Addressing brain injury in health care for the homeless settings: A pilot model for provider training

Abstract

BACKGROUND:

Brain injury has been recently understood to be a common occurrence among adults experiencing homelessness, resulting in the need for modifications to clinical practice in agencies serving this population.

OBJECTIVE:

A health care agency for adults experiencing homelessness initiated a pilot training for mental health providers to address the issues of brain injury.

METHODS:

Providers attended eight training sessions which focused on: screening for a history of brain injury, treatment planning, and specific strategies to implement with individuals with a history of brain injury. Strategies taught were based on current literature and therapeutic methods, adapted specifically for the clinic’s population of adults experiencing homelessness.

RESULTS:

Screening for a history of brain injury at the clinic indicated a high prevalence of a history of brain injury that was previously unidentified, indicating need for provider training. Providers reported increased ability to screen for and address the needs of individuals with brain injury within their clinical setting. Providers reported benefit from sessions tailored to address various cognitive functions which incorporated evidence-based practice and familiar therapeutic methods.

CONCLUSION:

Providers who engage individuals experiencing homelessness benefit from structured training in order to increase ability to screen for and modify interventions for a history of brain injury to better address their clients’ needs.

Keywords

Cognition mental health Ohio State University TBI Identification method

1 Introduction

Health care agencies specifically for those experiencing homelessness have developed models of care in order to accommodate for and address the unique needs of this population [1]. Individuals who have experienced homelessness, and especially who have been chronically homeless, have an increased risk of mental health, chronic health, and substance use conditions, as well as an increased incidence of brain injury [2 –10]. Some studies have indicated that mental health symptoms, substance use, and traumatic brain injury pre-date the person becoming homeless [4 , 12]. These pre-existing conditions are likely to worsen once a person becomes homeless. Hwang et al. [4] completed a survey of residents of a city shelter and found 53% of residents had sustained a brain injury with loss of consciousness. Topolovec-Vranic et al. [9] identified that 87% of individuals experiencing homelessness who screened positive for a brain injury were injured prior to becoming homeless. Within this study, a history of brain injury with a loss of consciousness was associated with: all mental health and substance use diagnoses other than psychosis, a history of suicide attempts or recent suicidality, and having migraines and epilepsy [9]. They also found that individuals who have a history of TBI with loss of consciousness, and have also experienced homelessness, are more likely to: have been in contact with the criminal justice system, more likely to visit the ER, and more likely to report unmet health care needs [9]. Many agencies serving those experiencing homelessness have long understood the impact of mental health and substance use on a person’s ability to self-manage in the community, and in light of recent evidence there has been an increased recognition of the needs of those with a history of brain injury. This recognition also indicates a need for modifications and specialized programming for these individuals.

Although a range of evidence exists regarding the cognition/cognitive difficulties of individuals with a history of brain injury, mental health conditions, and cerebrovascular accident [CVA], there is limited evidence regarding the cognition of individuals experiencing homelessness [2 , 13–15]. Existing studies examining neuropsychological and cognitive function have identified that individuals experiencing homelessness generally performed lower than the norms for their age groups, on measures of memory, intelligence, executive function, language, visuospatial, and processing speed [13 , 16–25]. Evidence indicates that individuals with a history of traumatic brain injury, substance use or mental health disorders also experience higher rates of cognitive impairment [16 , 27].

Common cognitive impairments seen in individuals with a history of brain injury include: poor concentration, decreased attention, memory difficulties, impaired judgement, and decreased ability to follow instructions [16]. Decreased cognitive skills can have a significant impact on a person’s ability to follow complex instructions, navigate complex social and health care systems, respond to new problems, and self-organize in order to maintain belongings or accomplish tasks [28]. Functionally, these cognitive impairments may also impact social interaction skills, problem solving abilities, skill acquisition, and in some cases, independent living skills. The experience of being homeless may only exacerbate these impairments, because of continually changing environments, structures, demands, and safety concerns. The impact of decreased cognition as a result of mental health, brain injury, traumatic experiences, and overall lower education may also increase the risk of becoming and remaining homeless due to difficulties in navigating complex insurance, social service, and housing programs [2 , 30]. In order to address the needs of individuals who have experienced a brain injury, agencies benefit from incorporating strategies to accommodate for impacted cognition. One health care agency implemented a small pilot which entailed two components. First, a brain injury screening tool was implemented in order to identify the prevalence of brain injury among their client population and support the need for specific provider training. Then to support clinicians, a pilot training program was implemented to train behavioral health providers to apply specific strategies for individuals with a history of brain injury.

2 Procedures

2.1 Setting

The health care clinic, located in in an urban area, is considered a Federally Qualified Health Center, in which services are provided on a sliding fee scale, and services are covered by federal funding, grants, and insurance reimbursement. The agency serves primarily individuals experiencing homelessness, which may include those living in shelters, on the streets, or “doubling up” without a consistent place to stay or a name on a lease. The clinic offers medical, mental health, case management, occupational therapy, and dental services to clients. A supportive housing team also works within the clinic to provide intensive ongoing community support for individuals living within subsidized housing and various housing voucher programs.

2.2 Brain injury screening

2.2.1 Participants

The brain injury screening tool was given to all clients who consented to complete the screening at the time of occupational therapy evaluation within a two year time frame, with 172 clients completing the screening. All clients were older the age of 18, able to consent for services, and engaged in care with behavioral health and/or primary care at the agency at the time the screen was completed. The screening was completed in conjunction with other formal occupational therapy evaluation and assessments, and results were recorded in the agency’s electronic medical record (EMR).

2.2.2 Instruments: Ohio State University Traumatic Brain Injury Identification Method

The Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) is a brief screening for a history of brain injury [31]. The instrument has been found to be valid and reliable, and can be used with individuals with a history of substance use and incarceration [31]. The OSU TBI-ID seeks to avoid errors in reporting by asking for a recollection of injuries to the head or neck (versus asking for a history of TBI), followed by the length of loss of consciousness (LOC) (if any), dizziness or memory loss, and age when the injury was sustained [31]. The responses are then scored to identify the presence of: a Worst injury (LOC of 30 minutes or longer), First injury (TBI with LOC prior to the age of 15), Multiple injuries (two or more TBIs sustained close together, or a period of time with multiple blows to the head without LOC), Recent injury (a mild TBI in recent weeks or severe TBI in recent months), and Other sources (any TBI combined with another way the brain has been impaired, such as chronic alcohol or substance use) [31]. All Worst injuries are given a rating of 1–5 (1 indicates no history of brain injury, 2 – head injury without LOC, 3 – LOC less than 30 minutes, 4 – LOC 30 minutes – 25 hours, 5 – LOC greater than 24 hours) [31]. The instrument can be completed within 5–10 minutes, making it easy to incorporate into routine health care appointments.

2.2.3 Brain injury prevalence data collection and analysis

The OSU TBI-ID was used to identify brain injury prevalence, including type of injury sustained, length of loss of consciousness, and age of injury. OSU TBI-ID forms were completed by the on-site occupational therapists. All OSU TBI-ID forms completed were collected by the first author and entered into a de-identified data sheet, which also included mental health and chronic health conditions, current age of the individual, and if there was a TBI diagnosis within the problem list prior to completion of the screening. Data was evaluated for prevalence by category on the OSU TBI ID, including “Worst,” “First,” “Multiple,” “Recent,” and/or “Other.” “Worst” data was also separately identified to determine level of worst injury (1, 2, 3, 4, or 5) which indicates length of loss of consciousness. Data was also evaluated to identify co-occurrence of a TBI (“Worst” category rating 3, 4, or 5) with other chronic health conditions and with mental health diagnoses.

2.3 Provider training program

2.3.1 Participants

Providers were recruited from the behavioral health team and supportive housing team at the agency. All providers on the team were approached with the opportunity to participate in the pilot. A total of 12 providers agreed to participate in the training. All providers were licensed clinical social workers responsible for providing direct treatment to clients within the clinic setting.

2.3.2 Training format

Providers attended a total of eight bi-weekly 45 minute trainings that were completed in addition to daily demands of the clinic over a period of 5 months. The initial 2 trainings focused on instrument use and SMART goal writing. The remaining 6 trainings focused on specific strategies to address cognitive factors associated with brain injury that could be implemented by mental health providers within their regular client sessions. Surveys were administered prior to and at the end of the training to assess for provider self-perception in addressing the needs of individuals with brain injury.

2.3.3 Instruments: Provider self-perception

Participating providers were given a 15 question initial and post-survey to ascertain their comfort in assessing for the presence of and addressing the needs of brain injury with their clients, rated on a Likert Scale (0 – Not at all to 10 – Very Well/Comfortable). Additionally, participants were asked which theoretical frameworks they use within their sessions with clients, frequency of their use, if they use any of these frameworks specifically for clients with brain injury, and their perceived effectiveness of these frameworks with clients with brain injury. Providers were then asked to rate their comfort level in addressing associated conditions/cognitive skills (attention, memory, cognition, behavior, communication skills, social/interpersonal skills, and trauma) on a 1–10 Likert scale (1 – Not at all Comfortable to 10 – Very Comfortable). Finally, providers rated their familiarity and use of SMART goals when setting treatment plan goals using a 1–10 Likert scale (1 – Not at all to 10 – Very familiar/Almost always use). Providers answered additional open-ended questions on their perceptions and understanding of cognition, and how understanding cognition impacts therapy and treatment planning. They also had an opportunity to discuss their primary concerns in working with those with brain injury. (See Appendix A for pre- and post-training Likert scale survey questions.)

2.3.4 Training sessions: Provider administered instruments

First, providers participating in the pilot were trained to use the OSU TBI-ID to determine clients who had a history of TBI. This helped them determine which clients on their caseload should be administered additional instruments, use SMART goals for treatment planning, and apply strategies taught within the pilot setting. The results of the OSU TBI-ID screens were documented in the EMR, and completed OSU TBI-ID forms were given to the first author for ongoing data collection.

Once providers had identified clients with a history of TBI using the OSU TBI-ID, they then administered the WHODAS 2.0 to determine level of disability as reported by the client. Training on the WHODAS was also included as part of the pilot program. The World Health Organization (WHO) developed the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) to link concepts of the International Classification of Function (ICF) to determine a standardized disability level for adults [32]. The measure has been found to be valid and reliable across adult populations, including in different countries and among varying disabilities [32]. In this study, the 36 item measure was used to determine level of disability across 6 domains of function, which include: Cognition (understanding and communicating), Mobility (moving and getting around), Self-care (hygiene, dressing, eating and staying alone), Getting along (interacting with other people), Life activities (domestic responsibilities, leisure, work and school), and Participation (joining in community activities) [32]. The client rates each of the 36 items on a 0–4 scale (0 - No Difficulty, 1- Mild Difficulty, 2 - Moderate Difficulty, 3 - Severe Difficulty, and 4 - Extreme Difficulty or Cannot Do). The scoring form determines a total score from 0–100, where 0 indicates no disability and 100 indicates full disability [32]. The WHODAS 2.0 can be administered in 5–20 minutes as part of a regular health care appointment.

2.3.5 Training sessions: SMART goals

SMART goals were introduced for managers and human resources in 1981. However, they have frequently been applied to various health factors for goal setting, including behavioral health and occupational therapy [33]. In the context of this study, the SMART acronym was used to represent goals that are: Specific, Measurable, Achievable, Realistic, and Time-limited. SMART goals were used in this study to give providers a way to write specific short-term goals that could be related to a client’s preference and responses to the WHODAS measure. For clients with brain injury, it provided a way to identify and measure shorter-term outcomes, where subtle progress may otherwise not be observed or measured. It was also used to assist providers in prioritizing the many needs of their clients, and address some of the underlying skills needed to achieve their client’s more long-term goals.

Providers received education on the SMART goal acronym and use of writing SMART goals as treatment plan goals. Providers were able to practice writing SMART goals and gave feedback to each other on the goals written, with supervision from the training facilitators. Providers were then encouraged to use SMART goals to update and modify treatment plans of the clients who screened positive for a TBI and completed the WHODAS 2.0. The SMART goals focused on areas identified in the WHODAS along with client preferences and long-term treatment plan goals.

2.3.6 Training sessions: Cognitive topics

Following the training on the instruments and SMART goals, providers engaged in 6 training modules that focused on different topics related to cognition. The topic sessions were structured to provide a brief education and background on the concepts, and included training on strategies to implement with clients. The six session topics included: Insight and Awareness, Learning and Teaching, Attention, Memory, Executive Function, and Communication. Strategies were divided into “external” or “internal” strategies and were based on existing evidence, described below. Providers first completed a session on the levels of awareness developed by Crosson et al. [34], in order to increase knowledge of clients’ ability to have insight into performance, and to assist in determining which strategies would be appropriate to use with each of their clients.

External strategies were defined as “strategies that are external to the person. The long-term goal of these strategies is to “enable individuals to compensate for impairments independently, with the use of the aids” [35]. External strategies were presented for each of the six session topics, and were adapted from evidence-based sources, including the Cognitive Rehabilitation Manual developed by the American Congress of Rehabilitation Medicine and from the Multi-Contextual Treatment Approach [35 –37]. The Multi-Contextual Approach provided a theoretical framework for the development of strategies for this training. The Multi-Contextual approaches conceptualizes cognition as an “ongoing product of the dynamic interaction among the person, activity, and environment” [37]. When working with adults experiencing homelessness, considering the impact of the person’s own abilities within the stressful environment of homelessness allows the provider to assist the client in developing effective methods to compensate for affected cognition. This approach also promotes the building of self-awareness of performance, and gives opportunity for providers to also give feedback on performance to the client [37]. The Cognitive Rehabilitation Manual is a comprehensive tool based on the systematic reviews of Cicerone et al., and incorporates evidence-based strategies and approaches to various cognitive components and skills [35]. Strategies were modified from these sources by the training facilitators so participants would be able to apply the strategies directly to the clinical context of working with adults experiencing homelessness, integrating clinical experience and feedback from provider surveys. The strategies focused on improving therapist-client interactions within sessions, structuring sessions, and to support the client with applying concepts discussed in therapy appointments into the community. For example, the provider might assist the client in developing a short list of coping strategies to use that the client can easily access to provide a visual cue for use, such as taping it to the back of a phone or putting the list inside their wallet. Providers had the opportunity to discuss and apply strategies to case studies or examples from their own client caseloads.

Internal strategies were defined as “strategies that include any self-generated procedure whose purpose is to enhance conscious control over thoughts, behaviors, or emotions” [35]. This is achieved by teaching individuals to cue themselves to use an image, word, or action sequence as a trigger to take the appropriate steps to address a task or problem at hand. The long term goal of this strategy is to enable individuals to become so familiar with the process and adept at using it, that they can use it in any situation, even without external assistance [35]. Internal strategies were also presented for each of the six session topics. Internal strategies were also adapted from evidence-based sources in order to develop insight into performance, such as the Cognitive Rehabilitation Manual developed by the American Congress of Rehabilitation Medicine and from the Multi-Contextual Treatment Approach as described previously [35 –37]. In addition to rehabilitation strategies, internal strategies also integrated behavioral health frameworks, such as Cognitive Behavior Therapy [CBT], Acceptance and Commitment Therapy [ACT], and Mindfulness [38 –40]. These approaches were incorporated in order to supplement the metacognitive approach which focuses on building self-awareness. These approaches are already familiar to behavioral health providers and allowed an opportunity for providers to modify already familiar strategies specifically to those with a history of brain injury.

ACT and mindfulness strategies were introduced to address attention and self-management. Stress management/self-soothing strategies were taught as a mechanism for managing frustration when upset and/or overwhelmed. Specific mindfulness techniques were included as a part of this process: exercises such as taking 10 deep breaths when upset, taking one deep breath before making a decision when upset, using the moment to think about a desired outcome, and teaching a mantra that helps individuals remain calm when feeling overwhelmed. An example of this mantra could be: “It’s okay I feel this way, I won’t always feel this way.” The goal of these selected strategies is to assist clients in becoming more mindful of emotions and learn to exist with them, rather than fighting against them. This is a tenant of the Acceptance and Commitment Therapy [ACT] model of treatment [38].

Strategies for building self-awareness additionally included mindful meditation as a daily practice. Meditation was introduced as an in-session practice, to help clients increase attention and feelings of calmness in their lives. An example of one of the practices taught: Drinking tea in a session and asking the client to draw their attention to how it feels to drink the tea. The provider may ask them to pay attention to the warmth, flavor, and the physical sensation while drinking the tea. This practice can be used for individuals who struggle with traditional forms of mediation, such as those with decreased attention. Finally, education is provided to explain why this practice is beneficial, and how it affects the brain and response to emotions.

These therapeutic modalities were also used to develop or increase insight. ACT provides a way for providers to help clients learn acceptance of newfound limitations, and the emotional responses which come from those limitations [38]. Specifically, the ACT concept of Values was used to help the clients define the kind of individual they want to be. Providers then assist the client in looking at behaviors and thoughts, and how their focus can be helpful in leading to who they want to be or lead further away. Next, providers and clients discuss the cost of continuing unhelpful behaviors. ACT takes a non-judgmental stance toward the self, thoughts and feelings, and looks at what is working to help the self and what is not [38]. This work is done through helping clients gain cognitive flexibility, learning mindful practice, and practicing acceptance [40].

Finally, Cognitive Behavioral Therapy [CBT] was used to assist in the development of cognitive flexibility [39]. Clients with insight and able to participate in cognitive work can be taught to look at the cost of negative thoughts, and belief in those thoughts. Providers then can work with clients to begin looking at where those thoughts come from, and if those thoughts make sense when put up against evidence. Thought records were presented as a strategy to support this method with this population, because of thought records’ concrete and objective way of looking at thoughts. Internal strategies were indicated for use for clients with higher levels of awareness or who presented with less tangible and immediate needs. Some internal strategies were also encouraged for use in order to help the providers build self-awareness with the clients but are not clinically appropriate for all clients.

All strategies and modalities taught within the training sessions were related to the cognitive constructs they were included to address. This allowed providers to learn more about cognition that may be especially impacted by a history of brain injury, and then develop tangible tools that could easily be applied within their regular sessions with clients.

2.3.7 Provider perceptions data collection and analysis

Provider self-perception surveys were collected by the authors of this study from the surveys administered prior to and at completion of the pilot study. Initial surveys were used to tailor the training sessions to address concerns presented by the providers, as well as to collect initial data regarding self-perception. Post-survey results of the Likert scale were analyzed to identify provider perception prior to and after the training. Open-ended feedback was reviewed to further support Likert scale ratings and provide qualitative reflections of the training program.

3 Results

3.1 Prevalence of brain injury

Of the 172 clients screened using the OSU TBI-ID, 84 percent screened positive for a history of an injury to their head or neck [Table 1]. 68 percent of clients screened experienced a loss of consciousness when they were injured, and 23% experienced a loss of consciousness greater than 30 minutes. Only 12 percent of participants were identified as having a TBI within their problem list [Table 1]. Over 50 percent of individuals with a Worst score of 3, 4, or 5 had co-occurring mood disorders, and findings were similar for individuals with substance use diagnoses (Table 2). Thirty-one percent of participants with a Worst score of 3 or higher also experience chronic pain, followed by neurological conditions and memory or other cognitive impairments as the most frequently co-occurring chronic health conditions (Table 3). The high prevalence of brain injury in the screened population supported implementation of the pilot training program.

Table 1
Number of TBI by Category (N = 172)

Positive screens % (n) TBI-ID Worst 3 (LOC >30 minutes) TBI-ID Worst 4 (LOC 30 minutes – 24 hours) TBI-ID Worst 5 (LOC <24 hours)

First 36 (62)

Multiple 39 (67)

Recent 10 (18)

Other 55 (94)

Worst 68 (117) 29 (50) 23 (40) 16 (27)

Two or more categories 55 (94)

Three or more categories 13 (23)

Four or more categories 7 (12)

Five categories 2 (4)

No TBI history 16 (27)

Injury to head without LOC 15 (26)

TBI on problem list prior to screening 12 (20) 3 (6) 3 (5) 5 (9)

	Positive screens % (n)	TBI-ID Worst 3 (LOC >30 minutes)	TBI-ID Worst 4 (LOC 30 minutes – 24 hours)	TBI-ID Worst 5 (LOC <24 hours)
First	36 (62)
Multiple	39 (67)
Recent	10 (18)
Other	55 (94)
Worst	68 (117)	29 (50)	23 (40)	16 (27)
Two or more categories	55 (94)
Three or more categories	13 (23)
Four or more categories	7 (12)
Five categories	2 (4)
No TBI history	16 (27)
Injury to head without LOC	15 (26)
TBI on problem list prior to screening	12 (20)	3 (6)	3 (5)	5 (9)

Table 2

Co-occurrence of TBI by worst injury and mental health diagnoses (N = 172)

	TBI-ID Worst 3 (LOC >30 minutes) % (n)	TBI-ID Worst 4 (LOC 30 minutes – 24 hours)	TBI-ID Worst 5 (LOC <24 hours)	Total
Affective disorder	22 (38)	16 (27)	15 (25)	53 (90)
Anxiety disorder	5 (9)	2 (4)	1 (2)	8 (15)
Post-traumatic stress disorder	6 (11)	8 (13)	4 (7)	18 (31)
Psychotic disorder	8 (13)	7 (12)	1 (1)	16 (26)
Substance use disorder	25 (43)	20 (35)	13 (22)	58 (100)

^*Categories are not exclusive.

Table 3

Co-occurrence of TBI by worst injury and chronic health conditions (N = 172)

	TBI-ID Worst 3 (LOC >30 minutes) % (n)	TBI-ID Worst 4 (LOC 30 minutes – 24 hours)	TBI-ID Worst 5 (LOC <24 hours)	Total
Cardiovascular conditions	4 (7)	0 (0)	2 (3)	6 (10)
Chronic pain	14 (24)	9 (16)	8 (13)	31 (53)
Diabetes	5 (9)	3 (6)	2 (3)	10 (18)
HIV	1 (1)	1 (2)	1 (1)	2 (4)
Intellectual/ developmental disability	2 (3)	2 (4)	0 (0)	4 (7)
Memory or other cognitive deficit	9 (15)	3 (6)	3 (6)	15 (27)
Neurological condition	7 (12)	6 (11)	4 (7)	17 (30)

^*Categories are not exclusive.

3.2 Outcomes of provider pilot training

Of the twelve participants who began the training and completed pre-surveys, seven providers were able to attend the majority of the sessions and complete the post-surveys.

3.2.1 Provider usage of instruments

Providers found the OSU-TBI ID to be helpful in assessing for a history of brain injury among clients. Providers demonstrated an increase in self-efficacy in their ability to screen for a history of brain injury (Fig. 1 Question 2) following the training on the use of the OSU TBI-ID. Providers noted “it helped me to know to focus on more specific strategies and problems, versus talking more generally.” Several providers noted the benefit of taking a history of brain injury to influence strategies and methods presented within sessions.

Fig. 1

Average provider response on Likert Scale Questions Pre- and Post-Survey.

Overall, providers reported the WHO-DAS was helpful in determining problem areas and goal areas for treatment for individuals with brain injury, generally easy to administer, and complemented other screening tools well. They also found the tool short enough to implement within a treatment session, and helpful in addressing the problems experienced by clients specifically with a brain injury. Providers found the WHO-DAS to be difficult to implement at a 3 month interval, and wished it could be split across treatment sessions in order to not spend entire sessions “screening” versus providing direct treatment. No providers were able to re-implement the WHO-DAS by the end of the training, demonstrating an additional limitation.

3.2.2 Use of SMART goals

Initially, providers were not all familiar with SMART goal formats, and noted their treatment goals tended to be “vague and less measurable.” The majority of providers also noted that their typical treatment plan goals did not adequately address the needs of those with brain injury. One provider reported “I find it hard to engage individuals in the goal-setting process, individuals with brain injury seem to have a hard time identifying goals for themselves.”

Following the training, providers demonstrated an increase in knowledge of SMART goals (Fig. 1 Question 5) and the use of SMART goals within their daily practice (Fig. 1 Question 6). Half of the providers who completed the training found that SMART goals were effective in addressing the needs of those with brain injury, but noted that goal setting continued to be a difficult process for many of their clients. One provider stated “It has been tough to get client buy-in, especially with those with decreased awareness or desire to have assistance.”

3.2.3 Use of strategies

Following the training, providers demonstrated an increase in self-efficacy in addressing the needs of clients with brain injury (Fig. 1 Question 1). Providers who rated themselves lower at the pre-survey demonstrated the most improvement at the post-survey following the training. Prior to the training, most providers identified frequent use of ACT, CBT, and Mindfulness-based strategies as part of their regular treatment, however, most providers noted that they did not use any of them specifically with individuals with brain injury. Following the training, providers reported an increase in specific application of these strategies and that they were effective with individuals with brain injury (Fig. 1 Question 3).

Additionally, providers demonstrated an increase in their comfort level addressing conditions associated with brain injury discussed in the training sessions [attention, memory, cognition, behavior, communication skills, social/interpersonal skills, and trauma] (Fig. 1 Questions 8A, M, C, B, CS, SS, T). Providers demonstrated the most increase in comfort level in the areas of memory, attention, cognition, and trauma. Providers commented “I enjoy having concrete methods that target certain areas. Very realistic strategies.” Another provider noted “understanding cognition and the other conditions associated with brain injury is useful to understanding the client’s experience. Sometimes there is a sense that the client is at fault for behaviors they cannot completely control.”

4 Discussion

Implementation of the OSU TBI ID increased the awareness of the number of clients with a history of brain injury within the clinic. Notably, only 12 percent of clients screened had a history of brain injury reported on their problem list in the EMR, however, 68 percent of clients were found to have a sustained an injury with a loss of consciousness at some point in their lifetime (Table 1). These findings are consistent with the literature indicating brain injury is under-identified in individuals experiencing homelessness, and is an important consideration when developing care and treatment plans for clients. The percentage of clients in this setting screened higher than the averages found in the literature. This may be due to the providers screening individuals who demonstrate symptoms or behaviors indicating a history of brain injury, such as functional or cognitive impairment. A full screening protocol across the clinic would give a stronger indication of overall prevalence in the agency’s population; however, the high rates suggest the benefit of a clinic-wide screening process. These findings additionally supported the need for the provider pilot training program to increase providers’ knowledge of tools and strategies for engaging this population.

Overall, providers both identified and demonstrated benefit from a targeted training regarding the needs of clients with brain injury. Despite the prevalence of clients with brain injury within the clinic population, providers within this setting reported not feeling confident or targeted in their ability to address their needs.

Providers reported a benefit to learning specific tools to identify a history of brain injury and to determine functional implications to support the treatment planning and goal setting process. These results do indicate a benefit from training multiple providers in the screening tool. Clinic-wide implementation of the tool could build awareness and also add information to the problem list in the EMR so that all providers who engage with the client are knowledgeable about a past history of brain injury and can modify interventions accordingly. Drawbacks to the screening tools were typical of many settings, in which providers find it difficult to complete several types of screening and engage in therapeutic interventions, especially with a population whose attendance may be inconsistent. Prioritization of tools is critical to maintain consistent completion, as well as adoption of assessment measures that can be used across all clients.

Providers additionally demonstrated benefit from structured training sessions in which to discuss and learn specific strategies targeted to common cognitive needs exhibited by those with brain injury. Education regarding external and compensatory strategies gave providers tangible tools in order to better structure sessions and support clients in self-management outside of sessions. Application of internal strategies using familiar modalities such as mindfulness, ACT, or CBT gave providers realistic methods for maintaining their therapeutic role, while also addressing the cognitive limitations that often co-exist with a history of brain injury. Minor modifications to therapeutic approaches and education on compensatory strategies empowered providers to address specific needs, and overall increase the efficacy of their interventions.

4.1 Limitations

Although the pilot training program overall demonstrated positive benefits to providers, limitations exist. Further evaluation of whether or not progress was made towards treatment plan goals warrant further evaluation as to the effectiveness of strategies and modalities included as part of the training program.

As within any clinic setting, attrition of participation of providers was mixed. Twelve participants initiated participation; however, only 7 were able to maintain attendance at the training for the entire course. Modifications to the program may improve accessibility to more providers. However, they may also limit the level of detail and application included within the training modules.

5 Conclusion

Use of the OSU TBI-ID at the agency indicates a high prevalence of brain injury among a population of adults experiencing homelessness, supporting the need for implementation of screenings and training programs to support clients’ access to care.

Development of a training program based in theoretical approaches increased access to providers to evidence-based approaches to increase the efficacy of their interventions specifically for individuals with brain injury. Providers’ perceptions of their ability to address the needs of this specific clinical population improved after a targeted program which provided new information and approaches, as well as modifications to familiar approaches.

Conflict of interest

None to report.

Footnotes

Appendix A

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