Cover Story: All in the Family

By C.A. Wolski

Arnie Fonseca works with a client at the Neuro Institute.

The Neuro Institute was created by a family that knows all too well how necessary immersion therapy can be.

Arnie Fonseca, Jr, had always dreamed about opening a rehab facility dedicated to the care of those with traumatic brain and spine injuries. It was a project he and his stepson, Brandon—who worked with him—spoke about often. But it was only a distant vision until August 20, 2001—when fate, or plain bad luck, changed Arnie’s and the entire Fonseca family’s lives and made his dream both a necessity and a reality.

On that night, 21-year-old Brandon—who had been drinking—was involved in a serious car accident that killed his best friend and left him with a serious head injury. It was in the days following the accident that the seeds for Fonseca’s Neuro Institute took shape. “At the time of his accident, [Brandon] was at a very well-known facility here in Arizona,” says Arnie. “After watching him go through rehab…I told myself ‘we can do so much better than this in Arizona,’ because it was atrocious. I saw absolutely no rehabilitation going on at all. It was an embarrassment to the therapeutic people who care.” And even when Brandon’s mother, Cari, was there cajoling the therapists to work with her injured son, that did not mean Brandon would get his therapy, she says. “I felt like I was getting short-changed, and my insurance company was paying out, and it was very bothersome to me,” she adds. Once Brandon’s condition stabilized, the Fonsecas had him transferred to the Centre for Neuro Skills in Bakersfield, Calif, where he received therapy for 7 months.

Born of necessity
While Brandon continued his recovery, Arnie had come to a decision. He was going to close his established rehab practice and make his dream a reality for both Brandon’s sake and the sake of other patients with traumatic brain and spine injuries in the Tempe, Ariz area. “I found a building, started planning it and drawing it up, getting loans,” he says. “It took about 7 months or so, and we opened our doors in December 2002.” Arnie’s announcement that he was going to open the Neuro Institute reached Cari when she was with Brandon in California. At first she was shocked, but realized it fit Arnie’s character. “Even before Brandon’s accident, we used to have confrontations at home about him being a workaholic,” says Cari. “But now that we have [the Neuro Institute], I understand the other end of it, because I see the gratification that he got from helping people. He wanted a place where Brandon could be taken care of for the rest of his life. And the only way to do that was to open something that we established and had our philosophy.” The 6,500-square-foot facility already has a waiting list of patients wanting to use its services. In addition to the three physical therapists, two occupational therapists, and a speech therapist it employs, the entire Fonseca family has taken roles in helping to run the practice, with Cari—who is the chief administrative officer—her three daughters, and even Cari’s 8-year-old granddaughter involved. All of the rehab staff have a background in neurology. The freestanding treatment center includes two individual treatment rooms, a speech therapy/occupational therapy room, a therapist’s office, a full-size kitchen for staff and patient use, and an open gym/rehab area outfitted with state-of-the-art equipment and weights.

Though the for-profit business is not making a lot of money, says Angela Seely, one of Cari’s daughters and the Neuro Institute’s administrative supervisor, the practice, with its emphasis on aggressive therapy, fills an important need. “The business model is set up where, from a therapist’s point of view and from Arnie’s point of view, we believe we need aggressive therapy to keep our patients up to speed with their bodies,” she says. “After [traumatic] accidents, patients’ bodies just tend to deplete themselves. Our clients are here much longer than if you just had knee surgery and you go in for an hour of therapy.” As the waiting list attests, the Institute has been getting the word out. Marketing efforts have included advertising, a gala grand opening, local press coverage, the creation of a Web site, and the oldest and most basic form of advertising—word of mouth. Seely says that she has even had inquiries from patients outside of the country. The almost instant popularity of the Neuro Institute has much to do with its aggressive and effective immersion therapy system.

Immersion Therapy
For many traumatic brain injury patients like Brandon, getting better is a full-time job, and the Neuro Institute’s emphasis on immersion therapy allows the staff to make rehab their vocation. The patients enrolled in the immersion program spend a minimum of 3 hours a day in therapy. Brandon spends 5 to 6 hours a day in a variety of therapeutic activities, with Arnie and the other therapists coaching and encouraging him. “With neurological rehabilitation, the best way to get a positive response is to immerse the patient in many, many hours of therapy a day, because that’s where you effect a neurological response, and it works,” says Arnie. “Brandon is getting better because he’s here 5 or 6 hours a day. What normally happens today is that therapists get somebody 1 hour three times a week and they get nothing done, so they tell the parent or caregiver ‘we’ve done all we can do, so move on.’” The immersion therapy is completely different than what would be offered in a typical rehab setting. “We’re doing everything different, because there’s no magic bullet, which means we’re using everything we can get our hands on. So we have FES equipment, we have regular weight equipment, we have unweighting systems, we have people pushing patients constantly for 2 or 3 hours a day,” says Arnie. “You don’t see that anywhere. You’re getting more therapy here than anywhere else. It’s just not done. If it works, we’re going to use it.”

During its brief tenure, the Neuro Institute has already had its share of miracles. These range from paraplegics who are regaining sensation below their mid-section, to patients who can walk and run again. These events have as much to do with sheer determination as they do with immersion therapy.

“There’s a lot of noise, and Arnie is the most passionate person here; he’s always yelling, encouraging patients.” says Cari. “He’s a coach—so you have to understand the mental frame of discipline that he has—and he implores like this for every one of his clients. We have a client whose mom was out for 6 weeks—she had to have major surgery. He has a spinal cord injury, and during those 6 weeks we went from getting him to crawl on the mat to standing and walking in a walker. When she came in, she didn’t know he was going to be up; he was actually walking and she started crying. And all of our therapists just stopped. Everything stopped. We get the joy of Brandon every day, but we get the joy of all of our other successes too. Our clients aren’t clients, they’re family.”

It is the Neuro Institute’s aggressive therapy program and the staff’s can-do attitude that make the practice stand out. “We do neuro with an attitude, which means we’re not just doing it, we’re trying to have an effect on people’s lives,” says Arnie. “When you walk into a place like this, if you don’t feel a buzz, and you don’t really feel deep down in your gut people wanting to help you, then you can leave. I would put our attitude up against anybody’s.”

All of the Neuro Institute’s 35 patients, the majority of whom are 17 to 25 years old and male, must be medically stable before they enroll in the immersion program. In many cases, family and caregivers are involved in the therapy as well. Sometimes, however, caregivers are purposely not involved. “In some of the cases we actually encourage the parents to leave…so that a patient can work harder, and [the parents] won’t ‘baby’ them,” says Seely.

Even if the business has yet to make money, there is no doubt in Arnie’s mind that the method works. After several initial setbacks, Brandon has shown marked improvement while in the immersion program.

Arnie believes immersion therapy could be more common if more therapists tried it. “Why aren’t we trying different things? Why aren’t we being innovative? Why aren’t we trying new equipment?” he asks. “The main reason is they don’t want to put the time into it. You can’t charge any more dollars to the insurance company if it’s neuro than if it’s orthopedic. So why should they put the time or energy into a neuro program? Why should they put the time and money into neuro rehab equipment that’s very, very expensive? We’ve done it because it’s personal.”

There is another reason immersion therapy is not the norm. Few insurers are willing to reimburse for the aggressive therapy program. Cari changed this for the Neuro Institute and the rest of Arizona, convincing the Arizona Blues to reimburse for long-term therapy.

Wrestling with the Blues
When Brandon was injured, he had a minimum Blue Cross medical policy. It was during his initial hospital stay that Cari quickly learned from her Blue Cross case worker that, in order for Brandon to get all the care he needed, she would have to become a medical advocate on his behalf. She eventually helped change the way rehab for neurologic and other injuries was reimbursed, benefiting patients, like Brandon, with long-term therapy needs.

In addition to the Arizona Blues, the Neuro Institute accepts Medicare and several other private insurance plans. In light of her experience fighting the Blues, Cari takes a hand in teaching patients how to be their own advocates. The results are not always as dramatic as hers, but several patients have had their own little victories.

“We had a client come in, and he worked all on his own to get the letters of medical necessity; he didn’t have any out of network stuff and he got the insurance company to cover six 4-hour visits for him—just so he could get started,” she says. “That insurance has been changed to another one we don’t take, so before he left yesterday I said, ‘Now remember, do exactly with this one what you did with the other one, you can do it, you’re a fighter.’ I teach everyone here to be advocates.”

Even with her victory over the Blues and Brandon’s progress in immersion therapy, there are still challenges that the Fonsecas have to overcome.

Ups and Downs
As Brandon has made strides in his stepfather’s immersion therapy program, it has come at a psychological price. Cari says that as his memories of his life before the accident have returned, living with his injuries can be more difficult. But even with the downs, Brandon has not given up, continues the immersion therapy, and is getting cognitively better—recently starting to do simple math, a big step forward that created a buzz at the institute.

For the Fonsecas, the Neuro Institute has healed more than Brandon’s body and mind—it has helped heal the family as well. “More than anybody else in the family, this place has helped me,” says Cari. “I think if I hadn’t been involved in this, if I hadn’t interacted, I wouldn’t have been able to see that there’s devastation everywhere and I would have just felt like this is a horrible thing that has happened to my family.

“I don’t look at it like that any more. I look at it as a blessing....These families who come in help me as much as we help them.”

C.A. Wolski is associate editor of Rehab Management.