The Neurobehavioural Model of Rehabilitation the BIRT Model

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The Neurobehavioural Model of Rehabilitationthe
BIRT Model

• Dr. Miles Rogish
• Clinical Neuropsychologist

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Overview

• An introduction to the services of the Brain
  Injury Rehabilitation Trust (BIRT).
• An overview of Neurobehavioural Rehabilitation,
  the BIRT treatment model.
• A brief description of the plans for Springburn
  Project, Glasgow.
• A case study typical of BIRT clients.

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• The Brain Injury Rehabilitation Trust (BIRT),
  part of the Disabilities Trust, is a leading
  European provider in specialist brain injury
  rehabilitation.
• BIRT offers a continuity of post acute care,
  ranging from low secure challenging behaviour
  rehabilitation, to support in the home or
  community based settings.
• The main treatment model of all BIRT services is
  the Neurobehavioural Model

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Basics of the Neurobehavioural Model

• What is Neurobehavioural Rehabilitation?
• A treatment model for individuals with an
  acquired neurological disability which
  incorporates, neuropsychological, cognitive and
  behavioural theories.

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• The Neurobehavioural Model focuses on acquiring
• everyday life skills
• social behaviours which are adaptive and lead to
  social integration
• The primary focus is maximising social
  participation after a neurological impairment
  using learning procedures with less emphasis on
  direct interventions to decrease neurological
  disability.

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The Neurobehavioural Model (Continued)

• The Neurobehavioural Model is typically NOT
  Hospital Based.
• It is community based Social Rehabilitation.

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Social Rehabilitation

• Post Acute
• Community Based
• Behaviourally Focused
• Emphasizes skill acquisition
• Inter-disciplinary
• Demands a structured environment
• Based on a continuum of care

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Aims of Community-Based Rehabilitation

• Community Reintegration
• Minimize social handicap
• Maximise social independence
• Promote adaptive behaviour
• Acquisition of socially relevant skills
• Establish social over-learned skills

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Key Aspects of Neurobehavioural Rehabilitation

• Assessment and Treatment in a neurobehavioural
  model requires evidenced based decision making.
• This is based on key components of learning
  theory as well as behavioural management.
• The use of psychotropic medications is often
  essential in the rehabilitative treatment
  process.
• In order to understand and evaluate the
  effectiveness of behavioural and pharmacological
  treatment it is important we quantify behaviours.

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Recording behaviour

• What do we record?
• The frequency of challenging/inappropriate
  behaviours
• The nature of these behaviours
• Possible causes or triggers
• Consequences and outcomes

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ABC chart example

• The use of Antecedent Behaviour Consequence (ABC)
  charts allow for detailed analysis of behaviours

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Example of recorded behaviour

• Careful analysis of medications and behavioural
  data allow for evidence based decision making

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Participation Graph

• Recording of participation allows us to look at
  the clients ability to engage and participation
  in the rehabilitative process.
• Monitoring of other behavioural date, such as
  time spent out of room, allows measurement of
  observable behaviour that indicates positive
  change.

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CARF Accreditation

• CARF is the Commission on Accreditation of
  Rehabilitation Facilities
• Founded in 1966, CARF is an independent
  non-profit accreditor of human service providers.
  
• Mission To promote the quality, value, and
  optimal outcomes of services through a
  consultative accreditation process that centres
  on enhancing the lives of the persons served.

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• Surveyors are peers in the field employed by
  organizations that have CARF accreditation and
  who have expertise in the types of programs and
  services accredited by the CARF family of
  organizations.
• Standards are developed by the CARF International
  Advisory Council advisory committees and
  regional, national, and international focus
  groups each year to review and revise standards
  and develop standards for new accreditation
  opportunities. The standards development process
  provides opportunities for persons served,
  organizations, surveyors, national professional
  groups, advocacy groups, third-party purchasers,
  and other stakeholders to be actively involved in
  developing standards.
• Standards are not quantitative, but client
  focused and qualitative in nature.

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The Outcome of a CARF Survey

• Accreditation by a CARF survey means that a
  service provides EVIDENCED BASED support of
  meeting client centred standards.

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Evidenced Based Outcomes
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Seamless Service

• BIRT emphasizes a Continuum of Care within its
  services
• Acute medical Care
• Hospital rehabilitation
• Behaviour disorder units
• Community rehabilitation units
• Slow-stream and residential units
• Supported housing (outreach) service
• Support at home
• Work placement programmes

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Specialist care within community

• Care packages are individualized to the specific
  client and family needs.
• We will work closely with social services to
  develop packages using local resources and BIRT
  resources to maximize quality of life for the
  service user and family system.

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BIRT Services throughout the UK
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Springburn Project

• Set to open Autumn 2009
• 25 bedded unit, 5 bedded behaviourally acute wing
  and a 20 bed community rehabilitation unit
  (including a self contained flat).
• Interested in developing a uniquely Scottish
  service with a neurobehavioural treatment model.
• Wanting to develop links to local services
  including day care services (Gorbals), shared
  posts with local NHS providers, and work
  colaboratively with the NHS (service level
  agreements/partnerships)

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Springburn Design
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Progress as of September 2008
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Case Study
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Traumatic Brain Injury and History

• Date of birth 6/12/66
• Date of admission 28/10/02
• Sustained a traumatic brain injury in 1985 at the
  age of 18 secondary to TBI
• Suffered a fractured skull and developed a
  frontal lobe syndrome
• Difficulties with behavioural control and alcohol
  abuse

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• Continued alcohol abuse
• Formal rehabilitation has been unsuccessful
• Steve is very close to his family
• Long history of difficulties with the law and was
  transferred to York House from prison on
  probation

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Presentation

• Fully alert and orientated
• Mostly settled and sociable
• Short episodes of agitated behaviour, which have
  led to verbal and physical aggression
• Generally interacts well with staff and clients
• Spends time in the communal areas of the unit

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• When more agitated is unable to accept the value
  of rehabilitation
• Expresses wish to leave the unit and return to
  his previous lifestyle although he has not
  attempted to do this

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Overall deficits

• Physical
• Epilepsy
• Retinitis pigmentosa
• Diabetes
• Impaired muscle strength in the right upper and
  lower limbs
• Reduced high level balance

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• Behavioural
• Fluctuating levels of irritability leading to
  verbal and physical aggression
• Poor impulse control
• Resistance to the rehab programme
• Easily bored

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• Cognitive
• Slowed information processing
• Limited learning capacity
• Reduced organisation and planning capacity
• Poor recent memory function

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Overall strengths

• Able to focus attention reasonably well
• Follow simple commands
• No primary deficits in language or spatial
  abilities and has
• Insight into his cognitive problems particularly
  poor memory

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Deficits relating to occupational performance and
independence
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Morning Routines, Bedroom and Bathroom Clean

• Able to carry out independently

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Kitchen Activities

• Difficulties in planning what he wanted to
  purchase and cook
• Difficulties organising and sequencing task
  appropriately
• Unable to read small print on packaging and
  temperature on cooker
• Difficulties in dividing attention between two
  tasks
• Perseveration over washing dishes during activity

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Community Skills

• Requires extra verbal direction in poor lighting
• Unable to read small print on products
• Unable to distinguish receipts etc. from
  money and bus tickets
• Did not demonstrate effective organisational
  skills when placing small items around his person

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• Limited forward planning
• Potential for becoming over-animated. This
  results in increase in volume and possibly makes
  him the centre of attention
• Jovial sense of humour can lead to inappropriate
  social comments and behaviour
• Does not necessarily pick up on verbal cues that
  his interactions may be bordering on socially
  inappropriate

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Time Management

• No awareness of his programme or cigarette times.
  Requires prompting to adhere to these
• Becomes agitated when is not able to follow his
  own very unstructured schedule due to external
  constraints
• Limited concern for time constraints especially
  when getting up in the morning

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• Limited forward planning before till
  transactions, catching buses etc. (i.e. preparing
  his money in advance.)

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Safety concerns

• Potential to lose money, and other personal items
• May become lost and disorientated in complex or
  unfamiliar environments
• Unable to maintain his personal safety in
  partially lighted/dark environments without
  support

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• Dependent on fatigue or sugar levels, may have
  difficulty in maintaining his balance
• May not pay adequate attention to his diabetic
  status
• May become vulnerable in community when social
  behaviour borders on inappropriate

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Recommendations for Rehabilitation

• Occupational therapy to liase with the Blind
  Society to identify further strategies and
  adaptations that will be of benefit to Steve as
  his eyesight continues to deteriorate
• To work with Steve in identifying meals that he
  could learn to cook for himself independently

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• Introduce an alarm clock that can be used by
  Steve to ensure he wakes in the morning and is
  ready for programmed sessions
• Introduce a diary for Steve to remember what he
  has done throughout the day and to record what
  meals he has ordered

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Goals for occupational therapy rehabilitation

• Plan, purchase and cook three self cater meals
  per week with minimal verbal prompts
• Catch the bus into town independently
• Utilise a wallet effectively, consistently
  placing money, receipts and bus tickets in
  separate compartments
• Utilise diary effectively

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Psychological Interventions

• CBT/anger management therapy
• Use of cue cards and environmental cues to engage
  in adaptive behaviours
• Incentive based programs to encourage pro-social
  behaviours
• Social skills practice in group, one on one, and
  community settings.

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Weekly programme

• MONDAY Plan self cater Shop for self
  cater Self cater Quaker
  Pantry Letter writing Diary

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• TUESDAY Plan community access Group
  Psychology Fitness Diary

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• WEDNESDAY Swimming(double session) Bus
  practice Self cater Diary

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• THURSDAY Anger management Self
  cater Quaker Pantry Fitness Diary
  

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• FRIDAY Community access (double
  session) Quaker Pantry Bathroom
  clean Diary

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Course of Treatment

• Admitted to York House October 2002, 17 years
  post injury.
• Discharged to TEM House June 2004, after
  approximately a year and a half at York House.
• Continued community based treatment at TEM house
  for another year and a half, approximately.
• Discharged to supported community setting, block
  of flats. Still there and living with minimal
  support and no significant behavioural issues.

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• Questions and comments?
• www.birt.co.uk