Development of the Resource Facilitation Program at RHI: From Research to Practice to Policy
Traumatic brain injury (TBI) can result in chronic disability. These chronic effects are associated with the primary effects of the injury (e.g., cognitive or neurobehavioral impairments), secondary co-morbid conditions (e.g., depression, substance abuse, and seizures), and increased health risks (e.g., higher rates of diabetes, pain, insomnia and fatigue, dementia, sleep disturbances, among many others). Recent efforts have begun to identify TBI as a chronic condition that should be managed as such.
Many individuals with TBI do not receive TBI post-acute services or have access to community-based supports owing to the absence of a system to manage TBI as a chronic condition. Thus, those with TBI are unnecessarily vulnerable to developing potentially preventable medical and psychosocial co-morbidities and institutionalization through hospitalization or incarceration. Consequently, health care cost increases over time, expenses for institutionalization fall on a variety of governmental agencies, and lost productivity of both the person with TBI and their family members increases societal cost. The work in Resource Facilitation at RHI is the beginning of building a new system to better manage moderate to severe TBI that could positively impact all of these domains.
RHI Resource Facilitation (RF) Research and Implementation in Indiana:
In 2009, Laura Trexler, then with the Indiana Brain Injury Association of Indiana, was working on a federal grant from the US Department of Health and Human Services, Health Resources Services Administration (HRSA) through the Indiana Vocational Rehabilitation Services (IVRS), and brought the idea of RF to RHI to explore the possibility of conducting a study to examine its potential efficacy. With some residual HRSA funding, a small randomized controlled trial of RF was completed at RHI by Lance Trexler, Laura Trexler, Jim Malec, Devan Parrott, and Daniel Klyce.[i] It was found that 64% of those with TBI who received RF returned to work and school as compared to 36% of those who did not. Through some initial funding from the RHI Foundation and with a grant from the Indiana Spinal Cord and Brain Injury Research Fund for $119,404, this team was complete a larger randomized controlled trial of RF[ii] at RHI that replicated the findings from the first study and demonstrated that not only did TBI participants return to work significantly more often, but they did so more quickly. It was also demonstrated that RF resulted in a significant decrease in level of disability on measures of abilities, adjustment, and participation in activities at home and in the community.
Based on this work and the vocational outcomes, Drs. Trexler and Parrott and Laura Trexler proposed a prospective clinical cohort study of IVRS clients with TBI to determine the effectiveness of RF to Peter Bisbecos, the then Director of Disability and Rehabilitative Services. In that study, the clients were on average almost 10 years’ post-injury. IVRS had historically been successful with returning 18% to work, but it was found in this study that if they got RF, 70% were successful in becoming employed or returning to school.[iii]
Based on the research, Indiana Vocational Rehabilitation decided to provide RF as a matter of policy for any person with a brain injury and who qualified for services in 2014, so the research to state-wide practice pipeline was accomplished in five years. Further, researchers at the Center for Business and Economic Research, Miller College of Business at Ball State University recently completed an economic impact study of RF on Indiana.[iv] They demonstrated that the annual aggregate lifetime savings generated as a result of RF for Indiana was $249.1 million a year for wages and benefits, $30.97 million a year for revenue from taxes, $80.1 million a year for savings to SSDI/private disability, $6.6 million a year for SNAP, resulting in a total of $366.77 million in savings a year.
RHI now has approximately 20 staff located throughout Indiana providing RF and, to date, 1786 people have been evaluated, and Indiana Vocational Rehabilitation Services has authorized 1,134 for RF services from throughout Indiana. Dr. Trexler and colleagues also brought in $2,900,000 in federal grants after the initial Indiana Spinal Cord and Brain Injury Research fund grant to continue our research and program implementation in Resource Facilitation. And since life is a circle, the RHI Resource Facilitation department is led by Peter Bisbecos.
In another HRSA grant in collaboration with the Indiana Department of Corrections, we found that RF resulted in a significant reduction in re-arrest/re-incarceration for people with people with TBI leaving incarceration.[v] In 2018, the HRSA grants were transferred to the US Department of Health and Human Services, Administration for Community Living (ACL), and RHI was again successful with this grant application. In this study, we are examining the impact of RF on health outcomes in another randomized controlled trial for people recruited at two Level 1 Trauma Centers, Ascension St. Vincent Hospital and IU Health Methodist Hospital. This study will be completed in May of 2021.
We will be submitting our next ACL grant in May, and in this study we will examine the impact of RF on health care utilization in collaboration with the Indiana University Health Accountable Care Organization. Along with all of the multiple clinical benefits of RF that have already been demonstrated, this study is hopefully the next step that will provide the economic basis for RF. Hopefully the research on RF that RHI has conducted over the last 12 years will establish the evidence that will result in a new system of care that is routinely integrated into health care systems to provide long-term follow-up and care management as needed to improve outcome for all who experience TBI.
[i] Trexler, L.E., Trexler, L.C., Malec, J.F., Klyce, D., & Parrott, D. (2010). Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury. Journal of Head Trauma Rehabilitation, 25(6), 440-446.
[ii] Trexler, L.E., Parrott, D.R., & Malec, J.F. (2016). Replication of a Prospective Randomized Controlled Trial for Resource Facilitation to Improve Return to Work after Brain Injury. Archives of Physical Medicine and Rehabilitation, 97(2), 204-210
[iii] Trexler, L.E. & Parrott, D.R (2018). Models of Brain Injury Vocational Rehabilitation: The Evidence for Resource Facilitation from Efficacy to Effectiveness. Journal of Vocational Rehabilitation. 49(2), 195-203
[iv] Patterson, B., Devaraj, S., & Hicks, M. J. (2017). Economic Impact of Resource Facilitation: Workforce Re-entry Following Traumatic Brain Injury. IN_Economic_Impact_of_RF_2017.pdf (squarespace.com)