Many factors have led to the increase in the number of outliers — complex and chronic neurological cases — in post-acute rehabilitation facilities. Gary Ulicny, former CEO of Shepherd Center in Atlanta, reveals innovations in care and care management to meet the growing demand.

“People who would’ve died ten years ago are now being saved and coming to the hospital and to rehab much quicker than they used to,” Ulicny told Paradigm Outcomes’ eighth annual Innovation Symposium exploring outliers and medical innovation.

Often, ICUs at Shepherd Center or at Mary Free Bed Rehabilitation Hospital in Grand Rapids, Michigan, receive patients on the day of injury.

Those with injuries also are living longer. A paraplegic injured at age 20 is now expected to live into their late 60s. A brain injury patient’s life-expectancy has increased by 2.5 years per decade since the ’60s. People on ventilators now live much longer because of advances in that technology.

Litigation is another factor. A recent study took a large subset of people with brain injuries and matched them by severity of injury. Then it looked at outcomes in those who had active litigation and those who didn’t. The people in the non-litigation category had significantly better outcomes.

“I don’t think you can diminish that in some of these outlier cases as well. Right now, a lot of people who come to Shepherd already have an attorney. That didn’t happen years ago,” said Ulicny, who is president and CEO of GRU Health Care, an international consulting group specializing in building business and treatment cultures that promote excellence.

Early Recognition and Red Flags

If 1% of cases — those that are most complex – accounts for 20% of costs, it makes sense to carefully manage these cases. Early recognition can’t be over-emphasized. Not every severely injured patient goes to a trauma center or to a trauma center with highly trained clinicians. Some go to small community hospital Emergency Rooms, which may only see two cases of spinal cord injury a year. Getting specialized care early helps prevent complications.

Ulicny also said you can never overestimate the problems associated with even a minimal loss of consciousness, so it’s crucial to track those who have lost consciousness. Red flags include criminal or legal issues, obesity, violent and aggressive behavior.

“They could walk in this room and you would have no idea they’re injured, but they’re so dysfunctional. Their wives divorced them or they beat one of their children. Now they’re in jail,” he said. “One of the most difficult things we deal with is families, especially dysfunctional families. Family support is a big issue.”

Shepherd Center started the Safe at Home program to help patients’ families create a safe household environment for a cognitively-impaired person. “It’s critically important because these patients are very impulsive and lack memory,” he said.

Increases in narcotic pain medication are another challenge. Detox is required with a traumatic brain injury because narcotics mask cognitive deficit.

Continuum of Care

Ulicny suggested thinking about the continuum of care as expanded and lasting much longer than it once may have.

“We know now that learning is really a lifelong process and through some of the techniques we use, we can restore function, or we can replace it with assistive technology. That’s very, very important. And you should be looking at providers who have access to or have developed these techniques and technologies,” he said.

“I call rehab the gift that keeps on giving. Restored function will pay off for the rest of your life. Restoring functional grip to a quadriplegic saves millions of dollars over that person’s lifetime. They brush their teeth, they can open the refrigerator, get snacks out, drive.

“It’s a return on investment. And even more importantly, projecting it out into the future, this much functional improvement in year one doesn’t go away in year two, it keeps on giving.”

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