PROJECT INNOVATION 3: BEHAVIOR MANAGEMENT IMPLEMENTATION BLUEPRINT - TEAMBI

A playbook designed to resource providers to implement evidence-based behavioral interventions on inpatient rehabilitation units.

THE QUALITY OF CARE GAP

  • Behavior change is common after traumatic brain injury (TBI).
  • There is a gap in workforce training in addressing behavioral changes using evidence-based environmental management.
  • This critical gap results in negative outcomes for persons with brain injury and the healthcare system.
  • These negative outcomes include barriers to accessing rehabilitation, over-reliance on medications, and increased rates of staff injuries, burnout, and turnover.

  • Compared to physical or cognitive changes, providers feel less confident in addressing behavioral changes.
  • Most rehabilitation providers do not receive formal training in evidence-based behavioral strategies.
  • This lack of training creates substantial economic impact within the healthcare system from staff injuries, burnout, and high rates of staff turnover.

  • Because not all providers have experience with or access to best practices for behavior challenges, a comprehensive guide is needed to support healthcare delivery.
  • Input from providers, persons with lived experience, and care partners is necessary to develop tailored educational materials about behavior changes.
  • Manuals and resources are needed to support the adoption of evidence-based behavioral strategies during inpatient rehabilitation.

What are challenges to have effective programs that manage maladaptive behaviors? "Limited knowledge of the nursing staff regarding TBI, anticipated behavioral issues, and appropriate management strategies".

Inpatient Rehabilitation Provider

PROJECT INNOVATION: HOW ARE WE SOLVING THE PROBLEM?

"TEAM BI PLAYBOOK” INNOVATION

I-HEAL’s TeamBI is developing a playbook to address TBI-related behavior changes. The TeamBI Playbook will contain materials to train staff and provide strategies to facilitate implementation in rehabilitation settings. The manual will include strategies on how to foster a positive team environment, improve communication between healthcare providers and patients, and best engage family members in order to support the transition home. This project's innovation includes the following objectives:

  1. Co-design a team-based behavioral interventions (BI) playbook through engagement of rehabilitation providers, persons with brain injury, and family members/care partners.
  2. Validate, refine, and disseminate the TeamBI playbook.
Image 1

The I-HEAL team will partner with subject matter experts to adapt an existing manual and blueprint for managing the challenges of persons living with TBI.

Image 2

We will validate the TeamBI Playbook to ensure it accurately addresses the needs of persons with lived experience of TBI and their care partners.

Image 3

TeamBI will pilot the playbook with healthcare policy and professional partners to gather feedback on how best to implement TeamBI Playbook within rehabilitation settings.

HEAR FROM OUR LIVED EXPERIENCE PARTNERS

Person 1

I-HEAL Partner, Nikki Davis, describes how environmental management rather than polypharmacy effectively manages challenging behavior saying: "Effective management of challenging behavior following brain injury relies not on excessive medication, but on structured environmental modifications that reduce triggers, support cognitive function, and encourage adaptive responses. Polypharmacy often masks symptoms rather than addressing their root causes, whereas strategic environmental adjustments—such as routine consistency, sensory regulation, and clear communication—empower individuals to navigate their world with greater stability and success."

Meet I-HEAL's Third Innovation Team

Photograph of Dr. Bogner

Jennifer Bogner, PhD, ABPP-RP, FACRM

Principal Investigator

Dr. Bogner’s relevant areas of experience include extensive research on measurement and treatment of agitation and other maladaptive behaviors following TBI, family involvement in rehabilitation, and the development and dissemination of implementation tools to improve inpatient rehabilitation evidence-based practice.

Photograph of Dr. Kretzmer.

Tracy Kretzmer, PhD, ABBP-CN

Principal Investigator

Dr. Kretzmer has primarily worked as an inpatient neuropsychologist, with clinical expertise in treating individuals with brain injury. She has participated in research activities focused on the evaluation and development of evidence-based interventions for individuals with TBI, and co-led the preliminary study for this project with Dr. Nakase- Richardson.

Photograph of Dr. Richardson

Risa Nakase-Richardson, PhD, FACRM, FNAN

Co-Principal Investigator

Dr Richardson has published extensively on the neurobehavioral consequences of TBI resulting in two position statements defining clinical phenotypes at risk for maladaptive behaviors and competency standards for inpatient rehabilitation teams. She developed team-based learning programs for managing maladaptive behaviors after brain injury and has mentored early career professionals in collaborative projects examining patient and healthcare system impacts of maladaptive behaviors including access to care.

INDIVIDUAL ENGAGEMENT PARTNERS

I-HEAL’s Individual Engagement Partners (IEP) ensure our work is relevant for healthcare settings. Each project has its own set of IEPs that engage with the I-HEAL project’s team throughout the grant. Project 3’s IEP are:

  1. Chris H. Persel, MA, CCM, CBIS, CPHM
  2. Shanti Pinto, MD
  3. Daniel Klyce, PhD, LCP, ABPP
  4. Arielle Reindeau, MS, BCBA
  5. Jill Massengale, DNP
  6. Kathryn Kieffer, MS, CCC-SLP
  7. Barbara Darkangelo, PT, DPT, NCS, ATP
  8. Meghan Geiss, PhD
  9. Melissa Johnson, RN
  10. Mary Kate Beals, SW

I-HEAL CORE PARTNERS

  1. Dr. Rebecca Campbell-Montalvo | Data and Communication Core
  2. Cassandra Decker | Data and Communication Core, Operations Core
  3. Dr. Natalie Gilmore | Operations Core

PROJECT INNOVATION 3'S INDIVIDUAL EXPERIENCE PARTNERS

Person 1

Chris H. Persel, M.A., CCM, CBIS, CPHM, Regional Director of Clinical Services, Director of Behavior Programming. Chris Persel has worked in the field of post-acute traumatic brain injury (TBI) rehabilitation since 1980. He is currently the Regional Director of Clinical Services and Director of Behavior Programming for Centre for Neuro Skills (CNS) and serves as the Chairman of the "Rehabilitation and Independent Living Special Interest Group" for The Association for Applied Behavior Analysis International. Mr. Persel has extensive experience in the design, implementation and staff training of functional skill development and behavior change programs. He has over 20 years experience training crisis intervention including being certified to teach “Behavior Tools”, “Professional Assault Response Training” and “Management of Assaultive Behavior.” He is a Certified Case Manager, a Certified Brain Injury Specialist and has been a Board Certified Associate Behavior Analyst and Certified Professional in Healthcare Management. Mr. Persel has given numerous presentations on behavior programming and rehabilitation concepts with the TBI population including for statewide and national conferences. He has provided consultative evaluation and coordination of home treatment programs, actively participated in the development of a living skills assessment scale and been instrumental in developing clinical information management systems. In addition to his educational presentations, Mr. Persel has co-authored a chapter on behavior programming in an edited text entitled Traumatic Brain Injury: Rehabilitative Treatment and Case Management, 4th Edition, published by CRC Press, Inc. of Boca Raton, Florida, and co-authored Working with Behavior Disorders: Strategies for Traumatic Brain Injury Rehabilitation, previously published by Communication Skills Builders, Tucson, Arizona. He has authored or co-authored several articles regarding topics that impact brain injury rehabilitation including behavior, COVID-19 and malingering. In 2014, he was named by the Brain Injury Association of California as the “Outstanding Professional in the Field”.

Shanti Pinto, MD is an Assistant Professor in the Department of Physical Medicine and Rehabilitation at the University of Texas Southwestern Medical Center with subspecialty certified in Brain Injury Medicine. Her current position is 0.5 FTE clinical and 0.5 FTE research. She serves a co-investigator for the NIDDLR funded North Texas-Traumatic Brain Injury (TBI) Model Systems. The TBI Model Systems includes 16 national centers that are collecting longitudinal outcomes up to 30 years following moderate to severe TBI. She has over 20 publications in peer reviewed journals and book chapters focused on traumatic brain injury. Clinically, she treats patients with TBI as part of the Physical Medicine and Rehabilitation consultation service at Parkland Hospital, one of the largest county hospitals in the nation, as well as in my outpatient clinic at UTSouthwestern.

Person 2
Person 1

Daniel Klyce, Ph.D., ABPP, is a board-certified rehabilitation psychologist in Richmond, VA. He serves as the co-principal investigator for the Department of Veterans Affairs Polytrauma Rehabilitation Center Traumatic Brain Injury Model Systems (PRC-TBIMS) project at the Central Virginia VA Health Care System. As a clinician, he has practiced primarily in the setting of inpatient brain injury rehabilitation. Dr. Klyce serves as the Rehabilitation Psychology Advisor for the Sheltering Arms Institute, a Collaboration with Virginia Commonwealth University Health System, where his role involves clinical knowledge brokerage and consultation to interprofessional treatment teams. He is an associate professor (affiliate) in the Department of Physical Medicine and Rehabilitation and was the primary psychologist for the inpatient brain injury rehabilitation service at VCU Medical Center from 2013-2020. Dr. Klyce have served as a research associate, co-investigator, and principal investigator with VCU’s TBIMS program, funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). He has authored or co-authored multiple peer-reviewed articles related to brain injury or rehabilitation, and he is an incoming associate editor of my field’s flagship the journal, the American Psychological Association’s Rehabilitation Psychology. Dr. Klyce serves on the board of directors for the Brain Injury Association of Virginia and the Academy of Rehabilitation Psychology.

Arielle Reindeau, MS, BCBA is a Board-Certified Behavior Analyst (BCBA) with 10 years of experience using the science of Applied Behavior Analysis (ABA). Arielle has served populations with special needs, developmental disabilities, and acquired brain injuries. She has served in school, residential, home and hospital-based settings. Arielle is the first BCBA to work full-time within a TBI Model Systems Hospital serving as the Neurobehavioral Rehabilitation Supervisor at Craig Hospital. In her position she utilizes the science of ABA to create individualized behavior plans, individualized data collection systems, hospital-wide education on behavior management and individualized protocols for skill acquisition and/or behavior reduction. Arielle runs a team of BCBAs and Registered Behavior Technicians (RBT) that function as a support staff for any escalated behavioral events. She is an early career researcher with primary focus in behavioral management on inpatient brain injury units.

Person 2
Person 1

Jill Massengale, DNP is a Registered Nurse at James A. Haley Veterans’ Hospital in Tampa, Florida. For the past five years, she has practiced as the Chief Nurse for Nursing Education/Research/EvidenceBased Practice facilitating dissemination of research findings and implementation of evidence-based practice. Dr. Massengale has 10 years of experience as an Advanced Practice Registered Nurse diagnosing and treating individuals with brain injury. Her research activities have primarily focused on traumatic brain injury populations, including TBI characterization, TBI comorbidities, and caregiver quality of life. She has published over 20 peer-reviewed manuscripts in journals such as Archives of Physical Medicine and Rehabilitation and Rehabilitation Psychology. She has served as site PI and Co-I on several local and multisite funded TBI research studies.

Kathryn Kieffer, MS, CCC-SLP is a certified speech therapist at the Tampa VA with 25 years of experience in treating individuals with brain injury. In addition to her primary clinical responsibilities she also serves on the National VA Emerging Consciousness work-group, to develop toolkit for caregivers, staff and stakeholders in delivering best-practices care. She has also served as the program lead of the inpatient Polytrauma brain injury unit for 8 years, overseeing rehabilitation staff, program development and hospital accreditation standards. She has presented and published with Project 3 PI, Dr. Kretzmer on TBI behavioral management and community reintegration.

Person 2
Person 1

Barbara Darkangelo, DPT is a physical therapist with over 20 years of experience. She currently serves as PT Team Leader at James A. Haley VA Polytrauma Unit. Responsibilities include training PT residents, assisting in program development at the local and national level and assisting in the managing of CARF standards for both Brain Injury and Stroke unit accreditations. She has primarily worked in inpatient TBI rehabilitation units, and within interdisciplinary team settings. Dr. Darkangelo is a Neurological Clinical Specialist certified by the APTA since 2008. In addition to her clinical duties she have been involved in research that examines the impact of TBI rehabilitation treatment paradigms on long-terms outcomes.

Dr. Meghan Geiss is a Rehabilitation Neuropsychologist at the Polytrauma Rehabilitation Center, an acute rehabilitation inpatient unit for veterans and active-duty service members presenting with acute rehabilitation needs at the Central Virginia VA Healthcare System in Richmond, Virginia. She received a master’s degree in rehabilitation counseling at the University at Albany, State University of New York, and earned her Ph.D. in counseling psychology at the University of Memphis. She completed her clinical internship at the Malcolm Randall VA Medical Center in Gainesville, Florida, where she worked with veterans in polytrauma settings.

She has concentrated her clinical and research efforts on acute and post-acute rehabilitation issues among U.S. veterans with a history of Traumatic Brain Injury, including sleep behaviors. Dr. Geiss is a member of the American Psychological Association Divisions 40 (Society of Clinical Neuropsychology) and 22 (Society of Rehabilitation Psychology), the American Congress of Rehabilitation Medicine, and the National Academy of Neuropsychology.

Person 2
Person 1

Melissa Johnson is a dedicated registered nurse with 11 years of experience in critical care and rehabilitation services. She currently serves as a clinical care coordinator at James A. Haley Veterans’ Hospital delivering compassionate care to patients with traumatic brain injuries. She is committed to enhancing patient outcomes for her TBI patients. She received her BSN from Bellarmine University in Louisville, Kentucky and is currently working on her Master of Nursing degree at Capella University.

Mary Kate Beals, LCSW, became TBI Polytrauma Family Therapist at the James A Haley Veterans Hospital in Tampa, Florida in December 2010. Mary Kate has been a Licensed Clinical Social Worker since 1997. With over 30 years of clinical experience, and has specialized training in mental health, focused on treatment of persons with severe and persistent mental illness, PTSD treatment and family therapy. In her current role, she provides individual, family group psychotherapy, and education, supporting primary caregiver(s) to our Wounded Warriors and Veterans of the Armed Forces. Mary Kate has worked in a variety of clinical settings, including case management, community mental health, and psychosocial rehabilitation. She was a tenured faculty member in Sociology and Social Work at Lake Land College in Illinois. She also served on the local Board of Directors for the Family Caregiver Council for the Local Area Network for Senior Services, has been a mental health responder for school shootings and a disaster responder with the Red Cross. She moved to Florida and began her VHA career in 2009 at the Leesburg, FL Community-Based Outpatient Clinic, as the first mental health outpatient Social Worker in a CBOC in the Orlando VHA system of care.

Person 2

"TeamBI PLAYBOOK" INNOVATION

Progress and Achievements

  • Awareness of the TeamBI resources was generated with presentations at the 2024 VISN 8 Polytrauma and Military Exposure Conference, 2024 Military Health Science Research Symposium, 2024 American Congress of Rehabilitation Medicine.
  • Partnered with the I-HEAL Lived Experience Partners to ensure materials for upcoming focus groups were comprehensive and included all relevant items.
  • TeamBI’s Playbook has a finalized table of content with seven chapters in various phases of development.

PROJECT INNOVATION "TeamBI" PROGRESS & PRODUCTS

Project 3 Overview

Introduction to the TeamBI Playbook Innovation: aims, methods, and people.

Coming soon. Partner engagement identified chapters for TeamBI Playbook.

A straw poll was used with subject matter experts to identify starting points for discussion.

Coming soon. Guide to support healthcare delivery for patients with TBI experiencing behavior change in inpatient rehabilitation.

References

Kretzmer, T., Pinto, SM, Agtarap, S, Shapiro-Rosenbaum, A, Reindeau, A, Almeida, EJ, Nakase-Richardson, R. Impact of problematic behaviors on patient and healthcare system outcomes: A survey of brain-injury providers. 2022 ACRM Annual Conference Abstracts. Archives of PMR, 103(12), e45. doi.org/10.1016/j.apmr.2022.08.979

Nakase-Richardson, R, Kretzmer, T, Agtarap, S, Pinto, SM, Reindeau, A, Shapiro-Rosenbaum, A. Program elements that promote successful management of brain-injury related behaviors: Qualitative survey of providers. 2022 ACRM Conference Abstracts. Archives of PMR, 103(12), e45. doi.org/10.1016/j.apmr.2022.08.979

Nakase-Richardson R. & Evans C. Behavioral Assessment of Acute Neurobehavioral Syndromes to Inform Treatment. In Sherer M, Sander AM, ed. Handbook on the Neuropsychology of Traumatic Brain Injury. New York: Springer; 2014.157-172.

The views expressed are those of the authors and do not necessarily represent the official policy or position of the Department of Veterans Affairs or any other U.S. government agency. This work is funded by DOD CDMRP Award Number HT9425-23-1-0621 for Improving Health Care Access and Engagement for Veterans and Service Members with TBI Morbidity (I-HEAL). This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital. The administering institution for this work is the Tampa VA Research and Education Foundation.