the local wound environment. NPWT is thought to benefit wound healing by:

• Removing wound fluid and desiccated tissue • Decreasing the level of bacteria in the wound • Improving blood flow in the wound bed and

surrounding tissue • Promoting granulation tissue • Pulling the wound edges together and

stimulating cell growth

The dynamic interplay of these methods of action are thought to improve the state of the wound and promote healing.

BEST PRACTICE GUIDELINES FOR PRACTITIONERSAssess wound bed including edges and measure the wound(s) weekly and as needed between dressing changes.Document and coordinate treatment progress with the physician while looking for changes or developing signs of infection, advancing in stage, increased necrosis, non-adherence to treatment, and others.Initiate teaching patient/caregiver on wound care and/or foot care techniques.Stage pressure ulcer correctly at the time of admission, initiate preventive measures such as turning and positioning, skin care and use of lifting devices. Document ulcer characteristics: size, drainage, color and edges. It is important to document weekly.




The variety of available wound care products can be overwhelming. There are 13 different categories of products to care for wounds. No single skin or wound care product provides an optimum environment for skin health or healing all wounds. To save time, the most common wound care applications will be discussed here. The dressing should provide a moist healing environment and thermal insulation, and protect the wound from secondary infection. It should also remove drainage and debris from the wound.

ALGINATES: Alginates absorb exudates (drainage) and are not used if the wound is dry. Alginates, developed from brown seaweed, form a gel in the base of the wound at the time it touches the exudate. They can be used for longer periods of time when treating pressure ulcers. Their advantage is their ability to mold to the wound, absorb the exudate and keep the wound moist. Additionally, they are easy to use. These dressings tend to be expensive if used in large wounds. Some alginate examples are Sobrbsan, Curasorb and Medihoney. Alginates should be covered with a secondary dressing and should not be used with a Hydrogel (another type of product).

ANTIMICROBIALS: These are supplied from various product lines and include cleansers, creams, and ointments.

HYDROGELS: These dressings provide moisture to a dry wound bed. They are useful in softening eschar (scab) and cooling painful wounds. These work best in Stage III and IV wounds, abrasions, and burns. Their advantage is to provide hydration to non-viable tissue to promote debridement. Hydrogels facilitate wound repair and epithelization. They are not recommended for wounds with heavy exudate. Hydrogels will dehydrate if they are not covered and can cause maceration around the wound edges. Examples include: Solosite, DuoDerm Hydroactive Gel, NuGEl, Dermagran. These should be changed three times weekly but only if the wound remains wet. Protect the edges of these wounds with a secondary dressing.

COLLAGEN: Collagen products promote granulation. Collagen should be used for partial/full thickness and tunneling wounds with minimal to heavy exudate, skin grafts, donor sites and

granulating wounds. These absorb exudate, are easy to mold and remove and can be used in infected wounds. Collagen should not be used in third degree burns or eschar.

HYDROCOLLOIDS: Hydrocolloids are occlusive (closed) wafers that cover the wound, protecting it from oxygen, bacteria and fluids. They should be used on intact skin or newly healed wounds. Hydrocolloids should not be used with infected wounds or wounds with heavy exudate. They should be changed every three days but may be left in place up to seven days. Warm them before use to help them conform to the wound area. Do not use hydrocolloids on a diabetic wound. The most common example of a hydrocolloid is DuoDerm.

TRANSPARENT FILMS: Two transparent films are Tegaderm and Opsite which provide a moist environment and promote autolysis while protecting the wound from mechanical trauma and bacterial invasion. These dressings are used on non-infected wounds, blisters, eschar and necrotic (dead) tissue. Their biggest advantage is the ability to see the wound base while providing water and bacteria resistance. They cannot be used in a high moisture environment and their adhesive can cause stripping of the surrounding skin.

GAUZE DRESSINGS: Gauze is the most cost effective of all dressing choices as well as the most readily available. It may be impregnated with different substances; sodium chloride, iodine, petroleum, and bacteria-killing substances. One such product; Kerlix with PHMB is effective against Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococcus (VRE) and Acinetobacter Baumanni (MDRAB).

PRESCRIPTION PRODUCTS: Depending on the wound, prescription products may be necessary to promote healing. Products like Santyl, Accuzyme, Regranex, Xenaderm, Optase Gel and Granulex are a few examples.

• Santyl has the ability to digest collagen in necrotic tissue.

• Accuzyme does not harm viable tissue. • Regranex contains a platelet-derived growth

factor best used for diabetic foot ulcers.


WOUND CARE PRODUCTS



About the author

Kathleen Sobczak, BSN, RN, CBIS, WCC, CRRN Admissions Manager

In 1999, Kathleen started as the first nurse case manager to two of Rainbow’s medical houses. When Rainbow opened their NeuroRehab Campus® in 2007, Kathleen became the Nurse Case Manager. Her role there evolved and in 2011 she became the Nurse Manager. Throughout her Rainbow career, Kathleen has become Wound Care Certified, a Certified Brain Injury Specialist, a Certified Rehabilitation Registered Nurse, and an American Red Cross CPR instructor. Last year, Kathleen joined the Admissions team as an Admissions Manager at Rainbow’s Corporate Center in Livonia, MI.

• Xenaderm is made with Trypsin, Balsam Peru and caster oil, stimulates circulation and has mild anti-bacterial action.

• Optase Gel is the gel form of Xenaderm. • Granulex Spray stimulates capillary beds of chronic

wounds and uses a mild debriding agent.

ADDITIONAL PRODUCTS:• Abdominal dressing holders and binders• Tapes and closures• Wound pouches• Wound cleansers• Skin sealants• Composites• Specialty absorptive• Foam• Elastic bandages• Compression bandage systems

NUTRITIONAL SUPPLEMENTS:• Centella • Aloe Vera • Arginine • Glutamine • Zinc • Copper • Superoxide Dismutase • Vitamin C • Vitamin B5 • Vitamins B5 and C in combination • Bromelain • Curcumin


Assess need, order and instruct in the use of supportive surfaces, such as a special bed, mattress, chair cushion and heel support.Assess nutritional status and teach the importance of adequate nutrition e.g., protein intake; recommend nutritionist as needed.Use compression therapy for confirmed venous ulcer diagnosis as ordered by a physician and refers to vascular clinic if indicated.Evaluate and recommend other services such as physical therapy and follow up as services are ordered. ❚

Sources: Baranoski, Ayello. “Wound Care Essentials.” Lippincott: 2008.

Sussman, Bates-Jensen. “Wound Care.” Lippincott: 2007.

LIFE center, Rehabilitation Institute of Chicago, Nursing Practice Council.

New 2014 Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline.

Medical Rehabilitation Standards Manual (2017); Commission on Accreditation of Rehabilitation Facilities



CARF SKIN INTEGRITY AND WOUND CARE STANDARDS The Commission on Accreditation of Rehabilitation Facilities (CARF) is an internationally recognized accreditation authority promoting and advocating for quality rehabilitation services. Every year, standards change based on input from the medical rehabilitation field and its stakeholders (e.g., patients, physicians, payers). CARF introduced new Skin Integrity and Wound Care Standards in January 2017. Medical rehabilitation programs seeking accreditation must meet these standards and Brain Injury Specialty Programs are included.

THE SKIN INTEGRITY AND WOUND CARE STANDARDS ADDRESS THE FOLLOWING SEVEN AREAS:

1. Initial and ongoing assessments of each person served must document information about skin integrity, risks to skin integrity and results of previous interventions (if applicable).

2. When skin integrity risks are identified, the interdisciplinary team addresses the identified needs that are within the scope of the program.

3. When a wound is present, the interdisciplinary team will have written protocols for care within the scope of the program and for when a referral is needed to address needs that are outside the scope of the program. Written protocols address interventions, standards of practice, nutrition, equipment, supplies, education and follow up.

4. The program identifies and utilizes local, regional, provincial, national, or international resources to facilitate wound care.

5. The interdisciplinary team demonstrates efforts to optimize outcomes for the person served through exchange of information, education, collaboration and arrangement of follow-up care at the time of discharge.

6. The program provides documented competency based training to personnel providing skin integrity and wound management services.

7. Through initial and ongoing assessments, the program gathers information on each person served, conducts a written analysis, monitors trends, develops action plans for improvement and provides necessary education and training to maximize skin integrity and minimize the occurrence of wounds.

For a full description of the new standards, contact CARF.

Independence:

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800.306.6406 rehabtransportation.com

Where do you want to go and when do you want to get there?

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Experienced drivers are also specially trained in caring for individuals with special needs. So while you are enjoying your independence you’ll also have confidence that comes from knowing you are safe.

Rehab Transportation. We are…

your license to GO!


• 2018 CONFERENCES & EVENTS

FebruaryFebruary 13 CMSA Detroit Dinner Conference Burton Manor – Livonia, MI cmsadetroit.org

February 28-March 2 Brain Injury Business Practice College Doubletree by Hilton Austin – Austin, TX biausa.org/businesspracticecollege

MarchMarch 14-17 NABIS Legal Issues in Brain Injury Conference Hyatt Regency – Houston, TX nabis.org

AprilApril 10 CMSA Detroit Dinner Conference Burton Manor – Livonia, MI cmsadetroit.org

April 12-13 Michigan Guardianship Spring Conference Radisson Hotel – Lansing, MI michiganguardianship.org

April 19 Western Michigan Brain Injury Network Symposium Prince Conference Center – Grand Rapids, MI 888.492.9934

April 21 BIAMI Annual Legacy DInner Suburban Showplace Diamond Center –Novi, MI biami.org

April ICLE No-Fault Summit The Inn at St. Johns – Plymouth, MI icle.org/no-fault

MayMay 10-11 Comprehensive Brain Injury Rehabilitation Training Rainbow Rehabilitation Centers – Livonia, MI rainbowrehab.com

May 3-5 Williamsburg TBI Rehabilitation Conference Double Tree Hotel – Williamsburg, VA braininjurysvcs.org

May 17 DMC/RIM Spring Symposium Cobo Hall – Detroit, MI RIMrehab.org/symposium

JuneJune 19-23 CMSA National Conference & Expo McCormick Place Lakeside Center – Chicago cmsa.org

SeptemberSeptember 13-14 BIAMI Annual Fall Conference Lansing Center – Lansing, MI biami.org

OctoberOctober 18-20 ARN National Conference West Palm Beach, FL rehabnurse.org

October 19 CMSA Detroit Day Long Conference Burton Manor – Livonia, MI cmsadetroit.org


NOTICE: The conferences and events information listed on these pages is dated information. For the most up-to-date information on industry-related conferences and events, please visit: rainbowrehab.com.

Registration at 11:30 a.m. • Lunch at Noon Presentation 12:30–2 p.m.

Learn Over LunchMeeting times are noon – 1:30 p.m.

(Registration at 11:30 a.m.)Cost: MBIPC Member $25 / Non-member $60

For information call 810.229.5880

February 13, 2018Mild TBI/Concussion Assessment and Management

Location: Calvin College, Prince Conference Center, Grand Rapids, MI

April 10, 2018Resilience after TBI

Location: Schoolcraft College, Livonia, MI

May 8, 2018The Injured Pituitary Gland:

Hormone deficiencies that can influence medical status and the rehabilitation process

Location: Calvin College, Prince Conference Center, Grand Rapids, MI

June 12, 2018Guidelines of TBI

Location: Schoolcraft College, Livonia, MI

For updates on meetings, visit rainbowrehab.com or mbipc.org

RINC meetings are presented the third Friday of each month except July, August and December

For location of meeting or more information, please email [email protected]

UPCOMING MEETINGSLocation and Topics TBD

January 19, 2018

February 16, 2018

March 16, 2018

April 20, 2018

May 18, 2018

June 15, 2018

Rehabilitation Insurance Nurses Council


The Aliens Have Landed!Employees and clients at Rainbow’s Oakland Treatment Center in Farmington, MI transformed the facility into an extraordinary haunted house. This year’s theme was The Aliens Have Landed and they literally got carried away (pun intended) with the alien abduction theme. Families, clients and employees were greeted by an array of extra-terrestrials, little green men, ghouls and even one creature with an indeterminable amount of eyeballs. Everyone agreed that this one night event was truly out of this world!

The Halloween fun continued at other Rainbow treatment centers with delicious potluck lunch parties and creative costume challenges.

The Rainbow Activities Committee organized a company-wide holiday charity project to raise money for families at Mott Children’s Hospital and Children’s Hospital at DMC.

The fundraisers included two jeans weeks where employees could pay to wear jeans to work for the day or the entire week, a penny drive with collection jars at each center for donations of pocket change, and a very popular bake sale.

With everyone’s help, Rainbow was able to raise $3,221.23 and will be able to support many families facing medical hardship this holiday season.

Rainbow’s “adopted family” from Children’s Hospital DMC was a family of a single mom raising three young children. This year, the mother had to leave her job to be with her youngest son full time who was diagnosed with leukemia.

Our Rainbow family is grateful to be able to support this family and many others this holiday season!

Making spirits bright this holiday season


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This past September at the Brain Injury Association of Michigan’s (BIAMI) Fall Conference, several employees of Rainbow shared their expertise on a variety of topics.

Dr. Colin King, Rainbow’s Clinical Director of Adult Behavioral Services and Sandra Cross, Substance Misuse Counselor, presented Triple Diagnosis: Traumatic Brain Injury, Substance Misuse and Mental Illness. Dr. Carolyn Scott, Neuropsychologist, presented An Introduction to Brain Injury. Don Daniels, Vocational Manager and Laurie Cooke, Vocational Therapist presented Best Practices for Vocational Rehabilitation for Persons with TBI.

Rainbow prides itself on the extensive community education activities that we are a part of to help people better understand brain injury.

In the ongoing effort to share the mission of Rainbow with the public, Rainbow has created an Instagram account!

Instagram is a social networking platform that allows users to capture and share pictures, videos and messages for an audience in a creative and simplistic way. With over 700 million accounts worldwide, Instagram is the fastest growing social networking platform today.

The Rainbow Instagram account allows us to share pictures and stories of employees, programs and services, company events, and much more to show Rainbow’s culture, values and unwavering commitment to serving our clients.

To date, one of our most popular posts is a photo of Opus, Rainbow’s furriest therapist. You can read more about Opus in One Thousand Words at the back of this magazine.

You can follow our Instagram account at instagram.com/rainbow_rehab.

Let’s Connect! Rainbow is now on Instagram

Rainbow employees share expertise at BIAMI Conference

Rainbow helps save lives through blood driveThis past September, Rainbow hosted a successful blood drive through the Red Cross at the Livonia Corporate Center in Livonia, MI.

Between Rainbow employees, friends, families and others we had 32 people attend the drive. That resulted in a total collection of 25 units of blood! That blood will be used to save many lives.

One unit of blood is roughly equivalent to one pint. With just one pint of blood, up to three lives can be saved. A single car accident victim can require up to 100 pints of blood to sustain life.

Because of the success of our first blood drive, Rainbow plans to host many more drives, expanding to other treatment centers and locations. Thank you to all of the people who took time out of their day to give a little to save a life!

Dr. Colin King and Sandra Cross present at the BIAMI Fall Conference in Lansing, MI.


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Employees of the Season Spring 2017

Therapy StaffStephanie TaylorNatalie BrownAmanda MiuccioAngie McCallaKerri TorzewskiRandy GreenHollie WheelerBrit AustinSarah McGrathSandy Cross

Residential Program ManagersLaurie ShipleyDenise GenereauxCassandra RiceJulie TiberiaHeidi AldridgeCynthia Treharne

Professional/ Administrative StaffCrystal FoumiaNickole BurnhamJill Hamilton-KrawczykTanya LeeKim WaddellLillian Sparks

Maintenance TeamBob AdamsJason Rosentreter

Rehabilitation Assistants Arbor: Riad AlhakimBelleville: Vanesha SmithBrookside: Desmond Trinity, David MulcahyCrane: Lori BaileyElwell: Adriena MurryGarden City Apts: Michelle Rousselo, Jacquelin JordanHillside: Tamara Brooking, Karen ButchGTC: Taylor Peyton, Rachel Benish, Bradley Bessette, Kiara Brown, DeAisha Green, Alonzo JonesHome Care: Veronica KimbleMaple: Arlitia ShawNRC: Teijaina Reynolds, Catherine OrbanNRC Kitchen: Annie Harris

Rehab Techs: Sabrina Bentley, Jeff BrozoskiRIPROC: Cesar CruzShady Lanes: Gina Mathaw, Kristen ClevelandSouthbrook: Thomas PhilpottSpring Valley: Trina Nelson-SimpsonStoney Creek: Josephine Agbaeze, Kayci DrakeWestmoreland: Ashley BrownWhittaker: Lisa SteeleWoodsides: Maria Sakofske, Elizabeth Penley, Judy Hartman, Amanda Thornton, Amanda KleinschmidtYTC: Tanille ScottRehab Transportation: Joy Sharp

Pillars of Excellence AwardsThe new Rainbow Pillar of Excellence Awards were introduced at the 2017 Spring Employee of the Season luncheon. The Pillar of Finance and Pillar of People awards are given to recognize employees who have gone above and beyond to strengthen Rainbow in those areas of the company.

Tammy Zentz was awarded The Pillar of Finance award. Tammy joined Rainbow in 2005 and was quickly promoted. When she took over Rainbow U in 2016 her attention to overall customer satisfaction, as well as the financial impact of each decision was truly impressive. During this endeavor, Tammy continued to be a great resource helping out when needed in other areas at Rainbow and has improved the financial results of everything in which she has been involved.

The Pillar of People Award went to Cheryl Helber. Cheryl is a Human Resources Generalist with the HR team and also administers Rainbow’s employee benefit program. Cheryl has been with Rainbow since July 1996. In every interaction, whether with a long-time employee, a new hire, a former employee, or a manager, she shows care and compassion. Cheryl makes sure people feel like they are being heard and that they are being treated with dignity and respect.

Pillar of Excellence Award winners Tammy Zentz (left) and Cheryl Helber.


Employees of the Season Summer 2017

Clinical and Therapy StaffCereste Duprat-FabreChris HerdellDanielle ConklinMichelle James-MannKatie DumsaNancy Miller

Mi’chal HarrisStephanie TaylorTina KowalskiAngela AspergerAnn Moncrieff

Residential Program ManagersAbid TurpenChayla TurmanDebbie MayGabby ChristmasLaura Munro

Maintenance TeamBob Adams Ryan KovacsJason Rosentreter

Rehabilitation Assistants Belleville: Kimberly Nolasco, Octavia Hubert Brookside: David MulcahyCarpenter: C’Aira Pickering, Chalaha BegumCrane: Brett HutcheonElwell: Chelsea KellyFHTC: Tonia GoodwinGTC: Shatara Morrison, Teneya ParrishNRC: Emily Bolewitz, Jacqueline Brown, Latasha Watkins, Lenora Ealy, Lizzietta Battle, Salina BrownNRC Kitchen: Melenie Swayze, Sara Headlee, Sheila Reid, Dominic Parent, Latonya CrawfordPage: Brittnee FairchildRehab Techs: Sabrina Bentley

RIPCO: Claire Jenkins, Terrell BrazierShady Lanes: Aisha Mobley, Angel Hudson, Cecil Newlin, Jason Collins, Lynn VaughnSouthbrook: Lakeshia HollisSouthfield Center: Karen Hardy, Michelle RousseloStoney Creek: Julia CokerTextile: Juanita WashingtonWestmoreland: Stephanie PalmerWoodsides: Kasey Jodway, Kathryn Sobaszko

Rehab Transportation: Cassandra Blackburn

Professional/Administrative StaffAmy GelsoAmy HoltMatt SpiveyEd WryobeckReese RobinsonJae HouJoe WurmlingerChristen FoderaDarlene TownsendDel Bancroft

Jennifer GriewahnKelli BlackwoodKent JohnsonLisa KeenMarianne KnoxSheryl CarpenterTresa EllisTricia SeddonValerie Kolesar

Buzz Wilson and Leadership AwardsThe new Buzz Wilson Award and Rainbow Leadership Award were introduced at the Employee of the Season luncheon held on Dec. 6, 2017.

Residential Program Manager Laurie Shipley, was presented with the Buzz Wilson Award for being an employee who most embodies the mission and the values that Buzz Wilson established at Rainbow. Laurie was hired in July, 1983. She was literally here from day one and worked at Rainbow’s first residential home. She has overseen many different Rainbow homes and the care of many clients. More importantly, she has been a big part of the history of Rainbow. Laurie’s impact on clients and employees is remarkable. She is honest, compassionate, and above all else, is incredibly kind.

Mark Evans, Director of Clinical Administration, was presented with the Rainbow Leadership Award for his many years of outstanding work at Rainbow. He has been described as a model employee, a walking Rainbow history book, a bank of knowledge, and as someone who always does what is necessary to make sure the best interests of the clients, employees, and the organization are consistently served. Mark has helped lead Rainbow to success by serving as interim case manager, as well as providing interim leadership for the NeuroRehab Campus® and the Genesee Treatment Center. Award winners

Laurie Shipley (left) and Mark Evans.


New Professionals

Carol Holcomb, BAResidential Program ManagerCarol joins Rainbow as a residential program manager at the NeuroRehab Campus® in Farmington Hills, MI. She graduated from Marygrove College with a Bachelor of Arts. Carol has previously worked at a residential group home for foster care at-risk LGBTQ youth.

Alissa Humes, PT, DPT, NCS, CBISPhysical TherapistAlissa joins Rainbow as a Physical Therapist at the Genesee Treatment Center in Flint, MI. She earned a Bachelor of Science from the University of Michigan and her Doctor of Physical Therapy from Wayne State University. Her previous position at the University of Colorado was a senior PT in an acute care setting, as well as the lead PT on a pre-kidney transplant fraility project.

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Stephen Bardzilowski, MS, LPC, COTAMental Health ClinicianStephen joins Rainbow as a mental health clinician at our Genesee Treatment Center in Flint, MI. He earned a Master of Science from the University of Dayton in Dayton, OH and has provided over 25 years of mental health services in homes, and schools for children and families. Previously, he worked as a behavior therapist for the Flint/Beecher school clinics through Mott Children’s Health Center and has also worked with Autistic children.

Sabreen Ettaher, LMSWCase ManagerSabreen joins Rainbow as a case manager at the Oakland Treatment Center in Farmington, MI. Previously, she worked within a medical-legal partnership to improve access to health care for children and families in southeast Michigan. Sabreen earned her Master of Social Work from the University of Michigan.

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SPECIALIST

Earn 14 CCM and/or RN CEs

The Academy of Certified Brain Injury Specialists (ACBIS) offers a national certification program for experienced professionals working in the field of brain injury. ACBIS provides an opportunity to learn about brain injury, to demonstrate learning with a written examination, and to earn a nationally recognized credential.

As a service to our brain injury community, Rainbow is offering a free training course to prepare for the CBIS exam. Receive a discounted exam fee of $200 ($100 less than the individual application cost) when you take the exam with Rainbow’s group.

Nurses, case managers and other professionals who partner with Rainbow and have at least one year of experience working in the field of traumatic brain injury rehabilitation are invited to attend.

FREE CBIS TRAINING

COMPREHENSIVE BRAIN INJURY REHABILITATION TRAINING June 28-29, 2018 • 8:30 a.m.–4:30 p.m.PROCTORED EXAMS Scheduled at your convenience

LOCATION Rainbow Rehabilitation Centers17187 N. Laurel Park Dr., Suite. 160, Livonia, MI 48152

2018 SERIES DATES

THIS CLASS IS NOW

2 DAYSAND USES THE

NEW EBIG 5.0

Textbooks will be available for loan with a deposit or purchase

at a discounted price of $80

This activity has been approved by the Ohio Nurses Association. The Ohio Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission. (OBN-001-91). This program has been approved by the Commission for Case Manager Certification to provide board certified case managers with 14.0 clock hour(s). To verify successful completion of this program and 14.0 contact hours, you must sign in and sign out on-site each day, attend the entire presentation and complete an evaluation form after the program concludes. The planners and faculty have declared no conflict of interest. Please call Marianne Knox at 734.482.1200 for more information about contact hours.


One Thousand Words

Meet Rainbow’s furriest therapist, Opus! Clients at our NeuroRehab Campus® love playing fetch with Opus, feeding him treats and having him as a companion in the therapy area. It is proven that therapy dogs provide many benefits for people in clinical settings including lowering blood pressure, releasing endorphins that have calming effects, lessening depression symptoms and decreasing anxiety.

“Opus went through basic puppy training, starting when he was 8 weeks old. He then progressed to higher level classes learning how to adapt in different environments, adjusting to smells and sounds, learning fun tricks and making sure he enjoyed what he was doing” said Opus’s owner, Beth Albano, an occupational therapist at Rainbow. “When our trainer and I felt Opus was ready, he took his Animal-Assisted Therapy (AAT) certification test. Now every year we have to log a certain amount of hours of therapy work to keep up his certification.”

Locations [email protected]

GENESEE COUNTYGenesee Treatment Center5402 Gateway Centre Dr., Suite B, Flint, MI 48507T: 810.603.0040 F: 810.603.0044

OAKLAND COUNTY Farmington Hills Treatment Center 28511 Orchard Lake Rd., Suite A Farmington Hills, MI 48334T: 248.306.3170 F: 248.306.3197

NeuroRehab Campus®25911 Middlebelt Rd., Farmington Hills, MI 48336T: 248.471.9580 F: 248.471.9540

Oakland Treatment Center32715 Grand River Ave., Farmington, MI 48336T: 248.427.1310 F: 734.629.0453

Southfield Center25285 W. Eleven Mile Rd., Southfield, MI 48033

WASHTENAW COUNTY Ypsilanti Treatment Center5570 Whittaker Rd., Ypsilanti, MI 48197T: 734.482.1200 F: 734.482.5212

Vocational Rehab Campus5 West Forest Ave., Ypsilanti, MI 48197T: 734.390.2450 F: 734.217.8174

WAYNE COUNTY Rainbow Corporate Headquarters17187 N. Laurel Park Dr., Suite 160, Livonia, MI 48152T: 734.482.1200 F: 734.482.3202

THROUGHOUT MICHIGAN Home Care T: 800.968.6644

Home and Community-Based RehabilitationT: 810.603.0040 F: 810.603.0044

Rehab Transportation®A wholly owned subsidiary of Rainbow Rehabilitation Centersrehabtransportation.comT: 800.306.6406



SOUTHFIELD CENTER The new Southfield Center offers comprehensive rehabilitation services provided by

professionals who specialize in caring for individuals who have been injured.

The program focuses on treating medically stable individuals with:Traumatic brain injuries • Spinal cord injuries

Neurologic impairments • Orthopedic injuries • Co-morbidities

The Southfield Center is conveniently located in Southfield, MI, close to medical facilities, community activities and major freeways.

The fully-accessible facility boasts numerous amenities including: Beautifully appointed 14-bed living environment • Fully accessible private rooms and baths

Cable TV, phone and Internet availability in each bedroom • On-site dining servicesTherapy areas on-site • A large patio deck, perfect for outdoor activities

If you would like to tour Rainbow’s newest premier facility, give us a call at

800.968.6644

Presorted StandardU.S. Postage

PAIDPermit 991

Ypsilanti, MI17187 N. Laurel Park Drive, Suite 160Livonia, Michigan 48152

Tell us what you think about RainbowVisions! Do you have a story idea or comment? Email: [email protected]

INSIDE:

Concussion: The Expectations for Recovery

A therapeutic approach to day treatment programming for residential and outpatient clientsRainbow U is adding more options than ever in more places than ever! Our day treatment program is offered in Washtenaw, Oakland and Genesee Counties.

Contact a member of the admissions team today to learn more about this innovative and popular program!

800.968.6644

Day treatment designed around "U"

RAINBOWVISIONS - Brain Injury Rehabilitation Centers · address ethical questions and allow for...

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