Jenny Quigley-Stickney RN MSN MHA CCM Jordan Hospital & Tufts Medical Center Case Management Society of New England May 2, 2011

 Acute onset of injury  ED admission  Triage to Trauma Center  Critical Care Unit  Medical Surgical Unit  Transition to Rehabilitation Center

 Determination of patients prognosis and level of care  Evaluation of cognitive and functional recovery  Fiscal resources  Family support and provisions for care

 LTAC admission criteria  Acute Rehabilitation admission criteria  Skilled level of care and admission criteria  Home Rehabilitation care

 LTAC provides acute medical care and rehabilitation for ELOS of 30 days or more  Acute Rehabilitation care (IRF) ELOS of days  Skilled level of care ELOS 2 weeks to 100 days  LTC in nursing home private pay, MH or LTC policy for additional nursing and 24 hour care

 Assist with reviewing insurance and determine additional needs for insurance  Assist with accessing resources for LTC policies, STD, LTD and need for FMLA  Assist in accessing SSI and SSDI resources  Introduce Mass. Brain Injury Association and resources  Complete SHIP application and acknowledgement of new Brain injury  Complete PCA application if eligible

 Criteria for safe transition to the community based on FIM, cognition and behavioral management of the TBI survivor  Supervision provided in skilled level of care, family through FMLA, PCA program, LTC policies and private pay HHA  Discharge to home with home care or outpatient rehabilitation, Skilled level of care, Foster care and TBI Group homes

 Insurance coverage  Fiscal availability and Private funds  LTC plans  Family availability for supervision and hands on care  Family understanding on TBI and management of behavior, cognition and substance abuse issues

 Supervision  Management of Behavior, Cognition and substance abuse issues  Fiscal challenges for care provision  Gaps in care from rehabilitation discharge and safe management of the survivor in the community  Case management assistance with modifying care plan as the survivor copes with challenges living in the community

 Electronic devices for safety monitoring  Development of outcome criteria for Transitions of Care  Development of Day Programs for brain injured survivors  Increased development of group homes designed to retrain survivors for re-learning and independent living.