Traumatic Brain Injury: Reducing Disparities From the ED Through Rehab

Désirée Lie, MD, MSEd


April 26, 2010

Case Response

Mr. Gomez is among a significant group of young persons at risk for poor integration back to his premorbid role from TBI, without adequate rehabilitation and attention to psychosocial and physical issues. TBI is a chronic condition arising from an acute presentation that requires longitudinal care. The primary care physician is in an ideal position to intervene to optimize his functional outcomes.

Because he was aware of his wife's visit to you to discuss his condition, it would be appropriate to call him from your office to persuade him to come in for an examination. Both he and his wife should understand that recovery from TBI is a long process requiring continued support and care. Mr. Gomez should be assured that he has received and will receive the most appropriate care for his TBI and that his concerns or anxieties about his treatment and his future can be addressed with medical visits. In addition, his wife's report suggests possible clinical depression, in which case he should have a full psychiatric evaluation. Marriage counseling may be indicated for the couple to adjust to his changing role in the family, help his wife adapt to his role, and to encourage his greater participation at home. He should be reassured that some problems, like his stubbornness and poor memory, may reflect residual injury that will improve.

An in-person assessment of his current communication skills, his health literacy, and his language preference is vital to optimize communication and treatment adherence. An interpreter or telephone interpretation should be provided if he is unable to communicate effectively in English.[28,29,30]

Communication with the rehabilitation services and access to his progress reports would help in coordination of his long-term care. A referral to a Spanish-speaking social worker may be indicated after your initial assessment and one may already be available through rehabilitation services, to encourage job retraining and access to disability income resources. If he is eligible for worker's compensation because of the injury occurring on the work site, the social worker may also be able to help if this has not yet been addressed.[31]. With worker's compensation he will be able to access additional community and rehabilitation center services beyond the period covered by his wife's health insurance.

He is likely to be even more vulnerable after discharge from rehabilitation services and his primary care records should be flagged for regular follow-up and continuity. Of note, having a practice patient registry for chronic diseases would greatly facilitate management of his multifaceted needs over time and is likely to prevent him from 'falling through the cracks,' optimizing long-term outcomes for this family.[27]


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