Brain Trust: Assessing the Viability of a New Concussion Management Social Enterprise

Abstract

This case illustrates the challenges of starting up a social enterprise within a nonprofit environment. Brain Trust Canada (Brain Trust), a charity located in the Central Okanagan region of British Columbia, Canada, was formed with the goal to provide brain injury prevention, education, and support programs for those suffering from brain injuries. In late December 2019, the organization was just completing the pilot year of a social enterprise called Brain Trust Concussion Clinic (BTCC), offering a service gap in the market. Brain Trust CEO Mona Hennenfent was tasked with reporting to the Board of Directors a recommendation on whether expanding this social enterprise was the right decision.

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Resources
Exhibit 1: Brain Trust’s Vision, Mission, Values, and Strategic Priorities
Vision

To be established in our community as a key collaborative partner in meeting the unique needs of youth and adults affected by acquired brain injury, and in providing successful, evidence-based approaches to brain injury prevention and education.

Mission

To bring the issue of brain injury to the forefront, maximize the potential of those who have been affected by brain injury, and reduce preventable brain injuries, especially among youth.

Values
Collaboration

We are committed to collaborating with other agencies for greater social impact. We seek opportunities for key partnerships with the health, education, nonprofit, and corporate sectors.

Innovation

We constantly seek new ideas and approaches that support best practices in the field of brain injury. We bring creativity to the service of our mission.

Professionalism

We bring specialized knowledge and skill sets to our work with clients and community. We treat our clients with dignity, compassion, and respect. We seek ongoing opportunities for professional development.

Resilience

We adapt to changes in the political, social, economic, and financial environment. We’ve been doing it for over 30 years.

Responsible Stewardship

We carefully manage both our human and financial resources. We effectively use the time and strengths of our staff and board members, and we wisely spend the funds invested in our cause.

Service

We focus on service excellence in all program areas. We provide services tailored to the unique needs of our clients. We respond to all requests for assistance; if we can’t help, we connect individuals with a key partner who can.

Strategic Priorities 2017–2020
Increasing Community Presence

Establish BrainTrust Canada as a key community partner—the “go-to” organization—in the field of brain injury.

Creating Financial Sustainability

Build ongoing streams of income that will increase capacity and consistency of service within our organization

Filling Critical Gaps

Expand our organizational and service delivery models to ensure that we fill critical service gaps that meet essential needs in the community.

Source: BrainTrust Canada Strategic Action Plan, https://braintrustcanada.com/about-us/

Exhibit 2: Brain Trust’s Financial Statements 2016–2018
Brain Trust Canada Association Statement of Revenue and Expenditures, Year Ended December 31st

2018

2017

2016

2015

Revenues

Contract income

509,965

418,185

423,130

466,972

Grants

115,766

118,167

104,755

53,134

Events revenue

87,936

76,227

78,724

37,987

Gaming

62,807

56,553

52,745

62,728

Donations

68,223

35,061

38,072

22,472

United way

14,535

21,535

32,443

23,508

Conference

44,514

41,393

26,659

21,981

Rental revenue

4,200

4,400

6,450

4,000

Investment income

455

703

569

1,460

Total revenues

908,401

762,224

763,547

697,352

Expenditures

Salaries and wages

574,671

490,532

472,903

529,524

Rental

45,097

42,076

61,692

54,886

Office

29,206

29,449

54,035

31,504

Special events

39,186

60,918

47,160

26,314

Contract services

95,170

50,495

25,501

27,661

Travel

33,006

24,864

24,341

26,207

Telephone

9,416

8,089

10,581

9,211

Utilities

6,219

7.106

7,605

7,407

Professional fees

6,786

6,713

6,713

7,213

GST Expense

5,262

300

Training

3,950

4,803

4,881

2,078

Amortization

1,758

2,495

3,544

5,039

Insurance

3,114

3,411

3,535

4,606

Advertising and promotion

1,437

3,250

2,013

11,060

Meeting cost

2,091

1,059

1,837

1,195

Business license and memberships

1,508

1,799

1,817

1,698

Interest and bank charges

3,128

2,296

1,617

574

Unrealized loss on investments

2,418

-

-

-

Total expenditures

858,161

739,355

735,037

746,477

Net surplus (deficiency)

50,240

22,869

28,510

(52,125)

Net assets, beginning of year

117,469

94,600

66,090

118,215

Net assets end of year

167,709

117,469

94,600

66,090

Brain Trust Canada Association Statement of Revenue and Expenditures, Year Ended December 31st

2018

2017

2016

2015

Assets

Current assets

Cash and deposits

138,722

93,095

152,895

71,149

Accounts receivable

9,776

13,902

14,555

13,966

Prepaid expenses

5,940

4,083

2,395

2,464

154,438

111,080

169,845

87,479

Equipment

4,251

6,009

8,504

12,048

Restricted cash

50,000

50,000

50,000

50,000

Total assets

208,689

167,089

228,349

149,527

Liabilities and net assets

Current liabilities

Accounts payable

13,766

19,903

20,513

13,694

Deferred revenue

27,214

29,717

113,236

69,743

Total liabilities

40,980

49,620

133,749

83,437

Capital asset fund

4,251

6,009

8,504

12,048

Restricted fund

50,000

50,000

50,000

50,000

Unrestricted fund

113,538

61,460

36,096

4,042

Net assets

167,709

117,469

94,600

66,090

Total liabilities and net assets

208,689

167,089

228,349

149,527

Exhibit 3: Brain Trust Concussion Clinic Recovery Program—Seven Steps
  • 1. Intake form to request services for concussed child/youth is completed; trained concussion clinician reviews form within 24 hours
  • 2. In-person clinical assessment completed by concussion clinician using the SCAT5 (Sport Concussion Assessment Tool 5th Edition) or Child SCAT 5 (for those 12 and under)
    • symptom evaluation of 22 potential symptoms
    • cognitive screen (orientation, immediate memory, concentration, delayed recall)
    • neurological screen (vision, balance)

A rectangular box houses the text which reads,

The text to the left of the rectangular box reads,

SCAT5 followed by a copyright sign.

The text in the center of the rectangular box reads,

SPORT CONCUSSION ASSESSMENT TOOL—5TH EDITION

DEVELOPED BY THE CONCUSSION IN SPORT GROUP

FOR USE BY MEDICAL PROFESSIONALS ONLY

Supported by,

Five logos displayed as follows.

International Ice Hockey Federation, Federation International Football Association, International Olympic Committee, World Rugby, Federation International Equestrian

Header design of the SCAT5 form.

The text reads as follows:

OFFICE OR OFF-FIELD ASSESSMENT

Please note that the neurocognitive assessment should be done in a distraction-free environment with the athlete in a resting state.

STEP 1: ATHLETE BACKGROUND

Each entry is followed by a blank line.

Sports/team/ school:

Date/ time of injury:

Years of education completed: -------------------------------------

Age: --------------------------------------------------------------------

Gender: M / F / Other

Dominant hand: left / neither / right

How many diagnosed concussions has the athlete had in the past? ---------------------------------

When was the most recent concussion? ----------------------------------------------------------------

How long was the recovery (time to being cleared to play) from the most recent concussion? ----------------------------------------------------------------------------------------------------------(days)

Followed by a questionnaire with yes/no options outlined housed within a box at the end of each question.

Has the athlete ever been:

Hospitalized for a head injury?

Yes

No

Diagnosed/treated for headache disorder or migration?

Yes

No

The corresponding side of the page depicts as follows.

A rectangular box houses texts which reads as follows. Every entry is followed by a blank line.

Name:

DOB:

Address:

ID number:

Examiner:

Date:

Followed by details of STEP 2. STEP 2 is enclosed on all the three sides of the page with a line except for the base. The number 2 displays on the left side top corner of the enclosure. The text reads as follows.

STEP 2: SYMPTOM EVALUATION

The athlete should be given the symptom form and asked to read this instruction paragraph out loud then complete the symptom scale. For the baseline assessment, the athlete should rate his/her symptoms based on how he /she typically feels and for the post injury assessment the athlete should rate their symptoms at this point in time.

Followed by an entry and two checkboxes along the same side with text between them which reads.

Please Check: checkbox followed by the text Baseline. Check box followed by the text Post-injury

Followed by the text at the center of the box which reads.

Please hand the form to the athlete

Followed by the list of symptoms each graded on a scale from 0 to 6 in a tabular form. Zero categorised as none, 1 and 2 categorised as mild, 3 and 4 categorised as moderate, and 5 and 6 categorised as severe. The text reads.

 

None

Mild

Moderate

Severe

Headache

0

1

2

3

4

5

6

“Pressure in head”

0

1

2

3

4

5

6

Neck pain

0

1

2

3

4

5

6

Nausea or vomiting

0

1

2

3

4

5

6

Assessment form with STEPS 1 and 2 of the SCAT5 document.

The text reads as follows:

STEP 3: COGNITIVE SCREENING

Standardised Assessment of Concussion (SAC)*

ORIENTATION

What month is it?

0

1

What is the date today?

0

1

What is the day of the week?

0

1

What year it is?

0

1

What time is it right now? (within 1 hour)

0

1

Orientation score

of 5

IMMEDIATE MEMORY

The Immediate Memory component can be completed using the traditional 5-word per trial list or optionally using 10 words per trial to minimize any ceiling effect. All three trials must be administered irrespective of the number correct on the first trial. Administer at the rate of one word per second.

Please choose EITHER the 5- or 10-word list group and circle the specific word list choices for this test.

I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order. For Trials 2 and 3: I am going to repeat the same list again. Repeat back as many words as you can remember in any order, even if you said the word before.

The corresponding side of the page depicts as follows.

A rectangular box houses texts which reads as follows. Every entry is followed by a blank line.

Name: ------------------------------------------------------------------

DOB: -------------------------------------------------------------------

Address: ---------------------------------------------------------------

ID number: ------------------------------------------------------------

Examiner: --------------------------------------------------------------

Date: --------------------------------------------------------------------

CONCENTRATION

DIGITS BACKWARDS

Please circle the Digit list chosen (A, B, C, D, E, F). Administer at the rate of one digit per second reading DOWN the selected column.

I am going to read a string of numbers and when I am done, you repeat them back to me in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7.

Concentration Number Lists (Circle one)

List A List B List C

 

 

 

4-9-3 5-2-6 1-4-2

Y

N

0

6-2-9 4-1-5 6-5-8

Y

N

1

3-8-1-4 1-7-9-5 6-8-3-1

Y

N

0

3-2-7-9 4-9-6-8 9-4-8-1

Y

N

1

Assessment form with STEP 3 of the SCAT5 document.

The text reads as follows:

STEP 4: NEUROLOGICAL SCREEN

See the instruction sheet (page 7) for details of test administration and scoring of the tests.

Can the patient read aloud (e.g., symptom checklist) and follow instructions without difficulty?

Y

N

Does the patient have a full range of pain-free PASSIVE cervical spine movement?

Y

N

Without moving their head or neck, can the patient look side-to-side and up-and-down without double vision?

Y

N

Can the patient perform the finger nose coordination test normally?

Y

N

Can the patient perform tandem gait normally?

Y

N

BALANCE EXAMINATION

Modified Balance Error Scoring System (mBESS) testing*

Which foot was treated (i.e., which is the non-dominant foot)

Followed by two small square boxes one below the other with the text left and text right, respectively.

Testing surface (hard floor, field, etc.) -------------------------------------------------------------------

Footwear (shoes, barefoot, braces, tape, etc.) -----------------------------------------------------------

Condition

Errors

Double leg stance

of 10

Single leg stance (non-dominant foot)

of 10

Tendon stance (non-dominant foot at the back)

of 10

Total Errors

of 10

The corresponding side of the page depicts as follows.

A rectangular box houses texts which reads as follows. Every entry is followed by a blank line.

Name: ------------------------------------------------------------------

DOB: -------------------------------------------------------------------

Address: ---------------------------------------------------------------

ID number: ------------------------------------------------------------

Examiner: --------------------------------------------------------------

Date: --------------------------------------------------------------------

Followed by details of STEP 5. STEP 5 is enclosed on all the three sides of the page with a line except for the base. The number 5 displays on the left side top corner of the enclosure. The text reads as follows.

STEP 5: DELAYED RECALL

The delayed recall should be performed after 5 min have elapsed since the end of the immediate recall section. Score 1 point for each correct response.

Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order.

Followed by the text which reads.

Time Started, followed by a small rectangular box to the right.

Followed by the text which reads.

Please record each word correctly recalled. Total score equals number of words recalled.

Followed by three lines running across the page within the enclosure.

Followed by the text which reads.

Total number of words recalled accurately: followed by two small rectangular boxes side by side with the text which reads of 5 or of 10, respectively.

Assessment form with STEPS 4 and 5 of the SCAT5 document.

  • 3. File review by concussion physician upon intake, and during periods when child/youth’s activity level is increasing
    • plan for child/youth’s recovery developed collaboratively by concussion physician and clinician
  • 4. Daily check-in with concussion clinician via phone/text/email/FaceTime/Skype
    • information and strategies for managing concussion symptoms which continually change during the recovery process
    • symptoms may be cognitive, physical, emotional, or sleep-related
  • 5. Guided implementation of return-to-learn and return-to-play protocols
    • personalized direction for the safe, gradual return to learn/work/play, with adherence to internationally approved healing protocols
    • concussion physician provides medical oversight as child/youth’s activity levels increase
    • protocols may be implemented separately or simultaneously depending on the individual
    • helps prevent another concussion while child/youth is still healing from the initial one
  • 6. Communication with coaches/trainers, teachers, family doctor includes suggestions for accommodations required by concussed child/youth
  • 7. Sign-off by concussion physician clearing return to regular activities, provided recovery has been achieved. Referrals are made to other healthcare providers if needed.
Where/How the Service Will Be Performed
  • qualifying clients must:
    • have a doctor’s diagnosis of concussion
    • be aged 5 to 25
    • not be clients of WorkSafe or ICBC as a result of the concussion
    • have experienced their concussion in the last 7 days
  • intake form completed online
  • clinician intake performed remotely and in-person at BTCC within 24 hours of request for service (assuming client qualified for service)
  • intake review by concussion physician
  • daily review of symptoms and recovery strategies by clinician; periodic review as needed by concussion physician
  • upon completion of return-to-learn/play protocols, medical clearance given by concussion physician

Source: Brain Trust company files. All information and images reprinted with permission.

Exhibit 4: Brain Trust Concussion Clinic Vision, Mission, and Goals
Vision of Brain Trust Concussion Clinic

A solution for any family or individual who asks the question: “What do I do when my child is diagnosed with a concussion?”

Mission of Brain Trust Concussion Clinic

BTCC provides an affordable, medically supervised approach to helping children and youth ages 5 to 25 heal safely from concussion, so they can get back to school, sports, and the activities they love. Concussion clinicians provide the one-on-one guidance, information, tools, and reassurance families need to get through the first 10 to 30 days after concussion, from the convenience of home.

Goals of Brain Trust Concussion Clinic
  • recover as many concussed children/youth as possible through the provision of a model that adheres to internationally approved standards for concussion care
  • provide early intervention that ensures full recovery is achieved, mitigating the risk of the child/youth experiencing chronic, long-term effects or secondary concussion
  • provide a recovery plan for those with persistent post-concussive symptoms through referral back to the medical system
  • relieve stress on parents by providing frequent contact and medical supervision during the recovery process
  • funnel revenue into the nonprofit side of the organization

Source: Brain Trust company files. Reprinted with permission.

Exhibit 5: Number of Youth and Households in Target Market for BTCC

Location

Number of children/youth aged 0–24 years

Number of households with children with household annual income of CAD 50,000+

Kelowna

33,750

21,690

West Kelowna

8,905

Kamloops

25, 195

12,440

Salmon Arm

4,355

2,080

Summerland

2,410

Penticton

7,135

4,210

Oliver

955

Osoyoos

750

Vernon

9,710

6,750

Lumby

525

Armstrong

1,275

Enderby

650

Source: Census Profile, 2016 Data, Central Okanagan, Regional District, British Columbia, Statistics Canada

Exhibit 6: Competitor Chart

Organization

Brain Trust Concussion Clinic

Complete Concussion Management (CCM) Clinics

Lifemark Clinics

Advance Concussion Clinic

Mandate

Case managementa approach providing daily contact and adhering to internationally approved concussion healing protocols, serving children and youth ages 5 to 25.

Multimodal baseline testing, treatment and rehabilitation to patients and athletes. Mandate is to share education, policies, and concussion protocols with sports organizations and schools.
Services treat all ages from children to elderly.
CCM offers concussion management training for licensed healthcare practitioners

Concussion management for symptomatic issues

“BC’s Only Dedicated Concussion Clinic”
Interdisciplinary team of concussion specialists providing education, informing diagnosis, guiding recovery, providing clearance and coordinating rehabilitation
Adheres to best-practice standards, to support complete recoveries in the most efficient time periods

Location

Within two-hour radius of the Regional District of the Central Okanagan

Physio Active Clinic in Kelowna, Pro Physio Clinic in Penticton, Sunshine Valley Chiropractic in Osoyoos

Approximately 80 locations across Canada

Vancouver, BC

Service offering

Immediate access to a qualified concussion clinician who implements a case management approach
Intake and assessment by concussion clinician using the SCAT5 or Child SCAT5.
Oversight by concussion physician.
Daily contact to assist with managing symptoms that continually change
Personalized recovery plan that guides the safe, gradual return to school/work/play (developed collaboratively by concussion physician and clinician)
Clearance by a concussion physician on the safe return to regular activities
P.A.C.E. app included—interactive recovery guide.

Pre-injury multimodal baseline testing.
Follow return-to-learn/work/play protocols.
Post-concussion treatment and rehabilitation.
Concussion treatment and rehabilitation services may include exercise therapy, manual therapy, vestibular rehabilitation and vision therapy, diet and nutritional intervention, and/or education and reassurance.
Trained practitioners who offer accessible and timely care.
Free Concussion Tracker app available—supports communication between sports, schools, parents, and healthcare practitioners.

Assessment by physiotherapist
Available services include physiotherapy, occupational therapy, chiropractic, massage, dizziness and balance and vestibular rehabilitation programs.

Individualized, guided support through prevention, baseline testing, post-injury assessment and rehabilitation to achieve the most complete recovery possible.
Symptom reports, neurocognitive screening, balance testing
Assess vision, exertion tolerance, and cervical spine function to identify root causes of reported symptoms and inform Returns and treatment planning when needed
Evaluate and treat patients on an individual basis.
Timely and appropriate intervention for those who are slow-to-recover, or for more complicated or chronic conditions

Price

Safe Start: Day 1 to Day 10—CAD 249
Concussion Recovery: Day 11 to Day 30—CAD 249

Physio—CAD 63–190 per visit
Chiro—Initial visit CAD 83, subsequent visits CAD 55, consultation CAD 130

Physio—CAD 63–190 per visit
OT—CAD 111–121 per hour
Chiro—Initial visit CAD 83, subsequent visits CAD 55, consultation CAD 130

Physio—CAD 63–190 per visit
OT—CAD 111 –121 per hour
Clinical Counselling—CAD 150/50 min.
Kinesiologist—CAD ~75/hour
Athletic Therapist—CAD ~110/hour

Exhibit 7: Pilot Results and Year 2 Projections for the Brain Trust Concussion Clinic
Year 1 (2019) Results

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Total

Unit sales

Recovery

2

3

3

4

4

4

4

4

5

10

10

5

58

KGH grant subsidy

10

10

5

25

Revenues (in CAD)

Recovery

349

698

1,047

1,047

1,396

1,396

1,396

1,396

1,396

1,745

3,490

3,490

1,745

20,242

KGH grant subsidy

349

3,490

3,490

1,745

8,725

COF grant

15,000

15,000

Total revenues (in CAD)

698

1,047

1,047

1,396

1,396

1,396

1,396

1,396

16,745

6,980

6,980

3,490

43,967

Cost of sales (in CAD)

Recovery

180

360

540

540

720

720

720

720

720

900

3,600

3,600

1,800

14,940

Total cost of sales (in CAD)

360

540

540

720

720

720

720

720

900

3,600

3,600

1,800

14,940

Gross margin (in CAD)

338

507

507

679

679

679

679

679

15,845

3,380

3,380

1,690

26,027

Operating expense (in CAD)

Marketing/PR

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Insurance

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Accounting/admin

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Management (Mona)

667

667

667

667

667

667

667

667

667

667

667

667

667

8,004

Rent/utilities

333

333

333

333

333

333

333

333

333

333

333

333

333

4,000

Office supplies

25

25

25

25

25

25

25

25

25

25

25

25

25

300

Computer/equip/phones

100

100

100

100

100

100

100

100

100

100

100

100

100

1,200

Software (Ocean, podio)

50

50

50

50

50

50

50

50

50

50

50

50

50

600

Total operating expense (in CAD)

1,175

1,175

1,175

1,175

1,175

1,175

1,175

1,175

1,175

1,175

1,175

1,175

1,175

14,014

Operating surplus (deficit) (in CAD)

(837)

(668)

(668)

(499)

(499)

(499)

(499)

(499)

(14,670

2,205

2,205

515

14,923

Year 2 (2020) Projections

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Total

Unit sales

Recovery

15

15

14

10

8

6

4

4

8

8

11

7

110

KGH grant subsidy

10

10

5

25

Revenues (in CAD)

Recovery

349

5,235

5,235

4,886

3,490

2,792

2,094

1,396

1,396

2,792

2,792

3,839

2,443

38,390

KGH grant subsidy

349

3,490

3,490

1,745

-

-

-

-

-

-

-

-

-

8,725

Corporate sponsorship

32,000

32,000

Total revenues (in CAD)

40,725

8,725

6,631

3,490

2,792

2,094

1,396

1,396

2,792

2,792

3,839

2,443

79,115

Cost of sales (in CAD)

Recovery

180

4,500

4,500

3,420

1,800

1,440

1,080

720

720

1,440

1,440

1,980

1,260

24,300

Total cost of sales (in CAD)

4,500

4,500

3,420

1,800

1,440

1,080

720

720

1,440

1,440

1,980

1,260

24,300

Gross margin (in CAD)

36,225

4,225

3,211

1,690

1,352

1,014

676

676

1,352

1,352

1,859

1,183

54,815

Operating Expense (in CAD)

Marketing/PR

525

525

525

525

525

525

525

525

525

525

525

525

525

6,300

Insurance

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Accounting/admin

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Management (Mona)

667

667

667

667

667

667

667

667

667

667

667

667

667

8,004

Rent/utilities

333

333

333

333

333

333

333

333

333

333

333

333

333

4,000

Office supplies

25

25

25

25

25

25

25

25

25

25

25

25

25

300

Computer/equip/phones

100

100

100

100

100

100

100

100

100

100

100

100

100

1,200

Software (Ocean, podio)

50

50

50

50

50

50

50

50

50

50

50

50

50

600

Total operating expense (in CAD)

1,700

1,700

1,700

1,700

1,700

1,700

1,700

1,700

1,700

1,700

1,700

1,700

20,040

Operating surplus (deficit) in CAD)

34,525

2,525

1,511

(10)

(348)

(686)

(1,024)

(1,024)

348

348

159

(517)

34,411

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