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Home / Four reasons for investing in inpatient brain injury rehabilitation
By Dr Sara da Silva Ramos, Senior Research Fellow at Brainkind
There is no doubt that providing rehabilitation for people with acquired brain injury (ABI) is the right thing to do, if we are to optimise recovery [1]. However, at a time when the whole world appears to be under never ending financial pressure, we looked at the most recent evidence regarding the value of investing in inpatient brain injury rehabilitation.
Inpatient brain injury rehabilitation is expensive – there is no doubt about it. There are the so-called hotel costs, incurred in providing basic things like administrative and managerial support, as well as accommodation and food, and there are also the costs of providing a specialist multidisciplinary team, and equipment, without which the possibility of progress would very likely be compromised [2].
In the UK, inpatient brain injury rehabilitation is often funded by the public purse, and free for patients who are deemed by funders to need it. As funds are, sadly, not unlimited, it is important to understand the benefits that inpatient rehabilitation can bring in terms of outcomes for patients, but also to understand whether the costs of providing it can be recouped within a reasonable time span.
One of the most direct cost-benefits that inpatient rehabilitation can offer is in the long-term reduction in the costs of providing ongoing supervision and care.
For example, a patient might not be able to be on their own immediately following a brain injury, because they are not able to move about the house, may need help getting dressed, may need someone to support them while preparing a snack or a hot drink, or someone to ensure they are safe while eating or drinking it. A person might not even be able to act in an emergency.
However, rehabilitation, such as that which Brainkind provides, can help the person re-acquire many of these skills, or find ways of circumventing their difficulties, ultimately allowing them to live more independently.
While before rehabilitation our hypothetical patient might require the presence of a carer, for a significant part of the day, they may need only a few short visits, or no support at all, after rehabilitation.
Several studies [3], including one recently carried out in Australia [4], have demonstrated that rehabilitation, including inpatient rehabilitation, does enable patients to regain independence, and that as a consequence, the costs to the state of supporting people in the long term are also reduced.
One of the most novel aspects of this latest study [4] is that the researchers were able to evaluate outcomes up to three years post-injury, providing robust evidence that the benefits seen at the end of rehabilitation do not just ‘disappear’ after the programme has ended and people are discharged. They are maintained over time.
As Lannin and colleagues [4] point out, many studies investigating the cost effectiveness of inpatient rehabiltation have used measures that best capture physical disabilities, raising the question as to whether comparable outcomes would be achieved for people with ‘hidden’ disabilities resulting from cognitive or behavioural problems.
The answer is ‘yes’. Similar benefits can be gained from a neurobehavioural approach to rehabilitation, where the primary needs are often psychosocial, and where the aims of rehabilitation focus on increasing people’s abilities to engage in activities, and participate in social life through work, education or hobbies.
Studies by Wood and colleagues [5], Worthington and colleagues [6], and Oddy & Ramos [7], consistently showed that people with brain injuries could become more independent and thus require less support from paid carers over time, after a period of post-acute community based inpatient rehabilitation.
As well as finding evidence of clinical and financial benefits from rehabilitation for ‘hidden’ or ‘invisible’ disabilities, these studies also found that such benefits could be achieved even among those admitted ‘late’ (> 1 year) into rehabilitation, giving strength to the idea that ‘it’s never too late to rehab’.
Many of us working in this field, as well as people with brain injuries and other stakeholders, acknowledge that the potential benefits of rehabilitation, including financial ones, are not limited to those brought about by reduction in direct care. Rehabilitation can empower people to regain the skills they need to later go on and thrive in their personal, social and / or professional lives.
A more independent person, will be able to start focusing on finding a job, or even if they are not able to do so due to the severity of their disabilities, maybe their partner, spouse, parent or child, is able to return to work after a period dedicated to supporting them.
As the great George Prigatano pointed out [8], we all need three things in life: work, play and love. So, as well as returning to work, rehabilitation can help people with brain injuries engage in activities that they enjoy, or improve their relationships, even find new ones, increasing their wellbeing and reducing the risks of developing health problems later down the line.
Indeed, a study by Van Heugten and colleagues [9] demonstrated that after rehabilitation people were less likely to need healthcare services, and productivity losses from non-paid carers’ inability to work was reduced. Studies looking at these indirect benefits, especially over time, are quite difficult to implement, so there aren’t many of them, but the evidence so far is convincing.
But who, really, are the beneficiaries of these ‘savings’? It’s not like they would materialise in cash back or vouchers for taxpayers.
The answer is ‘we all are’. Although in practical terms, at least in the UK, money for rehabilitation comes from the healthcare budget, and the savings will likely be seen on different governmental budgets, such as local authorities’ social care, work and pensions, and so on, we all stand to benefit.
Money saved in one part of the system, can be freed up to invest in other things. Maybe more people can be well and engaging in some form of activity that will result in increased productivity and a growth in the famously sluggish GDP (Gross Domestic Product).
However, people who are well and happy may be less likely to need care and treatment. They may also be less likely to stop being able to pay their bills and become homeless, or to get caught up in a moment of impulsivity and end up committing an offence [10, 11].
Of course, these things do not happen to everyone who has a brain injury. However, becoming homeless or going to prison does seem to happen more often for those who did not access appropriate assessment or support for their injury at the right time, as for many in these situations, the brain injury occurred prior to becoming homeless or going to prison [12, 13].
Also, not everyone who has a brain injury will need inpatient rehabilitation. Neuroplasticity is ‘imperfect’, but improvements after milder injuries can be remarkable, through spontaneous recovery and adjustment, even without the provision of inpatient rehabilitation.
Nevertheless, the evidence of the benefits, clinical and financial, of inpatient rehabilitation, are out there for all to see. It is a safe investment – for the public purse, and for a fairer society. And it is also morally the right thing to do.
We cannot simply look at the monetary value, or ‘price’, of what rehabilitation costs for each individual person to reap the benefits of a positive outcome after a brain injury. What if they were your loved one? Could you?
