Better Outcomes for
Catastrophic Cases
Deborah Benson, PhD, ABPP-RP
© Paradigm Outcomes, Proprietary
Speaker Bio
Deborah Benson, PhD, ABPP-RP
Sr. Director of Clinical Services

Manages Clinical Directors, Associate Clinical Directors, Nurse Case Managers and medical/clinical specialists, to
develop clinical management plans that ensure positive outcomes for patients with catastrophic brain, spinal cord,
burn, amputation and multiple trauma injuries

Served as Director of Transitions of Long Island, a post-acute neuro-rehabilitation program within the Northwell
(formerly North Shore-LIJ) Health System, for 15 years

PhD in clinical neuropsychology from the City University of New York and board certification in rehabilitation
psychology from the American Board of Professional Psychology

Served on the board of the Brain Injury Association of New York State (BIANYS) and remains active in the
association’s local chapter. Currently serves on the board of Kids’ Chance of New York.
2
© Paradigm Outcomes, Proprietary
Objectives
 Understand what constitutes a catastrophic case
 Identify factors that drive up costs for these cases
 Address how to effectively manage these challenging
cases
 Identify important and impactful innovations and
future trends in trauma care
3
© Paradigm Outcomes, Proprietary
What Makes a Catastrophic Case?
The following clinical diagnostic indicators reflect complex cases often managed by
Paradigm.
Acquired Brain Injury
Spinal Cord Injury
• Traumatic brain injury
• Concussion
• Skull fracture
• Loss of consciousness
• Intracranial injury
• Seizures
• Cerebrovascular injury
• Physical Deficits
• Anoxia
• Cognitive Impairments
• Encephalopathy
• Challenging behaviors
• Spinal fractures
• Central cord syndrome
• Spinal cord injury (complete
• Cauda equina syndrome
or incomplete)
• Paraplegia
• Tetraplegia
Burn Injury
• Flame/Heat burns
• Over 10% TBSA burns, up to over 90% TBSA burns
• Chemical burns
• Burns to: Face, Hands, Neck, Feet, Groin, Major joints
• Electrical injuries
• Inhalation injuries
Multiple Trauma/Amputation
• Amputation
• Major abdominal injury
• Degloving injury
• Multiple fractures
• Major chest injury
• Crushing injury
4
© Paradigm Outcomes, Proprietary
The Golden Triangle
Research has found that despite cost containment efforts, a subset of complex cases
typically persist in driving costs: the “Golden Triangle.”
0%
6.2%
Case Count
6%
Case Dollars
0%
50%
49.9%
67.3%
13.8%
We can help you
gain insight into
your own Golden
Triangle and then
positively impact
those cases
100%
100%
Source: Lipton, et.al. “Medical Services by Size of Claim”, NCCI, 2009-10
5
© Paradigm Outcomes, Proprietary
A Small Set of Injuries Become Your Most Expensive Cases
These Golden Triangle injuries represent half of costs and consist mainly of catastrophic
injuries and complex pain conditions.
6.2% of Cases Drive 49.9% of Costs
Cases
All Other
93.8%
Costs
Catastrophic: 0.3%
Pain: 5.9%
Total: 6.2%
Catastrophic
17%
Pain
33%
All Other
50%
Sources: Lipton, et.al. “Medical Services by Size of Claim”, NCCI, 2009-10
Paradigm Analytics
6
© Paradigm Outcomes, Proprietary
Catastrophic Injury Costs
Why are these types of injuries so costly?
Extent and severity of acute
injury
Diagnoses with significant longterm impacts and risks for
complications
 Severe neurological injury and
instability
 Concurrent major organ injury
and medical instability
 Need for cardio-respiratory
resuscitation, emergency surgery
 Orthopedic injuries and
surgeries
 Need for acute and post acute
care
 Severe functional disability
 Brain injury
 Spinal cord injury
 Major burns
 Amputation
 Major multiple trauma
7
7 Proprietary
© Paradigm Outcomes,
What Factors Drive the Costs in This Population?
Clinical complexity/challenges, innovation, fractured care, and workers’ compensation.
Escalating Costs
Better Outcomes
 Hospital
 Greater survival
 Rehabilitation
 Increases in life expectancy
 Increases in functional outcome
 Medication
 Increase in quality of life
 Technology
 DME
 Service Duplication/Nonintegration
 Litigation
8
© Paradigm Outcomes, Proprietary
Setting and Mitigation of Reserves
Every catastrophic case is different.
• Injury type
• Severity
Baseline
• Complexity
• Comorbidities
• Psychosocial dynamics
Variables
• Jurisdiction
• Life expectancy
• Chronic effects
Duration
• Risks/Volatility
9
© Paradigm Outcomes, Proprietary
Acquired Brain Injury
© Paradigm Outcomes, Proprietary
Prevalence of Traumatic Brain Injury In the US
National TBI Estimates - Center for Disease Control
 Each year, an estimated 2.5 million people sustain a TBI.
─ Of them:
•
Approximately 52,000 (2%) die
•
Approximately 284,000 (11%) are hospitalized
•
Approximately 2.2 million (87%) are treated and released from an emergency department
 Estimated that between 3.2 million-5.3 million persons in US are living with a TBI-related disability
 Nearly 4 out of 10 will demonstrate functional decline by 5 years post-injury, compared to level of
recovery attained 1-2 years post injury.
 Costs of TBI:
─ Direct (e.g., hospitalization, rehabilitation) and indirect (e.g., lost productivity) medical costs
of TBI totaled an estimated $76.5 billion in the United States in 2010.
Source: Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation.
National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA.
11
© Paradigm Outcomes, Proprietary
TBI and Workers’ Compensation
 Head and central nervous system injuries are the most expensive types of
occupational injuries to treat as determined by Workers’ Compensation Claims1
 Falls are the leading cause of work-related injury; a study of TBI workers’
compensation claims found that the next most prevalent causes included being
struck by an object (26.3%) and motor vehicle crashes (18.3%)1
 Other common causes of TBI include sports-related injuries, interpersonal violence,
and alcohol and substance abuse
1
Source: DeVivo, Michael J. Head Neck Injuries in Industries and Sports in Frontiers in head and neck trauma: clinical and biomechanical. IOS press, 1998.
12
© Paradigm Outcomes, Proprietary
Reserving for Acquired Brain Injury
Base Costs
Volatility
 Severity of Injury
 Complexity of injury:
─ Other injuries causing
impairment
─ Mild, Moderate, Severe
 Implications:
─ Other injuries causing medical
illness
─ Extremely variable
─ Brain injury impairments and
complications
• Cognitive deficits
• Physical impairments
 Pre-existing co-morbidity (medical,
psychosocial)
• Behavioral challenges
 Prognosis, expectation for long-term
impairment, late effects and
associated costs
• Paralysis
 Life expectancy
 Jurisdiction: cost of care by state ,
scope of practice, MD practice
patterns
13
© Paradigm Outcomes, Proprietary
At Any Level of Injury, Early Intervention is Key
■ Identification and prevention of
complications should begin as
early as possible
– Proactive vs. Reactive approach
■ Greater awareness and
understanding
– Rehabilitation Centers of
Excellence
– Best opportunity for recovery
14
© Paradigm Outcomes, Proprietary
Effective Early Interventions for TBI
Medication and therapy can prove effective in addressing many issues associated with TBI.
Cognitive
Short-term memory
deficits, hazy/cloudy
feelings,
concentration
problems
Somatic/Physical
Fatigue, insomnia,
headaches, vision
impairment
Emotional/
Behavioral
Agitation, depression,
anxiety
• Neurostimulant medications (Amantadine, Ritalin, Adderall, Provigil)
• Structured environment with a daily schedule
• Compensatory strategies for planning to address memory deficits
• Hormone replacement in cases of pituitary gland impairment (as determined
by endocrine work-up)
• Medications to regulate sleep-wake cycle in cases of insomnia
• Relaxation, biofeedback, activity regulation, medication to address headaches
• Vestibular therapy to address dizziness/imbalance
• Vision assessments and interventions (therapy, lenses)
• Counseling and/or psychotropic medications for mood issues
• Behavioral programming
• Family education/training
15
© Paradigm Outcomes, Proprietary
Characteristics of Mild, Moderate and Severe TBI
Severe
Moderate
Mild
Glasgow Coma Scale 3-8
Glasgow Coma Scale 9-12
Glasgow Coma Scale 13-15
 Low arousal
 Not mobile
 Low responsiveness
 Mobile with some
physical limitations
 Agitation/behavioral
changes may include
irritability and
depression
 Long-term residual
impact
 May not be radiographic
evidence of
hemorrhage/ hematoma
 Identified as ready for
discharge or short rehab
 May be evidence of
behavioral or cognitive
changes
 May be significant
emotional component
16
© Paradigm Outcomes, Proprietary
Identifying High Risk Cases
Data
High Risk
Initial Glasgow Coma Scale score
<8 (severe)
Initial scan results





Coma Duration (GCS)
> 72 hours
Rancho Los Amigos scale

Levels 3-6 most challenging from behavioral perspective (localized
response to confused/appropriate)
Risk factors





Anoxic injury
Status epilepticus/late seizures
Alcohol/substance use/abuse
Neurologic deterioration
Increased ICP (intracranial pressure)
Psychosocial assessment







Family work/instability
Age >50
Psychiatric or Substance Use history
History of non-compliance
Education <12 years
History of developmental/intellectual disabilities
Previous ABI
Depressed skull fracture
Hemorrhage
Multiple injury sites (bilateral)
Midline shift
Ventricular enlargement
17
© Paradigm Outcomes, Proprietary
Stages of Recovery
These stages mark the common treatment levels for ABI patients; likely to take 1-2+ years,
depending on severity of injury and resultant disabilities.
Inpatient
 Acute medical,
e.g. ICU,
Med/Surg,
Trauma
 Sub-acute
rehab
 Acute rehab
Home/
Communitybased
Transitional
 Post-acute
residential
rehabilitation
 Day treatment
program/
outpatient
therapies
 Home-based
supports
 Communityreintegration
18
Long-Term
Supports
 Skilled nursing
facility
 Home (indep./
semi-indep.)
 Supported living
 Social Day Programs
 Voc./Avocational
reintegration
© Paradigm Outcomes, Proprietary
Recovery from Severe TBI
 ~ 35% of patients thought to be in vegetative
state are actually conscious
 Of those patients who were following
commands upon discharge from acute rehab:
─ 8-21% were functioning INDEPENDENTLY
upon discharge
─ 56-85% functioning INDEPENDENTLY by 5
years post injury
 Of those patients who were not following
commands upon discharge from acute rehab:
─ 19-36% were functioning INDEPENDENTLY
by 5 years post injury
Source: Archives of PMR, 2013; 94:1855-60
19
© Paradigm Outcomes, Proprietary
Spinal Cord Injury
© Paradigm Outcomes, Proprietary
What is a Spinal Cord Injury?
Compression or other damage that causes spinal cord injury or dysfunction.
 Incidence total and work
comp
–
11,000 new spinal cord injuries
per year
–
Approximately 1,200 new spinal
cord injury cases per year caused
by on-the-job injuries1
 Traumatic vs. non-traumatic
(medical)
 Not all spinal injuries cause spinal
cord injury and not all spinal cord
injuries involve damage to the
spine
 Key signs of spinal cord
dysfunction
 Causes
–
Motor vehicle accidents 46%
–
Falls 22%
–
Gunshot wounds/violence 12%
–
Herniated disc
–
Non-traumatic causes
–
Paralysis/weakness
–
Sensory change in an anatomical
location
–
Bladder and/or bowel dysfunction
–
Gait disorder
–
Weak arms
 A host of potential medical
problems
1Source:
21
Spinal Cord Injury Facts and Figures at a Glance, 2011
© Paradigm Outcomes, Proprietary
Reserving for Spinal Cord Injury
Base costs
Volatility
■ Severity = NLI (Neurological Level of
Injury)
■ Complexity of injury:
– Other injuries causing
impairment
– Exact level: C1-S5
– Other injuries causing medical
illness
• Tetraplegic: high, low
• Paraplegic: high, low
– Spinal cord impairments and
complications
– Completeness of injury: A, B, C,
D, E
■ Pre-existing co-morbidity
■ Prognosis, expectation of long-term
impairment, late effects and
associated costs
■ Implications: paralysis, neurogenic
bowel and bladder, pain
■ Life expectancy
■ Jurisdiction: cost of acute medical
care by state, scope of practice,
provider practice patterns
22
© Paradigm Outcomes, Proprietary
Severity Determines Rehab Potential and Medical Resources
It depends on the neurological level of injury (NLI) and completeness.
 Neurological Level of Injury
 Complete vs. Incomplete
– Tetraplegia
– ASIA levels
– Paraplegia
– Determine how neurologically
complete an injury is
– Exact neurological level of injury
– Must include a rectal exam
– Based on a very specific physical
exam
– Is there a major chance for recovery?
This is key information to obtain as soon as possible
23
© Paradigm Outcomes, Proprietary
Outcomes by SCI level: Predictable Neuroanatomy
With each intact level comes the potential for greater function.
 Paraplegia (T2-S1)
 Tetraplegic (C1-C8)
– Not all persons with paraplegia
are alike
– C4 and below should be vent
wean-able
– T4 and above have respiratory
issues
– Ventilator dependence can
cost $500,000 per year
– High level (thoracic) paraplegia
have truncal weakness
– Vulnerable to pneumonia and
pulmonary insufficiency
– Low level paraplegia (incl. cauda
equina syndrome)B&B
dysfunction
– All persons with tetraplegia
will need personal care
assistance
– Most persons with paraplegia
will need some level of
support/assist
Source: Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health-Care Professionals.
Consortium for Spinal Cord Medicine, Paralyzed Veterans of America (1999).
24
© Paradigm Outcomes, Proprietary
Stages of Recovery
These stages mark the common treatment levels /phases for spinal cord injury patients;
likely to last 1-2+ years.
Inpatient
Reintegration
Residential/
Community
Maintenance/
Living with SCI
Late Effects
of Disability
 Acute medical ICU, Med/Surg
Trauma
 Sub-acute
rehab
 Acute rehab
 Post-acute
rehab
 Outpatient
rehab
 Establish care
protocols
 Home/personal
care
 Provider
management
 Productive
engagement
 Rehospitalizations
 Declines in
function
 Comorbidities
 Pain Management 
25
© Paradigm Outcomes, Proprietary
Burn Injuries
© Paradigm Outcomes, Proprietary
Stages of Recovery
These stages mark the common phases of treatment for burn patients; can take 3+ years,
for those with severe/extensive burn injuries.
Early Phase
 Medical
Stability
 Acute
surgeries/skin
coverage
 Wound care
 Bedside rehab
Mid Phase
 Aggressive

Rehab
(inpatient/outp- 
atient)
 Secondary

surgeries
(contracture,

scar mgmt)
 Home/pers.
care
 Pain Management 
27
Late Phase
Maintenance of
function
Maintenance of
skin integrity
Adjustment
issues
Voc/Avoc
reintegration
© Paradigm Outcomes, Proprietary
Amputations/Multiple Trauma
© Paradigm Outcomes, Proprietary
Stages of Recovery
These stages mark the common phases of treatment for Multiple Trauma/Amputation
patients; can take 1-2 years, depending on complexity/extent of injuries.
Early Phase
Mid Phase
Later Phase
 Medical stability
 Acute surgeries
(I&D, repair,
stabilization)
 Wound care
 Bedside rehab
 Weight-bearing
restrictions
 Aggressive rehab
(inpatient/outpatient)
 Prosthetic prep
 Secondary surgeries
(revisions, neuromas,
hardware removal)
 Prosthetic training,
advancement
 Maximization of
function
 Vocational/Avocational reintegration
 Pain Management 
29
© Paradigm Outcomes, Proprietary
Tips to Manage More Effectively
How do we make catastrophic cases less volatile?
Early
Late
 Understand severity and complexity of
injuries
 Manage late medical/surgical outcomes
early and concurrently
 Know the acute care facility and engage
the providers
 Address injured worker coping and
adjustment
 Predict/project the course of recovery
 Assure providers address restorative vs.
maintenance/supportive treatment
needs
 Identify medical, rehabilitative providers
with the necessary expertise AND
evidence-based approach
 Know community providers’ treatment
philosophy; establish collaborative
engagement
 Assess and monitor post-acute providers
closely; help determine reasonable/
realistic end-points
 Identify and manage IW and family
expectations
 Proactively identify and address “red
flags”
 Establish long-term supports to ensure
durability of outcomes
30
© Paradigm Outcomes, Proprietary
Current Trends
Innovations in Trauma Care
Game changers
Questionable
The Future
Traumatic
Brain Injury





DOC programs
Concussion Awareness/Mgmt
Pharmacology
Neuro-imaging
Apps/Wearable technologies




Hyperbaric oxygen
Transcranial magnets
QEEG/Neurofeedback
‘Brain-training’

Spinal Cord
Injury



Diaphragmatic pacers
Robotics/Exoskeletons
Tendon/nerve transfers



Spine stimulators
Pain pumps
Body-weight supported
treadmill training



Pharmacology
Stem cell tx
Brain-computer
interfaces
Major Burns


Early excision/closure
Critical care medicine advances
(e.g., oxandrolone)
Temporary skin substitutes
(cadaver, pigskin)
Artificial skin (CEA)
Reconstructive techniques
Laser treatments
Wound management




Hyperbaric oxygen
Fluid Resuscitation
Pressure Garments
Chronic pain RX





3D printing
Stem cell tx
Transplantation
Biomarkers
Non-invasive imaging





31




Brain-Computer
interfaces
Neuro-modulation
Genomics
Stem Cell tx
Biomarkers
© Paradigm Outcomes, Proprietary
Current Trends
Innovations in Trauma Care
Game changers
Questionable
The Future
Amputations
 Myoelectric
prostheses
 “Life-like”
prosthetic gloves
 Osteointegration
 3D printerfabricated
prostheses
 Insatiable demand
for ‘latest and
greatest”
 Secondary
feedback
prostheses
 Direct neural
interface
prostheses
Multiple Trauma
 Dedicated
Trauma Centers
 Multidisciplinary
Approach
 Limb salvage
 Outcome
Measurement
 Pain management
(interventional, RX)
 Genetics
 Limb transplants
32
© Paradigm Outcomes, Proprietary
Exoskeleton:
https://www.youtube.com/watch?v=LOmZx-aE1LM
Brain-Computer interface:
https://www.youtube.com/watch?v=inCvbDLfXBo
33
© Paradigm Outcomes, Proprietary
Direct neural interface prosthesis:
https://www.youtube.com/watch?v=suwZ5D9
bk0M
3D printing for burns:
Limb transplant:
Face transplant:
34
© Paradigm Outcomes, Proprietary
Thank you!
Questions?
Q&A
35
© Paradigm Outcomes, Proprietary