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August 2004


Cover Story: Independence Served Here

By C.A. Wolski

Kevin E. O'Keefe, PsyD

Located on the site of a former corporate hunting and fishing lodge, the Florida Institute for Neurologic Rehabilitation (FINR) in Wauchula, Fla, specializes in treating adults and children with traumatic brain injury. But its goal is more ambitious-to help its clients return to lives that are as independent as possible.

"The mission we have is to work with individuals who have head injuries that have affected their physical, cognitive, or emotional functioning, and provide them with the services necessary for them to reach their highest level of functional independence," says Kevin E. O'Keefe, PsyD, director of neuropsychology. "Everyone is going to have their own highest level. And that's the important thing to look at. Because head injury is a lot more individualized than we tend to credit, and people recover at different rates and in different ways, it's important to look at them as individuals and address their needs."

Aiding this individualized treatment is FINR's location-900 acres in rural central Florida. The institute has a summer camp feel with all the patients residing in cabins surrounded by thick vegetation and water. The setting is particularly helpful in treating those who have traumatic brain injuries. "Most people with a brain injury have some sort of frontal lobe damage, so the typical problems you see include impulsivity, poor decision making, poor problem solving," says Steve Johnston, OTR/L, senior occupational therapist. "Being in a setting that's fairly rural allows us more of an opportunity to deal with these difficult behaviors."

In addition to offering a safe location in which the patients can be treated, FINR's setting is helpful for physical therapy. "We do work outside," says Wendy Guzman, PT, senior physical therapist. "One of the nice things about the facility is that it's somewhat large and there are distances that people have to travel from one place to another, so it helps them work on endurance."

A UNIQUE EXPERIENCE
The for-profit FINR opened its doors in 1992 with 65 beds and 25 patients. Today it has 127 beds with a population of about 89 adults and 38 children, housed on separate areas of the institute grounds. In addition, it has a 15-bed skilled rehabilitation center and operates off-campus housing for the higher functioning patients.

Patients come from all over the country, attracted by its unique approach to rehab-the goal of maximum independence. The only criterion is that the patient has reasonable expectations for improvement. Though a for-profit organization, FINR will accept patients who cannot pay.

Because treatment is highly individualized, a recognition of the unique nature of every head injury, patients may have very different experiences during their stay, which begins with a 30-day evaluation period.

A 30-DAY START
Because of the complex nature of head injuries, the medical and rehab staff use the initial 30-day period at FINR to get to know the client and evaluate their needs and goals. "We want to really get to know that client," says Johnston. "We want to do an in-depth evaluation during that first 30 days. During that time, we'll get to know the client much better. We'll get to know their strengths and deficits. We'll evaluate every area that we think is pertinent to occupational therapy, which includes motor skills, perceptual skills, and cognition, and we'll also look at how these skills go together to allow this person to function." As part of this evaluation, which is used to formulate a treatment plan, Johnston measures the patient's vocational skills and makes recommendations to FINR's vocational department.

Though this period sets the stage for long-term treatment, O'Keefe says that unlike typical evaluative medical tests, those that are conducted at FINR can be difficult for one reason-they depend on the cooperation of the patient. "One of the downfalls of neurological psychological testing is you basically need to have the cooperation of the person that you're working with," he says. "You can't knock them out and do the testing, you can't force them to do the testing. It's very unlike a CT or MRI scan where you put them into the machine and they're passive to the process. With neuropsychology, it's an active process. They have to basically give their best effort. If they just flat out refuse to do anything, then we can't do any assessment. Or if they're too delirious on their medications to give an accurate response, we're not doing any good then." Patient stays at FINR can range from the 30-day evaluative period to over a year.

Every patient at FINR has some level of supervision, beginning with constant monitoring and progressing to visual or periodic supervision. The highest functioning patients just have to check in with staff at regular intervals. In addition to the cognitive and psychological deficits caused by their head injury, there may be other physical issues that patients may be dealing with as well. There are some patients who are confined to wheelchairs and their beds.

Though treatment is highly individualized, it has a single goal in mind, to get the patient as independent and productive as possible.

INDEPENDENCE TRAINING
The four-person occupational therapy staff works with the patients to develop vocational and life skills to get them to their highest functioning level. FINR's vocational program is all-day-long, 5-day-a-week rehab that has, depending on the patient's functional level, clients working in the institute's workshop, greenhouse, or canteen, or with FINR's maintenance crew. The highest functioning patients will be introduced to work in the nearby community with a volunteer job of some sort.

Though the goal is to, if possible, have the patient work at a full-time job in the community, it is recognized by the staff that they will probably never return to their profession-particularly if it was a highly technical or skilled job. "The sad thing about brain injury is that many, many people don't get to the point where they can enter competitive employment," says Johnston. "If they can, we set up job coaching and that kind of thing." Even those with low functional ability take part in the vocational program, being read to or mentally stimulated until they progress to a higher level and take part in the vocational program proper.

Occupational therapy is also a part of the children's experience at FINR. There is a school on site and O'Keefe and other staff members work with local school districts to develop an educational strategy for the children. Their therapy, which is guided by an occupational therapist assigned full-time to their grounds, is designed to be meaningful for them-such as soccer and other kid-related activities.

In addition to vocational training, Johnston and his staff of three occupational therapists also work on life skills. These skills, such as bathing or cooking, are reinforced by the staff who live with the patients in their residences.

Physical therapy is even more fundamental, emphasizing gross motor skills, says Guzman. In addition to using the natural setting of FINR, the therapy staff also has access to a pool and hippotherapy. "We see miracles everyday-small ones and big ones," says Guzman. "Anytime I see somebody who comes in and they're in a comatose state and they leave and they're walking around, to me that's a miracle."

Treatment, however, involves much more than just occupational and physical therapy. There are other psychological and social issues that sometimes need to be addressed as well.

BEYOND THERAPY
O'Keefe says that there are numerous psychological issues that sometimes need to be addressed with patients. Some patients are at FINR for behavior modification more than strict rehab. "A lot of times individuals who have head injuries continue to have difficulty with social integration and appropriate community skills, and need booster sessions or some more behaviorally modeled intervention in order to succeed in a standard community. And those generally are the individuals who were injured longer ago," he says. "They may have been psychiatrically hospitalized, they may have been held in jail overnight because they have not had the appropriate interventions to be able to monitor their own behaviors and be appropriate."

As part of the initial assessment, the medical staff reviews the patient's medications to make sure they are appropriate and to reduce them as much as possible. Many of the medications given to control behavior problems tend to cloud cognitive functions, says O'Keefe. This idea of care is to not only look at the person, but at the patient's entire family. Caregivers are trained to help care for the patient, and FINR staff does perform home evaluations to make sure they can care for their loved one if the patient returns home. However, there are times when a family cannot adequately take care of the patient once they leave FINR.

"In many cases, before a client goes home with the family, the family has to come and demonstrate that they can provide the type of care and supervision that the client needs," says Johnston. "If the family really can't do it, then we're not going to recommend that the client go home with that supervision. We're going to contact the insurance company and see if they need a home health care aide 24 hours a day. Do they need some other level of service? We're going to make the recommendation that is the best and the right thing for the client."

The success of the rehabilitation program at FINR is attributable to its holistic approach to treatment, says O'Keefe. "We try to address what the client's specific needs are, and sometimes those needs go beyond what happened because of the brain injury," he says. "We want to treat the whole person, so we don't just limit ourselves to what was necessarily a direct result of the head injury. There may have been other factors in their lives."

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

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