What’s in a Milieu? The Pros and Cons of Residential Rehabilitation

Volume 3, Issue 4
Winter 2002
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What’s in a Milieu? The Pros and Cons of Residential Rehabilitation
Suzanne S. Lentz, MCD, CCC-SLP, Teri Groves, LCSW, ACSW
Bancroft Rehabilitation Living Center, Covington, LA
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Suzanne S. Lentz, MCD, CCC-SLP Clinical Director Ms. Lentz is a Speech-Language Pathologist who received a Masters of Communication Disorders from Louisiana State University Medical Center. She has worked in the field of neurological rehabilitation for over twelve years and has served various populations including pediatrics, adults in home health, group homes, post-acute and long-term care settings. Currently, Ms. Lentz serves as the Clinical Director for Bancroft’s community based residential programs in Louisiana.

Ms. Lentz has been with Bancroft for over 5 years. Her specialties include community reintegration and cognitive remediation training. She is a certified ACCBIS instructor and examiner and oversees the transdisciplinary treatment team. She is responsible for program development, upholding CARF and licensing standards, and coordinating outcome and follow-up data.

Teri Groves, LCSW, ACSW Clinical Social Worker Ms. Groves is a Clinical Social Worker who received her degree from Tulane University School of Social Work. She has specialized in working all parts of the rehabilitation continuum including inpatient acute care, neurobehavioral care and community reentry. She has worked with families, adults, adolescents, children and infants in the field of brain injury and neurological rehabilitation and has provided services in Battle Creek, MI, Philadelphia, PA, Atlanta, GA and the greater New Orleans, LA area.

Ms. Groves is certified as an instructor ACCBIS and crisis intervention and has over thirteen years of experience including work as Program Director/Manager and clinical practitioner in community reentry services, residential/
inpatient programs, day programs, Early Intervention and group homes. Ms. Groves also serves as a consultant to local school districts and hospitals and has presented both regionally and nationally on brain injury education and family issues, grief/disability issues, staff training, program development and community reintegration topics.

ABSTRACT

Given the decreasingly available resources and funding for rehabilitation of acquired brain injury, hospitals are often forced to discharge their patients who continue to be disoriented and confused. Caregivers are often not prepared to deal with the 24-hour supervision and structure that is required to safeguard the survivor of ABI. Often without the support of a residential program, survivors of ABI and their families and funders find themselves relying on psychiatric and/or inpatient hospitalizations. The survivors of ABI are left to attempt to re-enter the community without the appropriate support, leaving them at risk for developing maladaptive behaviors and leaving the caregivers at risk for reinforcing these behaviors. These issues frequently contribute to poor coping skills, increased use of drugs or alcohol, and/or, re-injury. This can significantly increase the cost of care over the long term. This presentation will describe the best candidates for residential rehabilitation, the benefits of residential programs and characteristics of effective residential program.

A Therapeutic Continuum of Care

A continuum of care should be provided to respond to the changing needs of each person served. As an individual progresses, he or she can move into a more independent program within the facility’s continuum of services. When necessary, people can move to a more supportive program on a short or long term basis, if they develop behavioral and/or medical problems. Professional staff work together with family to ensure a smooth transition, including follow-along services.

A. Acute
B . Sub-Acute
C . Post-Acute
D. Community Re-Entry
E. 1. Residential
2. Outpatient
E. Day/Outpatient
F . Long Term Care

Identification of Candidates throughout the Continuum

Mild, moderate and severe patients with ABI
can be appropriate for residential treatment.
The severity of injury can be characterized
in the following manner.

WHO CAN BENEFIT

For individuals with MILD ABI

Candidate for Residential Treatment

• Failed attempt to return to pre-morbid lifestyle with or without outpatient services

• Questions regarding functional barriers (cognitive vs. malingering deficits, inability to self structure)

• Drug and alcohol abuse history

• Severe pain management issues

• Minimal or no family support

• History of psychiatric disturbances or post-morbid psychiatric admission

Does Not Require Residential Treatment
• Able to successfully return to pre-morbid lifestyle
• Strong family support
• Resolved cognitive and physical issues
• Adequate coping strategies

For individuals with MODERATE ABI

Candidate for Residential Treatment

• Failed attempt to return to pre-morbid lifestyle with or without outpatient services.

• Questions regarding functional barriers (cognitive vs. malingering deficits, inability to self structure)
• Drug and alcohol abuse history
• Severe pain management issues
• Minimal or no family support

• History of psychiatric disturbances or post-morbid psychiatric admission
• Requires 24-hour supervision
• Lack of local community ABI services to provide
treatment in the home and workplace
• Failed attempts to transition home
• Intimidates others with behaviors
• Post injury psychiatric admissions

Does Not Require Residential Treatment
• Able to successfully return to pre-morbid lifestyle
• Strong family support
• Resolved cognitive and physical issues
• Adequate coping strategies
• Family’s inability to support the program
• Caregiver consistently able to set limits
• Local services can be provided in the home
(discharge disposition) and work setting
• Is able to be left unsupervised for 8 hours

For individuals with SEVERE ABI

Candidate for Residential Treatment
• Failed attempt to return to pre-morbid lifestyle with or without outpatient services.

• Failed attempt to return to pre-morbid lifestyle with or without outpatient services.

• History of psychiatric disturbances or post-morbid psychiatric admission
• Requires 24-hour supervision
• Lack of local community ABI services to provide treatment in the home and workplace
• Failed attempts to transition home
• Controls others with behaviors
• Post injury psychiatric admissions
• Moderate to severe maladaptive behaviors
(i.e. physical aggression)

Does Not Require Residential Treatment
• Strong family support
• Family’s inability to support the program
• Caregiver consistently able to set limits
• Local services can be provided in the home
(discharge disposition) and work setting
• Is able to be left unsupervised for 8 hours

INTERVENTIONS
Residential Programming

Pros
• Consistent, routine 24 hour
• Increase generalization by rehearsing outside
the treatment sessions
• Help discern functional deficits vs. malingering
• Help discern psychiatric vs. cognitive/behavioral
• Transdisciplinary team
• Respite for families
• Medication management
• Therapeutic leaves of absence
• Pain management
• Provide learning experience
• Continuum of care-allows individuals to take supported risks
• Helps person regain individualization/separateness from family
• Environmental cues help decrease excess behaviors
• Social peer group serves as a community within a community
• Structured feedback in real-life situations in community to practice
• More advantageous in improving social skills
• Right to risk

Cons
• Separation from family
• Family training occurs, but not daily
• For a mild ABI, it is better to go directly home and try to resume lifestyle with
support
• It would be a disadvantage to be placed in a residential program if the program:
o is not freestanding
o does not have a transdisciplinary team
o does not have appropriate
staffing ratios

What to Look for in a Residential Milieu

A. Treatment philosophy includes an Interactive Role of Behavior Analysis and Cognitive Retraining
B. Staffing Ratios
C. Community access and participation
D. Staff training
E. Functional outcomes
F. Therapeutic programming-Individual and Group
G. Continuum of Care
H. Peer Group/Support
I. Structure and consistency (schedules, etc.)
J. Right to risk
K. Realistic length of stay

Peers in the Milieu

The importance of individual therapy within the rehabilitation process is evident; however, the importance of peer support and peer modeling is not always well understood.

• When one is involved in their rehabilitation process with peers, there are the added benefits of a peer group being built into the milieu, so they can support each other outside of therapy sessions as well as inside.

• Peers can offer vicarious learning experiences and modeling (both positive and negative) and feedback that is
generally better regarded, i.e., not from staff or authority figures.

• There are frequent opportunities throughout the days and evenings when staff can serve to intervene with peer interactions, such as reinforcing a wanted behavior or on the spot coaching in how to use an anger control strategy.

• Because residential programs offer transdisciplinary teams, more opportunities to practice and rehearse skills are available to help increase learning experiences.

• Since survivors are at such a high risk to lose their premorbid support, residential settings can help to bridge social and support systems and transition the survivor and family to their next phase of the rehabilitation process.

• Peers expose survivors and caregivers to other individuals dealing with similar loss issues which somewhat
normalizes the recovery process (“I am not alone, there are other people like me”). This plays a vital part in a person’s progress and ability to “move on” from the acute and post acute process.

Right to Risk

Regarding right to risk, residential programs offer an opportunity for survivors of ABI to re-enter the community with support and guidance from staff who can assist in fading supervision as skills improve. Persons served can have experiences that can become teachable moments, again allowing them to learn to use a particular compensatory strategy or perhaps, give them the opportunity to make some mistakes with a support system in place to assist them.

REFERENCES

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* Both the SRS and Mayo-Portland Adaptability Inventory (MPAI) are available for downloading at: http://tbims.org/combi/list.html.

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