Medical Rehab Matters S2 Ep 1

[Music] Welcome to season 2 of Medical Rehab Matters. We're excited to begin presenting our second series, and to kick off, we're looking back on some of the highlights from three episodes in season one. I'm Patricia Sullivan, co-host and producer of Medical Rehab Matters and AMRPA's Director of Communications. My co-host is Dr. Robert Krug, a past chair of the AMRPA Board of Directors and Vice President of Medical Affairs for the Mary Free Bed Rehabilitation Hospital Advisory Group. We'd like to thank our sponsor, Bioventus, for supporting Medical Rehab Matters. BioNAS, a Bioventus Rehab company, develops medical technologies which include neuromodulation systems, robotic systems, and software-based therapy programs that provide functional and therapeutic benefits for individuals affected by central nervous system disorders and orthopedic injuries to help return patients to active lives. Learn more at bioNASrehab.com. [Music] In episode seven on prior authorization, we spoke with Dr. Carrie Marr, Senior Vice President of Physical Medicine and Rehab Consulting and Education at Brooks Rehab and Michael Long, Rehabilitation Division President at Vibrah Healthcare, Kate Beller, AMRPA Executive Vice President for Government Relations and Policy Development and Dr. Bob Krug, co-hosted this episode. Today we're covering an issue that has been at the top of our policy agenda for years, prior authorization. As background, prior authorization is a practice used by commercial payers, including Medicare Advantage plans, that require plan approval for an item or service. Admission decisions made by rehabilitation physicians are consistently second-guessed and often denied by those with limited to no experience in physical medicine and rehabilitation, causing it best to lasen care or at worst patients being forced into less appropriate settings based on cost rather than clinical need. This is an issue. It's probably number one on our issue all the time, because it's something that we see every day from an operations perspective that we receive referrals from our hospitals, patients that they think are re-hab-- you know, and kind of know that they're re-hab appropriate. And when we're seeking authorization from the Medicare Advantage company, we're getting denied. And the denials even recently have been increasing almost exponentially in restricting care. And it's a shame from a couple of levels, one, you know, from the patients not getting the services that they need. And secondly, from a family perspective, families aren't getting, you know, seeing their loved ones get the care they need and support that the families need. And then, you know, thirdly, from a business perspective, you know, we're losing out on potential clients that we could be seeing in our hospitals. So, Carrie, if you could just sort of walk us through the process for the audience with regard to a patient who is considering an acute rehabilitation hospital and mission, they're at the acute care hospital as an in-patient. There are a lot of regulatory requirements that a facility or rehab hospital has to go through in order to admit that patient. Can you sort of walk us through that process? Absolutely. That's a really great question. So, when a patient is admitted to the acute care hospital for medical, surgical, neurological reasons, it could be a vast number of reasons. And the acute care hospital identifies that the patient now has not only a medical need but a rehabilitation need. They can't quite go home independently like they came in possibly. So, at that point, they're going to look at rehab facilities, skilled nursing, sometimes even a long-term acute care level of care. Most commonly patients fall within the group of an in-patient rehab hospital. Here at Brooks, being the medical director of rehabilitation for the admissions here at Brooks, I'm responsible for the pre-admission assessment following the Medicare rules. And it's a very detailed assessment for these patients that do they have a hospital level of care need? Number two, do they need an interdisciplinary team approach to care? Is there a chance that the patient is going to improve that they'll discharge home? And do they meet and require three hours of therapy a day, most importantly occupational and physical therapy? These are some of the rules that Medicare applies to a patient before coming into an in-patient rehabilitation hospital. So, through a lot for every Medicare patient, including the Medicare Advantage plans. So, we do a very good job, most rehab hospitals, in making sure that those patients meet those guidelines before they ever come into an in-patient level of care. The interesting thing too is when you go to the bedside of the patient who has a Medicare Advantage plan, they don't understand why they even need to be authorized. And they don't really understand the difference between the managed Medicare and the fee for service Medicare. And they're concerned as to why you're just not admitting my mother or father or the patient themselves. So, if you take care of hospitals, Bob, don't want to wait the 72 plus hours to admit a patient to in-patient rehab hospital level of care. And so then the poor Medicare Advantage plan stroke patients ends up getting admitted to skilled nursing. And they're not getting the appropriate post-acute level of care. Those 72 hour response timeframe for Medicare Advantage plans, that doesn't count weekends and holidays. So, to really underscore Dr. Cruz's point, you know, a Friday afternoon prioritization request, while the clock doesn't really even start ticking until really Monday morning. So, we're talking about a five day delay, which is just, at some point, becomes the default in terms of the patient's cancer in the hospital for that long. And we'll need to go somewhere else based again on cost rather than what the patient's actual rehabilitation needs are. And there really is a delay case, because it's not like Monday they pop up with a decision, usually Monday they call us and say, "We need all updated notes," and that delays us to Tuesday or Wednesday, so that it really becomes a very long delay when we come into the weekends. Or holidays. That's another example. I think the other critical point here, and I think the pandemic really highlighted this, is rehabilitation hospitals, there's a reason why they have the word hospital in their name versus a skilled nursing facility, because we have the ability to take care of more complex medical issues. There's physicians there, typically 24/7, patients are getting seen on a daily basis by a medical provider. And when a patient has to go home or go to a skilled nursing facility, when they really should be still at a hospital level of care, it's not just about not getting the necessary rehab that they need, but they often don't have the medical care that they need. And that results in an increased return to the hospital, which costs everybody more money, and certainly is not in the best interest of the patient. Well, Dr. Krueg knows that we have research in physical medicine rehabilitation, showing the quicker you get to rehab the better you do. So these five to seven day delays are, it's just too long, you're eating into the time in which the patients really can benefit from stroke rehabilitation or traumatic brain injury or spinal cord injury, or a medical patient getting up on their feet after a transplant or a COVID pneumonia. So all of these are really important. I would obviously agree with that, but it's not even just that five or seven day delay very often because as I we had already discussed, hospitals can't afford to have a patient sitting in a bed for five to seven additional days. So if they end up going to the wrong level of care, they never get the care that they really needed or it ends up being delayed weeks or months, and they may never get back to the level of care that level of function. So if the patient had a child of otherwise detained, had they gone through in a more expedient way. This isn't meant to be overly critical of CMS, of Medicare themselves. I mean, the folks that work at Medicare and Washington DC are some of the most passionate, smartest, most dedicated public health servants that we have. And they really do care what happens to Medicare beneficiaries. But I think it's incumbent upon all of us because we're boots on the ground that we educate them and make them understand what some of the issues are in the current system. And I think it's not about pointing fingers. It's about coming together all parts of the healthcare system providers, healthcare systems, CMS Medicare, and yes, the payers and figuring out a better way of doing things, a better system. That at the end of the day is going to not be more costly, but provide better outcomes and better patient experiences. Families can initiate an expedited appeal by talking to the acute care hospital case manager and tell them that, you know, they'll know that. know that the peer to peer has been denied, you can ask, well, I want to take it one step further and do it expedited appeal. And then they'll have to do it. So just to clarify, if somebody does move to another level of care, is it still considered in the appeal stage, or is it now a new referral? Because I think I need to understand that. For us, I mean, if they go to skilled and they're unhappy and two days later, they call us, it starts all over again. So we ask for therapy notes. But the way they get to us is they ask the skilled nursing facility case manager. I mean, most people in Jacksonville say, I want to Brooks referral and I want it now. And then it being goes into us and then we shoot a nurse out and we do a lot of sniff to earth and home referrals. In episode nine on spinal cord injuries, our guests were Dr. Christopher Comey from advanced neurosurgery associates in Lawrenceville, Georgia. Dr. James Wilson of physiatrist at Metro Health in Cleveland and Dr. Michael Kelly also of Metro Health. So I'm really excited about this topic and to have with the colleague and a friend Christopher Comey with us. We now neurosurgeoned who I have had the privilege of working with from a number of years in the past to discuss an important topic, which is spinal cord injury and something that continues to be a public health issue in this country. The demographics around it have changed a little bit. And I thought we would open up by just me listing a few statistics that I was able to get from the National Spinal Cord Injury Statistical Center. There's about 18,000 new spinal cord injury cases each year. And the United States approximately 300,000 people living with spinal cord injury in the United States with an average age of injury being 43, which is increased actually from 29 years of age during the 1970s. And that's something I plan to discuss with Chris during this program. About 78% of new spinal cord injuries are male, which we can talk about as well and isn't surprising. And in these times of health equity, it's interesting and I think important to point out that there's a higher prevalence than incidents among non-Hispanic African-American males as well in this country. We can also talk about the causes, motor vehicle accidents continue to be the number one cause, but vehicles are also much safer than they used to be. And falls continue to I think increase in terms of causation of injury and we can touch on that as well. So one of the things that you ported out is that the mean or median age of onset or injury is rising. And it's leading to more of a bimodal distribution of injuries. So classically, people think about the young man injured in a vehicular accident. That's the most classic. But we're seeing more and more elderly folks getting injured with falls, ground level falls. As demographic United States changes, we have a older and more fragile population. I think we're going to see you continue to shift in the median age injury and different injury patterns. One of the frustrating things about studying spinal cord injury systematically from a surgical standpoint is that it's a very heterogeneous disease. Now we see that you have a 23 year old man and you also have an 85 year old woman. They both have a cervical spinal cord injury, let's say, but their physiology and even their mechanism and their spinal anatomy is markedly different. So that's one of the frustrating things from a study standpoint with respect to spinal cord injury. In your experience, are we seeing less injuries happening as a result of car accidents and maybe some of that being replaced by falls or are willing to vehicle accidents, so they're still a while, while still the number one diagnosis, how those numbers going down. I think they're going down a bit because as we said, cars are definitely safer, but you can still can't afford those safety mechanisms by not wearing a seat belt by driving impaired. And also, you know, motorcycle helmets don't confer much protection for spinal cord injury. They do confer protection on motorcycles for head injury, but unfortunately, we're seeing a fair amount of spinal cord injuries from motorcycle accidents as well. I mentioned the concept of being discouraged and realistic regarding cancer cure that patients have, the guilty of that a little bit with respect to spinal cord injury. And I'll be more specific, particularly with regard to timing of surgery. So the thinking was if somebody comes in with a complete motor injury, that's it. There's nothing you can do, but Michael feelings and other people around the world have challenged that notion. And they're now similar to what happened with stroke care. I think what's going to happen in the next 10 years is that there's going to be a much more aggressive surgical stance regarding spinal cord injury. And there's already been several studies that have looked at early surgery defined as, you know, one study designs it is within 24 hours. Several other studies have looked at surgeries in eight hours. And they're finding that there's not an increase in complication risk, but there's an increase that statistically significant in motor levels gained with earlier surgery. So it used to be patient comes in injured, you try to prevent hypotension, you treat them supportively. And then if they needed a stabilization for a spinal fracture, you do that in a couple of days. The paradigm is moving to as long as the patient isn't unstable from other injuries. The paradigm is shifting to more rapid early surgery to decompress the spinal cord and stabilize the spine. In some cases, that will give dramatic results with respect to long track function regain. In other cases, it might give a segment or two of benefit that, you know, as you know, better than I do, that that can be the difference between full independence and independence with minimal dependence with support. So that's probably the most exciting thing is proving to ourselves as surgeons that early intervention is going to make a difference for patients. So as you mentioned, there's a number of patients that will have an incomplete injury. Not that there's any magic about it, but the first 24 hours are critical. So if an elderly person comes in and they fell three days ago and they haven't had any sensory or motion movement in their lower extremities, it's unlikely that you're going to get them bound. A converse would be a young person that has an incomplete injury after, you know, a car accident or a football injury, they can still, you know, move their big toe and they still have some reserve sensation. Those are the people that I'm inclined to be extremely aggressive with because I know the signal is getting through, albeit impaired. And those are the people that will be very aggressive and usually take the surgeries as soon as we safely can. I mean, rather be in the situation where we did, even if it didn't work, we did something and we were aggressive to try to get them every bit of function they could preserve or gain back. And I think it's important for families to and patients to have that hope and understand that the odds and the statistics are just that, odds and statistics and people deserve chances to be that other side of the coin, so to speak. Correct. I'll often tell families that the yard snick for recovery is months, not hours or days because it's the second most sophisticated organ in the body after the brain. And while it can heal, it's extremely complex, so it's healing takes a long time. So it sounds like you're both saying it can be a tough long road, but there is a certain degree of help. And I'll tell the families that please get some rest and please pace themselves because it is a marathon. And the patient, their loved one is going to need them two months from now, six months from now. And if they burn out in the first two weeks, that's not going to help anybody. I'm just curious, you know, from a neurosurgeon's perspective, a trauma, trauma, telegis perspective, where is the current thinking in terms of how quickly rehabilitation should get in there and start mobilizing the patient and doing their thing? That's a great question. I think it's all about that and treating these patients early and quickly because the sooner it's a patient comes in with a spinal cord injury and they need surgery, more quickly we get to those patients and get them decompressed or stabilized, the more they can be mobilized. And so we found actually in studies here and other and elsewhere that you reduce the complications associated with the QBDI pneumonia and prolonged get to patient. And the benefit too is Dr. Wilson can attest is that I-I-C-I rehab team sees patients pretty much immediately as soon as they're stabilized in the ICU to begin the rehab process. So getting a patient to surgery if they need it and getting them stabilized or decompressed allows them to get out of the ICU faster and get to rehab more quickly. And in Metro, we have the SA rehab doctors involved in the care upfront. Basically, you know, soon as they're stabilized in ICU, we get a spot where the jury have involved and they can help us to work on ventilator weaning and transitions to rehab almost immediately. These things are very beneficial to patients, the regressions delays to care and then hopefully improvements in functional outcomes. So all these things happen to Metro pretty much immediately and it all starts with day attacin-definitive care from a surgery standpoint as soon as possible. many potential complications that need to either be avoided or managed effectively, whether it's neurogenic bound, blood or ornament dysflexia, skin bright down and so forth. And having a team that really understands those problems, rehabilitation nurses, therapists, obviously, possessions is so critically important. So can you just speak to that? I 100% agree that's usually how I end my interactions with new patients when I've met them that the biggest focus for me in their acute care stay is preventing complications. And that when the nurses say they're turning, they have to turn, and when they say, you know, to do this for their bowels and do this for their bladder, that they really need to listen. You know, we want to get them into working hard and doing therapy and rehabilitation as soon as we can, but you have many complications is really, really important. And honestly, it's one of the biggest focuses of our acute rehab stay that patient education, family education, having them understand how to direct their own care, what things they need, what things how to ask for help to prevent further medical and neurologic complications. It's a big focus. In episode 10 on Brain Injury, we spoke with Dr. Richard Coons, a physiotherapist and associate professor at VCU and chief medical officer of the Sheltering Arms Institute Department of Physical Medicine and Rehabilitation, and Dr. Daniel Klice, a licensed clinical psychologist and board certified rehabilitation psychologist. He serves as the rehabilitation psychology advisor at the Sheltering Arms Institute. I'm not sure if I'll truly recognize, you know, how big of an issue this is, you know, nationally. We have 5.3 million, actually more than 5.3 million Americans living with a permanent brain injury related disability in the United States, approximately 180,000 hospitalizations, 36,500 deaths annually. And the causes of TBI, you know, certainly can be varied, but the most common is a fall. And as the population continues to get older in this country demographically, we're going to be seeing more and more of this. And so it really is going to be a growing healthcare crisis, I think, forward. And we really do need prevention, public awareness, and increasing access to brain injury facilities and experts like yourselves to manage this difficult problem. You've been talking about veterans and people in the military, active duty service, people have been injured in war. But the CDC has spread out in the report that older people, people 55 to 64 and 65 to 74 and then over 75, increasing levels, increasing numbers, they are the ones who are in hospitals for TBI. How does that integrate? Is the fact that they're older and possibly sicker leading to falls that cause brain injuries or they're my reading number? Yeah, it can be a little bit of both, right? Sometimes for the elderly population, the fall itself leads to the primary diagnosis to an issue. But in that said, they may still be admitted to the hospital, come to the MP should rehabilitation unit, but they have several co-morbidities just by virtue of age and general health. Yeah, we should clarify that I think we were talking about when Dr. Krugas, what is changed or what's different. The injuries and the stuff we're seeing coming out of the conflicts in Iraq are not a matter of volume to your point, but rather that that has driven research and inquiry in the area and awareness of the injuries in large part. But you're right, as the baby boomers, right? If you look at civilian demographics, they are the bulk of the folks that are coming in with these injuries and their falls and sub-role hemorrhages, these kind of things. That's more acquired, or at least could be. So the patient either has several co-morbidities that were pre-existing that affect their medical management in the rehabilitation space versus they've just had such a serious injury that it includes a lot of other trauma and organ systems that are dysfunctioning beyond the brain, the nervous system. So when the patients come home, what kind of help or support or education do the families and caregivers need before they get there? Yeah, so that's kind of the tricky piece about traumatic brain injury. It's the variety of ways that disability or impairment might end up being expressed following a injury like that. When you get together a brain injury, re-apt, and you're going to have providers who are all focusing on different aspects of recovery, right? The physical therapist focusing on mobility, strengths, balance, these types of things. The occupational therapist, like Dr. Ken Shescrib, took us on this activity of daily living. So everyone's kind of looking at this piece of the puzzle in the context of the overall recovery trajectory and it really depends on what the most salient needs might be. Now for someone with a very severe traumatic brain injury, a family might need to be prepared to do a lot of hands-on care-giving for some of those basic ADLs, activity, they living things like toileting or bathing, dressing, right? That maybe some of that someone requires a lot of assistance with or simply doing the transfer out of a bed to a wheelchair, for wheelchair to a standing position. Someone might be on a modified diet where a speech with solidities has been working on and then impaired swallow. So a family might need to be prepared to coach someone through safe swallow strategies as well as prepare an altered diet that would reduce the risk of some sort of chocopying or aspiration of it. So I mean on the severe end, it might be a lot more of that hands-on medical oriented management of a person's just kind of day-to-day functioning through those typical activities. Layered on top of that, on top of the physical impairment, right? You might have what Dr. Kahnum says describing a variety of cognitive impairments, either impairment across multiple domains or specific things like problems with learning memory or attention concentration that affects a house and when it interacts, interpersonal with people. That can wreak havoc for families where you know now there's a huge reversal of roles, right? Think of a married couple who were used to relating to each other's partners now once in a care-giving role, really taking care of the other one. That can affect not only that dynamic and how it might play out with other members of the vaccine, who were part of this entry event. Young children or older adults who might also be on the wrong, but you know just basically things like intimacy that we think are important to relationships. You know, your respective of like physical impairment that affects sexual functioning, but just sort of the cognitive and emotional awareness all that we need to be into the partners with people, right? Like I said, I've heard before is you know a spouse who may not remember that they were engaged into that activity earlier that day and this now can play, why don't we ever have this part of our release? It should be more someone who can't perspective to take to sort of do that. That might also be expressed as really problematic or inappropriate behaviors in the community. Someone who doesn't have the ability to inhibit a response that could be aggressive or really inappropriate. Someone who might not be able to think through the consequences of their actions and is there for it higher risk for coming into contact with a law enforcement officer, right? Who may not have the immediate recognition that this person does have a disability given the invisible aspect of of rage yourself absent that polytrauma, right? The signs of injury, a cast, they're a wheelchair, what have you, you know, it might not be obvious to some of this person has been through a significant medical event. So you know we ask families, I think, to do a lot, right? So they may be training on these specific types of skills for management of the medical, physical, cognitive, behavioral aspects of brain injury. And I think we do a decent job in that short length of state that we have of orienting people towards the information that they need and in fact, and a lot of the research that we do around families perspective on needs that are met by an patient care. So it's generally satisfied that they get good information about, you know, what's going on is my loved one, what kind of problems do they have? I think where people begin to identify unmet needs after they've made it a transition to the community. There's clearly a lack of access to emotional support, whether that's formal or informal, the ability to talk with someone who's loved one has been through a similar experience. And so you know, we try to lean heavily on our charity partners like brain-dreams, associations that are local and then have support groups for that. I mean those people, those organizations are truly co-equal members of three-abilitation teams just because they are up the community. They have people who have the perspective having been through something like this before. But then also the instrumental needs to come quite salient for people. And that may be lost productivity. If I'm in a charity of enrolled as a family, then I'm not able to work, right? I'm not able to bring home some of the resources that have otherwise supported our family and that livelihood is lost or just being able to take time for yourself to go do the things you need to do that you've otherwise taken for granted. So you know, I think we have, for better or worse, just a lot of the responsibilities for that post-acute care on the charity of these families. We ask a lot of them. We try to put the resources together for them, but it is at all order. You know, we could just go back to when a patient is more in the the acute to sub which you'd phase a brain injury and come into a rehabilitation hospital for treatment. The expertise and the understanding of the staff, whether it's the nurses, the therapists, and communicating that to the families, the fact that the patient is having trouble focusing with attention, processing information, you know, you or I, right, we can go to a cocktail party and have a conversation, but for folks with brain injury very often, there's all this sound and weight noise is hitting them and they can process it all and it gets interpreted as confusion. It can make them disoriented, agitated, and if you don't know how to treat it appropriately, we understand what's going on. And while this doesn't happen anywhere near to the frequency that it did maybe 10 or 20 years ago, it still does, people are inappropriately medicating these patients, sedating these patients, right? Oh, they're agitated. Well, let's give them, let's give them how to all or some other kind of suppressant. And you're actually prolonging the confusion and agitation or making things worse and losing valuable time, right? And managing these patients. So, you know, Dr. Kinsley, if you could just sort of take my lead there and talk about that a little bit, that would be great. - That's a great point that you're bringing up. So the clinical situation that you described, there is one place for that patient who one place only, right? And that's an inpatient rehab facility with brain injury specialty expertise. Like a skilled facility is gonna have trouble managing those patients, the acute care services oftentimes to your point are really overwhelmed. You have to have that specialized neuro rehabilitation team if you're gonna effectively get these patients from the ICU and that job really does start in the ICU, not on the step down, not at our front door in the earth. There is no neurosurgeon in my facility that I don't know very well. Maybe some of the spine guys, right? But you know what I mean? Like generally speaking, I know all my traumatologists, I know all of my neurosurgeons, I know all my neurologists because you are working with these folks within 24 hours of that patient being admitted. To your point, these patients can be confused for something more like dementia, right? And you're going down a management pathway if that's the perspective that is not gonna end well. And you know, that's not gonna work for those patients. If you can provide these patients a safe, secure unit with the right type of staff, you can actually reduce their medication list. You can create a much more optimal environment. Again, it's worth pointing out that that's precisely where we're being squeezed right now. The shortening those days, these patients, in fact, need more time in those environments to be able to really get them to a place where cognitively, they're able to transition home. And I wanna add something to Dr. Clices comments. And this really from what you asked is well, Patricia and Dr. Krueh Glatt with, when it comes to that elderly population and the folks who are having falls and they're on anticoagulants and they're more prone to bleed, this oftentimes is the difference between them going back to the community at all. Because the heavy lift that we ask the families to do to provide that supervision, 24/7 supervision for an elderly patient who is living independently, that may be the difference between them being unable to successfully go back to the community and live independently and winding up in another post-acute care location. And I've seen many times where it's precisely because the family simply cannot not go to work. They cannot, they can't take that time away from work that is necessary. And so you really have to make sure that you are effectively using your resources in the acute care environment and the earth environment to create as a promise of a situation as you can. - Dr. Krueh Glatt, I appreciate you taking the point about resilience because we've been talking about how multi-form the problem is for families and trying to manage the different aspects of impairment or disability after brain injury. And so it would be really unfortunate to paint the picture that this is just gonna be devastating for everybody, right? 'Cause that's not necessarily true. People do recover well for brain injuries and families do well. And there are positive aspects of having been in that caregiving role that are really valuable to people. A lot of the times what we'll see is that caregiving families not only rise to the occasion, they're really knocking out of the park and those are people we need to learn. What's the magic here? What are the skills or the ways of seeing things or the ways of coping with diversity that make them so successful in that way? You know, so we talk about a lot of different constructs and brain injury in among caregiving families, things like resilience, which you people have sometimes talked about as the ability to bounce back from a desiccene of medicine. And we like to think of it more as bouncing forward. I think whatever our colleagues just courts might have coined that term and saying, it's not just kind of bouncing back to where you were, but growing from that inflection point in the life of the family where trauma interrupted and they're normally doing things. Or things like post-traumatic growth, right? You've had this event that has kind of shattered your understanding of the way things are. But the upside to that is now that the table is clear to build fresh and stronger, right? And the often we'll frame that for patients and families in the inpatient setting is like, this is an opportunity to get healthy across the board, right? And we can talk about things like preventing secondary injuries or illnesses as results. So we can focus on kind of the dysfunction or you know, receive behaviors or whatever it was, might have brought someone to the experience of brain injury, but thinking about the wellness pieces of how do we thrive and doing good going forward from here and saying it's healthy as possible. So it's so important to make the point that, you know, this isn't just sort of a brain injury, which always not a monolithic thing. It's not sort of an experience that all families are going to find to be devastating, but there are people who do really well. And we would do well to not only focus on the problems, but also the things that go right and how we can learn from that replicated author interventions for people to try and develop those skills for ways to see things. And that's a lot of the focus of the work that we do. (upbeat music) - Bioness, a bioventus rehab company, develops medical technologies to support recovery for people living with the effects of stroke, brain injury, amazs and other conditions. The Bioness portfolio of products includes functional electrical stimulation systems, such as the L300 GoDrop Foot System and the H200 Wireless Hand Rehabilitation System. The Bioness Integrated Technology System fits a software-based therapy platform that uses an interactive touch screen display to challenge, assess, and track vision, cognitive, motor and balanced efficiencies. The vector, gate and safety system is a seemingly mounted robotic dynamic body weight support system designed to accelerate physical rehabilitation of patients with severe gate or balance impairment. Bioness combined portfolio helps drive efficiencies and improve patient outcomes for healthcare providers. Learn more at bionessrehab.com. - Thank you for listening to Medical Rehab Matters, a podcast by the American Medical Rehabilitation Providers Association. AMRPA would like to thank podcast sponsor Bioventus, as well as their 25th anniversary platinum partners, Bioness, D-I-H and Select Medical. You can learn more about medical rehabilitation at AMRPA.org. If you like what you've heard in this episode, please subscribe and leave a review. Thanks for listening. (upbeat music) [BLANK_AUDIO]