After Brain Injury, Older Adults Who Need Rehab Most Often Miss Out

When an older adult survives a traumatic brain injury, the road home is rarely smooth. Many leave inpatient rehabilitation facilities still struggling with basic self-care tasks such as dressing, bathing, and feeding themselves, and with mobility limitations that make stairs, sidewalks, and even bathroom transfers hazardous. The therapies designed to close those gaps—occupational therapy for self-care and physical therapy for mobility—are supposed to continue in the community through home health agencies or outpatient clinics. But a sweeping new analysis of Medicare data suggests that the patients who need this care most are often not the ones who get it, and that factors having nothing to do with medical need are quietly deciding who recovers and who stalls.

The study, published in the Journal of General Internal Medicine, followed 23,036 community-dwelling older adults who received inpatient rehabilitation for traumatic brain injury between 2020 and 2022. Led by Adam R. Kinney, an occupational therapy researcher at the University of Colorado and the VA Rocky Mountain Mental Illness Research, Education, and Clinical Center, the team linked Medicare claims with standardized functional assessments collected at discharge from inpatient rehabilitation facilities. That linkage is what gives the study its power: instead of inferring need from diagnoses, the researchers could measure exactly how impaired each patient was in self-care and mobility at the moment they left the hospital-based rehab unit, then track which community services each person actually received over the following 90 days.

The technical backbone of the analysis is the Section GG assessment instrument, a standardized set of functional items that inpatient rehabilitation facilities must record for every patient. Section GG produces separate scores for self-care performance and mobility performance, allowing clinicians and researchers to distinguish, for example, a patient who cannot dress independently from one who cannot walk across a room. The team defined clinical need for occupational therapy as worse self-care scores and need for physical therapy as worse mobility scores. They then used modified Poisson regression, a statistical approach suited to estimating relative risks for common binary outcomes, to model the probability of receiving each of four service types—home health occupational therapy, home health physical therapy, outpatient occupational therapy, and outpatient physical therapy—as a function of need scores, clinical covariates, and a set of non-clinical factors including age, race and ethnicity, marital status, Medicaid eligibility, and rural versus urban residence.

The headline finding is a stark mismatch between where rehabilitation happens and where it might best happen. Most community rehabilitation after brain injury was delivered through home health: 52 percent of beneficiaries received home health occupational therapy and 67 percent received home health physical therapy within 90 days of discharge. Outpatient care lagged far behind, with only 15 percent receiving outpatient occupational therapy and 27 percent receiving outpatient physical therapy. That concentration matters clinically. Home health delivers care in short episodes with defined visit limits, whereas outpatient settings can offer longer-term, progressive, high-intensity training. Clinical practice guidelines for locomotor recovery after brain injury emphasize progressive, task-specific, and often high-dose exercise—precisely the kind of training that outpatient clinics, with their gyms, treadmills, and equipment, are built to provide and home health visits frequently cannot match.

Need did predict some care. Worse self-care performance at discharge was associated with a higher likelihood of receiving both home health and outpatient occupational therapy, and worse mobility predicted receipt of home health physical therapy. But the relationship broke down at a critical juncture: mobility limitation did not predict outpatient physical therapy use at all. In other words, an older adult who left inpatient rehab unable to walk independently was no more likely to show up at an outpatient physical therapy clinic than someone with far better mobility. For a therapy discipline whose core purpose is restoring movement, that disconnect represents a systemic failure to translate assessed need into appropriate services.

More troubling still, non-clinical factors independently shaped access in ways that persisted after accounting for clinical need and health status. Beneficiaries who were younger, identified as Hispanic ethnicity compared with White non-Hispanic beneficiaries, or lived in rural areas were less likely to receive home health rehabilitation. On the outpatient side, those who were older, identified as Black or Hispanic compared with White non-Hispanic, were unmarried, or were eligible for Medicaid were less likely to receive outpatient occupational or physical therapy. Medicaid eligibility, a marker of financial hardship, and marital status, a proxy for available caregiving support, should not determine whether a brain injury survivor gets therapy—but the data show they do.

Each of these disparities has a plausible mechanical explanation, and together they sketch a map of the barriers stacked between patients and care. Rural residence limits the supply of home health agencies willing to travel long distances and the density of outpatient clinics within driving range. Outpatient rehabilitation requires transportation, scheduling, and often a caregiver to accompany a patient with cognitive or behavioral sequelae of brain injury—resources that unmarried patients and those with fewer financial assets lack. Medicaid eligibility may complicate billing and referral networks in outpatient settings that are already strained. Prior studies cited by the authors, including work showing racial disparities in community rehabilitation after traumatic brain injury among Medicare beneficiaries and in outpatient physical therapy after hip fracture, suggest these patterns are not unique to this population but part of a broader architecture of unequal post-acute care.

The stakes are high because traumatic brain injury in older adults is common, consequential, and increasingly recognized as a geriatric syndrome. Falls—the leading mechanism of injury in this age group—produce brain injuries that compound age-related vulnerability, and older patients tend to have worse functional outcomes at discharge even with lower injury severity. Recovery after brain injury can continue for months to years, and functional gains made in inpatient rehabilitation can erode without continued therapy. Untreated self-care limitations cascade into caregiver burden, nursing home placement, and loss of independence; untreated mobility limitations raise fall risk, and a second brain injury on top of the first can be devastating. The study’s authors frame their findings as identifying targets for improving transitional services, and the data point to concrete ones: discharge planners could prioritize outpatient referrals for patients with mobility deficits, and health systems could build transportation and caregiver-support scaffolds around the transition from facility to community.

The research also carries a methodological lesson for the field. By using the standardized Section GG scores rather than billing codes to define need, the study demonstrates how routine assessment data collected for quality measurement can be repurposed to audit equity in real time. The Continuity Assessment Record and Evaluation item set and the inpatient rehabilitation facility patient assessment instrument were designed to make functional status comparable across settings; this analysis shows they can also reveal exactly where the continuum of care snaps. Because the study relied on Medicare fee-for-service claims, it does not capture beneficiaries in Medicare Advantage plans, and the 90-day window may miss care initiated later; the authors also note the data are not openly available for privacy reasons. Still, the cohort’s sheer size and the consistency of the non-clinical signals make the conclusion hard to dismiss.

For the 23,036 older adults in this cohort, and the many thousands more who sustain traumatic brain injuries each year, the message is sobering: surviving the injury and completing inpatient rehabilitation is only the first hurdle. What happens in the 90 days afterward—whether a therapist knocks on the door, whether a clinic is reachable, whether someone is available to drive you there—may matter as much as the quality of the hospital care that preceded it. The study’s authors, funded by the Colorado Department of Human Services Mindsource Brain Injury Network and the National Institutes of Health, argue that clinical need should be the dominant driver of rehabilitation utilization. Right now, in the American system caring for older brain injury survivors, it is not. Closing that gap will require treating the transition home not as the end of care, but as the beginning of the hardest part of recovery.

Subject of Research: Access to home health and outpatient rehabilitation after traumatic brain injury in older Medicare beneficiaries

Article Title: Gaps in Access to Home and Community-Based Services Following Inpatient Rehabilitation for Traumatic Brain Injury in Older Adults

Article References: Gaps in Access to Home and Community-Based Services Following Inpatient Rehabilitation for Traumatic Brain Injury in Older Adults. (n.d.). https://doi.org/10.1007/s11606-026-10844-2

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10844-2

Keywords: traumatic brain injury, older adults, Medicare, occupational therapy, physical therapy, home health, outpatient rehabilitation, health disparities, inpatient rehabilitation, Section GG, rural health, transitional care