Traumatic Brain Injury in the NC MH/DD/SAS System MFP Transition Learning Series June 10, 2013

1. Traumatic Brain Injury in the NC MH/DD/SAS System MFP Transition Learning Series June 10, 2013 Janice White, M.Ed., SLP, CBIS NC TBI Program Coordinator

2. Causes of Traumatic Brain Injury • Falls-35.2% • Highest in ages 0-4 population and over 75 • Motor Vehicle Traffic-17.3% • Highest in ages 20-24 population; males • Struck by/against events-16.5% • Sports, gun shots • Assaults-10% • Unknown/Other-21% • Blasts are the leading cause of TBI for active duty Military in war zones (not counted in CDC numbers)

3. Prevalence/Incidence • The CDC estimates the annual civilian incidence of TBI to be 1.7 million civilians. • This does not include those who do not seek treatment or who are treated and released. • Approximately 3.17 million civilians presently live with the long-term effects of a TBI.

5. Definition of Traumatic Brain Injury A TBI is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. Centers for Disease Control and Prevention

6. TBI High Risk Groups • Males are twice as likely to sustain TBI as females. • 3 Highest risk age groups are: • 0 to 4 years old • 15 to 19 years old • 65 and older • 75 years and older equate to more hospitalizations and deaths. • Military personnel

7. Symptoms of TBI Physical: • Speech, vision, hearing and other sensory impairments • Headache • Dizziness • Nausea • Sleep problems • Fatigue • Lack of coordination • Muscle spasticity

8. Symptoms of TBI Cognitive: • Short and long term memory deficits • Slowness of thinking • Problems w/ reading & writing • Difficulty w/ attention & concentration • Lack of motivation or inability to initiate • Impairments of • Perception Planning • Communication Sequencing • Reasoning Judgment • Problem Solving

9. Symptoms of TBI Behavioral: • Mood swings • Denial • Depression/anxiety • Restlessness/impatience • Inability to self monitor/inappropriate social response • Agitation/irritability • Delusions/paranoia/mania

10. Division of MH/DD/SAS • LME stands for Local Management Entity. These are the local offices which manage care for NC consumers • MCO-Managed Care Organization • The Divisions local offices are now called LMEs/MCOs • This is where consumers go to register for services

12. Division of MH/DD/SAS • MCOs will manage Medicaid dollars for our MH/DD/SAS consumers • There are now 11 LME/MCOs • There are TBI consumers who do not qualify for Medicaid • These consumers may be eligible for State services • Each LME has financial requirements

13. Division of MH/DD/SAS • Traumatic Brain Injury may be treated within our service system: • Mental Health • Intellectual/Developmental Disability • Substance Abuse

14. Division of MH/DD/SAS • TBI can be funded under state MH, IDD or SA services • Consumers may access services through Integrated Payment & Reporting System (IPRS) or the LME may request TBI specific dollars. • IPRS is billed under State service definitions • TBI money is outside of this billing system

15. TBI & Mental Health • Individuals who have a TBI may display symptoms that can be mistaken as signs of a psychiatric disorder: • Anxiety/Sadness Mood disorder • Sleep disturbance Depression • Sensory dysfunction Psychosis • Attention changes ADHD • Impulsivity Intention to harm

16. TBI & Mental Health • Or individuals with a TBI may develop a mental health issue after sustaining a TBI: • Depression • Anxiety • Mood disorder

17. Definition of Developmental Disability • (12a)   "Developmental disability" means a severe, chronic disability of a person which: • a. Is attributable to a mental or physical impairment or combination of mental and physical impairments; • b. Is manifested before the person attains age 22, unless the disability is caused by a traumatic head injury and is manifested after age 22; • c. Is likely to continue indefinitely;

18. Definition of Developmental Disability • d. Results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, capacity for independent living, learning, mobility, self-direction and economic self-sufficiency; and • e.  Reflects the person's need for a combination and sequence of special interdisciplinary, or generic care, treatment, or other services which are of a lifelong or extended duration and are individually planned and coordinated;

19. Federal Definition of DD • Only includes TBI that occurs before the age of 22 • Consumers with a TBI which occurred after the age of 22 are not able to participate in Innovations Waiver services

20. TBI & IDD Services • If the symptoms of the TBI meet the eligibility requirements for an intellectual/developmental disability then the individual with a TBI may receive services within the IDD service system.

21. Division of MH/DD/SAS & DMA • Community Alternatives Programs (CAP) are Medicaid waiver programs: • Innovations • For those with Intellectual and/or Developmental Disabilities • CAP Disabled Adult (DA) • Allows those who qualify for a SNF to be served at home • CAP for Children (CAP/C) • Allows medically fragile children to be served at home

22. TBI & Substance Abuse • Some individuals may have had a substance use disorder (SUD) prior to the TBI • The SUD may have contributed to the TBI • Falls • MVC • Some individuals self medicate after the TBI and develop a new SUD

23. Mental Health & Substance Abuse • Many individuals with TBI enter the MH/DD/SA system with a Mental Health or Substance Abuse diagnosis • Some of those individuals will not yet be recognized by the provider as having a diagnosis of TBI • Training within MH/SA system now about TBI

24. Shifting Paradigms • TBI starts out in the “Medical Model” • Must shift thinking from hospital (medical) to community • Services provided in the community are generally more cost effective than those provided in facilities • Individual with a TBI moving from “patient” to “consumer”

25. TBI Services Integrated Into the Community • LME/MCOs manage service options for individuals who need services. • After Federal and State monies have been utilized, the LME may request additional support from the State TBI Funds. • State TBI funds are available only when all other funding options have been exhausted. • State TBI Funds are limited.

26. State CFAC • The State Consumer and Family Advisory Committee (SCFAC) is a 21 member self-governing and self-directed advisory organization, composed entirely of consumers and family members of consumers.  • The SCFAC model was included in the Division of MH/DD/SAS State Plans, which stated that this body’s role is to “provide input and conduct oversight of the Division’s operations and efforts to accomplish the strategic outcomes of the State Plan.”

27. State CFAC • The current SCFAC Chair is Sue Guy and Vice-Chair is Marc Jacques. You may contact SCFAC members at state.cfac@dhhs.nc.gov. • You will find more information about the State CFAC at: http://www.ncdhhs.gov/mhddsas/services/advocacyandcustomerservice/scfac.html

28. Local Consumer and Family Advisory Committee (CFAC) • Are required by general statute for each LME/MCO • Membership consists of adults and family members of individuals who receive services for MH/DD/SA • Terms for members shall be three years, and no member may serve more than three consecutive terms

29. Local Consumer and Family Advisory Committee (CFAC) • CFACs shall be a self-governing and a self-directed organization that advises the board of an LME/MCO on the planning and management of services • To find the Consumer and Family Advisory Committee in your county, review the county listing at www.ncdhhs.gov/mhddsas/lmeonblue.htm.

30. Division of MHDDSASas the State Lead Agency for TBI Lead Agency: • Helps to coordinate activities, provides leadership and creates partnerships with other agencies • Coordinates with State Brain Injury Advisory Council • Writes grant & receives HRSA TBI Funding

31. TBI Act Programs: • Fiscal Year 2012: • Health Resources & Services Administration (HRSA)-Receives 9.760 Million for: • HRSA TBI State Grant Program • Protection & Advocacy TBI Grant Program- in NC this goes to Disability Rights NC (DRNC) • The Centers for Disease Control & Prevention-Receives 6.1 Million-for research and data collection

32. Federal Funding from HRSA • Health Resources & Services Administration money may not be used for prevention or direct services but for implementation of services and partnerships: • Previous NC State Grant offered funding for: • Opening 4th Family Support office (Asheville) • Training for LMEs and providers • Development of evaluation tool for trainings • Outreach to Native Americans • Online training program: • www.nctbitraining.org

33. Present Four Year HRSA Grant • One million in funding over 4 years • BIANC to develop & coordinate: • Technical assistance for the development of TBI Clubhouses • Develop and oversee Ombudsman Program • Project STAR to develop & coordinate: • Substance Abuse/TBI training program • Now including MH & youth with substance abuse • First In Families to coordinate: • Lifetime connections Program • Social Support Networks for those with TBI • Future planning for families

34. Brain Injury Resources • The Brain Injury Association of America: www.biausa.com • Centers for Disease Control & Prevention: http://www.cdc.gov/traumaticbraininjury/ • The Brain Injury Association of NC: www.bianc.net

35. Brain Injury Association of NC 4 Offices in NC + 1 Volunteer Office: • Raleigh – Main Office • 800-377-1464 • Asheville -CarePartners Rehab Hospital • 866-890-7801 • Charlotte- Carolinas Rehabilitation • 877-962-7246 • Greenville-NC National Guard Family Assist. Cnt. • 252-717-3347 • Triad- Volunteer Resource Center-Wake Forest Baptist • 336-713-8582

36. Other TBI Resources • First In Families of NC: • 13 Chapters in 47 Counties • Other 55 Counties assisted through State office in Durham • www.fifnc.org • 919-251-8368 • To find local Chapters: • http://www.fifnc.org/help/local.html

37. For Information: • Contact Us: • TBI Program Manager Joan.Kaye 919-715-1294 Joan.Kaye@dhhs.nc.gov • TBI Program Coordinator Jan White 919-715-5989 Janice.White@dhhs.nc.gov