FROM THE NACHC LENS
Addressing the Care Challenges of Traumatic Brain Injuries Among Patients Experiencing Homelessness
Studies have found that some populations are more at risk for Traumatic Brain Injury (TBI) than others. These include people experiencing homelessness. One meta-analysis of 22 studies from The Lancet Public Health, found an average of 53.1% of individuals experiencing homelessness had at least one TBI of any severity, and 22.5% have had at least one moderate to severe TBI. This same study also found that for many people, a TBI occurred before becoming homeless.*
With people experiencing homelessness and unstable housing one of the many communities served by health centers, the National Health Care for the Homeless Council (NHCHC), a national training and technical assistance organization that supports health centers’ health care for the homeless programs, has made TBI education a priority.
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Health centers face numerous complexities caring for people experiencing homelessness who have or had a TBI. “Working with people experiencing homelessness who may have had one or multiple TBIs is very challenging because many of them may never have been diagnosed at the time of the TBI and have not received treatment,” says Caitlin Synovec, OTD, OTR/L, BCMH, Assistant Director of Medical Respite, NHCHC.
Some challenges treating people experiencing homelessness who have undiagnosed TBIs include difficulty responding to and understanding health information because their cognitive abilities have been impacted. Also, the effects of TBIs look different in every person because different parts of the brain can be impacted, making it more difficult to diagnose.
“Having an understanding of the prevalence of TBIs among people who experience homelessness and the need to identify and monitor for it is critical,” says Synovec. "The effects of a TBI can be so cross cutting, as it can impact a person’s ability to engage in health care and live healthfully when they do move into housing. Health centers have a prime opportunity to close this gap.”
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FOUR ACTION STEPS
to Close the Gap in TBI Care for Patients Experiencing Homelessness
1. Screen for TBIs and then connect patients with the TBI experts who can best treat them.
3. Adapt practices and workflows that apply trauma-informed care approaches.
4. Build relationships with TBI experts so your patients can benefit from a warm handoff.
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Primary Care on the Front Lines
of Brain Health
The Alzheimer’s Association estimates that one in nine adults over age 65 live with Alzheimer’s disease, the most common form of dementia that occurs when biological changes take place in the brain. With adults 65+ making up 11% of the health center population and growing, care teams, particularly primary care staff, can have a key role in early detection of dementia, help patients reduce risk factors, and support care management.
During her presentation at NACHC’s Early Detection of Dementia and Reducing Risk Factors webinar, Soo Borson, M.D., Co-Lead, BOLD Public Health Center of Excellence in Detection of Early Dementia and Professor of Clinical Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, shared that primary care providers provide 85% of first dementia diagnoses and 80% of the care for patients whereas memory disorder specialists diagnose about 15% of all cases. The webinar was part of NACHC's Brain Health Integration Into Health Center Services supported by the Centers for Disease Control and Prevention.
“Primary care is so on the front lines of this disease,” says Barak Gaster, M.D., Professor of Medicine and Director of the Cognition in Primary Care Program, University of Washington, Seattle, WA and a national dementia expert who also participated in the webinar. During his presentation Dr. Gaster shared, “We (primary care providers) are good at long term care continuity and chronic disease management, and many patients don’t necessarily want to see the specialist. They want their concerns addressed in the primary care setting.”
Health center primary care teams have an opportunity to set up systems and workflows to detect dementia early so patients can take advantage of some of the benefits of early diagnosis. Benefits include addressing modifiable risk factors that may slow progression, opportunities to participate in clinical trials, access to new medication treatments, and ability to plan ahead for when the patient can no longer make decisions.
Dr. Gaster recommends that for those patients who may have symptoms of cognition loss, primary care clinicians schedule another visit where the primary care provider can conduct
in-depth cognitive evaluation and observation that involves administering the:
- Montreal Cognitive Assessment (MoCa) and entering the score into electronic health records
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AD8—brief observer 8 item questionnaire interview that gets observational input from a family member or close friend
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Health Center Journey:
Dementia Early Detection and Risk Reduction
- Include early detection and risk reduction steps in current work flows for Annual Wellness Visits, Advance Care Planning, and Chronic Care Management
- Develop a systems approach to management of chronic conditions
- Enhance and expand partnerships and community linkages to support early detection and risk reduction
Learn more with these resources:
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Ece Tek, M.D.
Chief Medical Officer
Mental Health and Addiction Services
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Michael Couturie, M.D.
Chief Medical Officer of
Medical and Dental Services
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Fully Integrated Approach to Treating Mind and
Body in End-to-End Addiction Services
“We focus on treating the mind and body together, where psychiatric illnesses, including addiction, are treated just like any other medical issue,” says Ece Tek, M.D., Chief Medical Officer, Mental Health and Addiction Services, Cornell Scott-Hill Health Center, New Haven, CT. Dr. Tek co-leads Cornell Scott-Hill Health Center’s clinical care team of nearly 300 medical and behavioral health providers with Michael Couturie, M.D., Chief Medical Officer of Medical and Dental Services.
Together they partner to ensure that the health center fully merges behavioral health, addiction services, primary care and other medical services into one overall care model that greatly benefits patients and their care teams. “If we are working in a vacuum, we cannot collaborate working towards the best outcome for the individual patient and that is where we have done a particularly good job over the years,” says Dr. Couturie.
Through all-inclusive provider team meetings, and shared electronic health records, all members of a patient’s care team can understand the patient’s medical and psychiatric treatment plans. In the case of patients receiving addiction services, the whole care team will know and take action if a patient has a relapse.
This sharing of knowledge about each aspect of a patient’s behavioral and physical health has led to a shift in how staff approach patient care and has created shared mutual respect and collaborative spirit for each other’s specialties. “Behavioral health teams have become more 'medical minded' and primary care teams have become more 'psychiatric educational minded,'” says Dr. Tek.
New Recovery and Wellness Center to Create Ideal Addiction Campus with Fully Integrated Services
To meet the growing demand for behavioral and addiction services, the health center will soon open its new Recovery and Wellness Center (RWC). The RWC will house primary, women’s health, podiatry, infectious disease, behavioral, addiction, integrated care service where patients will be offered yoga, meditation, group counseling, and therapeutic shelter for both men and women all under one roof. With an estimated 80% of substance users having experienced some form of trauma, the new RWC will also have a focus on trauma and addiction, taking a trauma-informed care approach to treatment.
“Our new Recovery and Wellness Center is being built across the street from our detox services so we are able to create an ideal addiction campus where patients will first be screened and evaluated for their appropriate level of service by our team of nurses and then begin their treatment based on their evaluation,” explains Dr. Tek.
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Cheers to a Most Wonderful and Mindful Holiday Season
While this is the season of gratitude and cheer, many will also rush into the holidays with lots of stress to get homes and recipes ready for holiday dinners and parties. To help you keep calm and power through this hoiiday season, try incorporating these easy mindful moments into your planning and preparations.
Clean Mindfully
Cleaning for the holidays or just over the long weekend lends itself to a wonderful mindfulness practice. Try focusing on just one area or room at a time.
Cook Mindfully
If you are the one making the big holiday meal, do it mindfully, focusing ONLY on the cooking when in the kitchen. Put all other preparations on hold while you live in the moment of what you are creating, smelling, and taste testing!
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© National Association of Community Health Centers. All rights reserved. |
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