1. INTERFACE Boulder Colorado Sandy McCarthy Judy Dettmer Kevin Pettit

2. Colorado Traumatic Brain Injury Trust Fund Program

3. 3 Program Overview Passed into Law in 2002 Title 26, Article 1, Part 3, Colorado Revised Statutes Created TBI Trust fund Added surcharges to traffic offenses Created TBI Board Designated allocation of funds Placed in Department of Human Services

4. 4 Surcharges $15 for each conviction of driving under the influence (DUI), or driving while ability impaired (DWAI) $10 for each conviction of speeding Surcharges began January 2004 Generated over $4 million in first 2.5 years

5. 5 TBI Board 13 members 3 members designated in statute 10 members appointed by the Governor with the consent of the Senate Diverse group of people with expertise in TBI, including medical providers, health care professionals, survivors and family members, researchers, and State officials Role is to oversee the operations of the Trust Fund

6. 6 Allocation of Funds 65% to provide services to individuals with TBI 30% to support research related to the treatment and understanding of TBI 5% to provide TBI education for survivors, family members, professionals, educators, and others in the community

7. 7 Role of Department of Human Services Financial management Policy development Program development and implementation Contract management Program monitoring Administrative support Website maintenance Public assistance and information Reporting Public relations

8. 8 Client Services Overview TBI Definition Eligibility Criteria Care Coordination Purchased Services Intake and Eligibility Process Children’s Services Adult Services Limitations Wait List

9. 9 TBI Definition Statute – Injury to the brain caused by physical trauma resulting from but not limited to incidents involving motor vehicles, sporting events, falls, and physical assaults. TBI Board – Damage to the brain caused by external physical force, including acceleration / deceleration injuries. This does NOT include brain injury caused by a congenital causation, degenerative diseases, surgical interventions or anoxia.

10. 10 Eligibility Criteria Colorado resident & proof of legal presence in U.S. Documentation of a TBI that is sufficient in severity to produce a partial or total disability as a result of impaired cognitive ability and/or physical functioning No other health or rehabilitation benefit funding sources that cover the services provided by the Trust Fund Do NOT have to exhaust private funds

11. 11 Care Coordination All individuals receive Care Coordination services Assigned care coordinator Develop care coordination plan Identify individual needs Apply for benefits Access existing benefits Find resources in the community Coordinate services from different service providers Arrange for services through Trust Fund

12. 12 Purchased Services May purchase services including but not limited to: Community residential services Structured day program services Psychological and mental health services Prevocational services Supported employment Companion services

13. 13 Purchased Services (continued) Respite care Occupational therapy Speech and language therapy Cognitive rehabilitation Physical rehabilitation One-time home modification Many other services that are appropriate for individuals with TBI

14. 14 Excluded Services Institutionalization Hospitalization Medications

15. 15 Intake and Eligibility Process Brain Injury Association of Colorado performs client intake and eligibility Assist individuals with the application process Determine eligibility Refer eligible individuals for Trust Fund services

16. 16 Children’s Services Denver Options, Inc. and the Colorado Department of Public Health and Environment, Health Care Program (HCP) for Children with Special Needs provide children’s services Under age 21 Care coordination provided through 14 local health departments around the state Purchase services from service providers throughout the state

17. 17 Adult Services Denver Options, Inc. provides adult services Age 21 and older Care coordination provided by Denver Options staff and some contracted care coordinators Purchase services from service providers throughout the state

18. 18 Limitations on Services Limited resources Program intended to fill gaps, not designed or funded to be the individual’s primary source of services Not an entitlement program (like Medicaid) Services are subject to available funding First come, first served Individuals may receive funds for services for 1 year

19. 19 Limitations on Services (continued) May re-apply to receive another year of care coordination but will go to end of wait list if program is at capacity $2,000 life time limit for purchased services Purchased services must be included in Care Coordination Plan and approved in advance Trust Fund does not pay clients directly

20. 20 Research Program TBI Board awards research grants annually Initial grants funded at $50,000 per year In 2007 research program was changed to fund 3 levels of grants at $50,000, $250,000 and limitless for level three grants Research priorities related to Basic Science, Clinical Science, and Health Services and Outcomes Annual application and review process Have awarded a total of 16 research grants

21. 21 Education Program Program brochure in English and Spanish Website: www.tbicolorado.org Presentations and exhibit table at conferences Education Grants: a total of 46 grants have been awarded

22. 22 Additional Information Brain Injury Association of Colorado 4200 West Conejos Place, Suite 524 Denver, CO 80204 888-331-3311 – toll free www.biacolorado.org Department of Human Services Office of Behavioral Health and Housing 3520 West Oxford Avenue Denver, CO 80236 303-866-7477 www.tbicolorado.org

23. Clinical Intervention Things to Keep in Mind

24. 24 GREIVING AS IT RELATES TO BRIAN INJURY Brain injury affects all aspects of a persons life (often not the same person anymore) Grieving is an on-going process and may be heightened at times of transition Can not rush the grieving process Recognize when grieving is occurring and provide support as needed

25. 25 POTENTIAL BARRIERS TO CLINICAL INTERVENTION Short term memory loss Attention and concentration Organizational ability

26. 26 POTENTIAL BARRIERS TO CLINICAL INTERVENTION Fatigue Lack of inhibition Lack of awareness/insight

27. 27 STRATEGIES FOR ADDRESSING MEMORY ISSUES Encourage the individual to write information down or tape record it Encourage individual to use as many environmental aides as possible (labeling items, shelves, using bulletin boards etc.) Give brief and concise instructions Encourage the individual to ask for instructions repeated as needed

28. 28 STRATEGIES FOR ADDRESSING CONCENTRATON/ATTENTION ISSUES Provide the individual with an uncluttered environment Eliminate as many auditory and visual distractions as possible Eliminate as many interruptions as possible Allow the individual to work on one task at a time

29. 29 Organizational/Planning Skills Strategies Do not assume that the individual has the ability to take responsibility for the organizational aspects of his/her program Understand that it will take an individual with a brain injury longer to learn routines and understand what is expected of them Provide individual with a day timer and calendar to assist with memory and organization Assist the individual in using the day timer and calendar until this becomes routine

30. 30 Organizational/Planning Skills Strategies Routines are critical to minimize the need to initiate tasks Individual may need support to see a task through to completion until the task is routine Reminder calls may be necessary to ensure follow through when the individual is engaging in an unfamiliar task Prepare the individual for transitions and disruptions to their routines

31. 31 STRATEGIES FOR ADDRESSING FATIGUE ISSUES Encourage the individuals to take rest breaks, may have to schedule breaks until individual can begin to recognize when they need a break Be aware that medications an individual is taking may make them fatigued If individual is overloaded or fatigued do not keep pushing

32. 32 STRATEGIES FOR ADDRESSING ISSUES RELATED TO DISINHIBITION Gently provide feedback regarding an individual’s behavior at the time the behavior occurs Video taping (with the individual’s consent) When possible, ensure the participant is not in an environment that could cause him/her difficulties Role playing consistently and repeatedly may be helpful

33. 33 STRATEGIES FOR ADDRESSING ISSUES RELATED TO DISINHIBITION Need to be concrete and consistent when providing feedback e.g. do not talk to a woman about her looks The individual may benefit from attending a support group for individuals with brain injury When dealing with employment, be up-front with the employer so that they are not caught off guard but rather are proactive and supportive

34. 34 STRATEGIES FOR ADDRESSING ISSUES RELATED TO AWARENESS Building a new identity following brain injury takes time Provide individual opportunities to try different activities in a safe environment (work, community and home related) Provide feedback on an on-going basis Video tape the individual (with their consent)

35. 35 STRATEGIES FOR ADDRESSING ISSUES RELATED TO AWARENESS Do not assume the person in “denial” Professional counseling may be beneficial Allow time for grieving

36. 36 KEY ELEMENTS FOR SUCCESSFUL CLINICAL INTERVENTION The participant is in charge Skills often do not transfer, train the individual in the environment they are expected to perform the task Be consistent when teaching strategies and allow for sufficient time for them to become routine Understand that grieving and creating a new identity takes time

37. 37 TBI and Substance Abuse 67% of individuals in a rehabilitation program for TBI have a history of substance abuse prior to injury Individuals with TBI test positive for alcohol in 2/3 of motor vehicle crashes Approximately 20% of persons who did not have substance abuse problems prior to TBI are vulnerable after TBI Corrigan

38. 38 Five Stages of Change 1.Precontemplation 2.Contemplation 3.Preparation 4.Action 5.Maintenance

39. 39 Stages of Change and TBI Limited self awareness will affect ability to work through stages Need to assess individuals ability to self reflect May not be able to independently implement coping strategies Repeated practice with strategies will help individual become more independent

40. 40 Mental Health and TBI Depression Anxiety Personality Changes Aggression Social Inappropriateness NAMI

41. 41 Effective Treatment Approaches Not much research Clinicians feel that techniques found effective for people in general can also be effective for individuals with TBI However, special considerations or accommodations may be required

42. 42 Specific Interventions Motivational Interventions Cognitive-Behavioral Therapy Therapeutic Community