Two Plans

While working on their recoveries at TLC, patients often tell staff about all of the activities they will engage in when they get “all better.”  They will tell staff about plans regarding work, vacations, school and family, clearly having spent significant time planning their future activities for when they are at the identical skill level as before their injury.  There is nothing inherently wrong with this planning but there is a important plan that is missing.  The majority of the patients at TLC have suffered severe traumatic brain injuries and have multiple areas of deficits.  Moreover, insurance companies and other funding sources will only fund rehabilitation for a limited amount of time.  Funding sources will not allow patients to stay indefinitely in therapy until they are “100%”.  After a number months (the exact number differing between funding sources and insurance plans), even if the patients are not finished with their recoveries, the sources will cut off funding and force discharges.  This is why it is important for patients and their families to make at least two plans; one plan on the basis of a full recovery and one plan on the basis of a less than full recovery.

The first plan, based on a full recovery, tends to be fairly straight-forward.  Patients generally want to return back to the majority, if not all, of their pre-injury daily activities.  The second plan, based on a less than full recovery, is more difficult.  This is an emotionally more difficult plan to make, as it forces the patients and families to confront the possibility that, at least temporarily, this journey will be longer and more complex than they originally hoped for.  It also means that patients and families will have to identify needs, resources and accommodations necessary to be successful in spite of having deficits.  This takes a considerable amount of time and effort.  But not making these plans can be very problematic, and in some cases, very dangerous.  For instance, if a patient has difficulties with balance and there is no plan on how to accommodate the balance issues at home, a patient may go home without necessary equipment such as grab bars and a shower chair to compensate for balance problems in the bathroom.  This would place the patient with balance deficits at a high risk for a fall, which could lead to a serious injury.  Similarly, if no plan is made for a patient who is confused and experiences disorientation, the patient may be left at home alone.  The confused and disoriented patient may leave home and become lost or wander through neighborhoods, which could place the patient in extreme personal danger.

The obvious question when making a plan for a less than full recovery is how does one plan for this when the patient is still actively recovering?  Do you guess than someone will be 25, 50 or 75% better?  Experience dictates that it is generally preferable to plan based on the worst-case scenario, which makes it more likely that all contingencies will be covered, no matter what the level of improvement that the person will experience.  So what is the worst-case scenario?  The worst-case scenario is what would happen if the patient did not continue to get any better than where they are at right at this moment.  After all, as long as the patient does not have some other health issue arise (e.g. seizures), then their overall recovery should not decline significantly from it’s present state so right at this moment is the worst off he or she should be.  So how does one talk about this thorny issue?  After introducing the topic and having the patient agree to discuss the topic, I usually say to the patient, “I can see that you are working hard and getting better through rehabilitation.  However, no one has a crystal ball to predict the future.  All I know for sure is today.  So, if let’s pretend for a moment that you did not get any better or maybe that the insurance company decided that you would have to discharge tomorrow, what would you need at home to be successful?  What activities could you take part in own your own, with help or perhaps cannot do at your current recovery level?  By doing this, we can be bettter prepared for even the hardest post-discharge situation.”  With this type of an introduction, patients more easily are able to discuss various potential future issues.

As eluded to earlier, this discussion can be very emotionally difficult for patients and family members.  It forces a focus on the “what if” and can be a very painful reality check on skills and needs.  It is important that everyone understands that this does not mean that it is assumed the patient is not going to get better or that rehabilitation is useless.  This planning is to raise the likelihood that the patient and family members are ready for all possibilities and lower the likelihood of unexpected dangers and headaches later in the recovery journey.  Overall, the goal is to have a smooth and successful transition to home after inpatient rehabilitation.

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