Download Update from Ohio Brain Injury Program

Brain Injury Advisory Committee
Meeting Minutes
Date: April 16, 2015
Place: Ohio Union, 1739 N. High St.
Columbus, Ohio 43210
Attendance
Members: Daniel Arnold, Jo Ann Boggs, Julie Fasick-Valley, Julie Johnson, Barry
Knotts, Bonnie Nelson, Diana Pollock, Anna Prebis (via phone), Stephanie Ramsey,
Elizabeth Sammons, Denise Schaad, Kathy Stachowski, Adreana Tartt
Brain Injury Program Staff: John Corrigan, Monica Lichi, Hannah Thompson, Laura
VanArsdale
Volunteers: Kristin Hildebrant, Julie Johnson
Guests: Katie Knotts, Laura Leach, Hope Roberts, Donna Rudderow
Welcome and Introductions
Adreana Tartt called the meeting to order and the committee provided selfintroductions.
Old Business
Review/Approval of Minutes.
Stephanie Ramsey motioned to approve the January minutes. Barry Knotts seconded.
Motion passed.
Update from Ohio Brain Injury Program
Establishing the program at Ohio State University - As reported at the meeting in
January, a request has been made to increase the budget of the Ohio Brain Injury
Program. At this point in time, the request is still pending. Monica Lichi and John
Corrigan met with Jackie and Michael Moore, the founders of the TBI Resource Center
in the Toledo area. It is probable that Jackie Moore would be open to speaking to the
committee on what the plans are for the resource center. It will likely take between six
months and a year to evaluate how the center is performing. Monica Lichi is on the
Planning Committee for the NASHIA Annual Meeting in October 2015. Laura
VanArsdale is working on setting the BIAC meeting schedule for 2016.
Incidence & Prevalence Data - The hope was to again have the module for
prevalence of TBI in the 2015 Behavioral Risk Factors Surveillance System, but
unfortunately, it was not chosen. There were enough respondents to the 2014 module to
be able to acquire reliable analysis results. This data is being analyzed at the CDC with
the help of an epidemiologist. The results should be returned by June. There have been
some issues with the intermediaries between hospitals and Medicaid/Medicare.
Community Integration - The first HRSA grant training was completed on April
14th. Dan Arnold commented that the training was done really well and professionally.
Adreana Tartt added that there was good quality on the webcast portion of the training.
Diana Pollock appreciated the content of the training and said that the data and graphs
were beneficial. The information was relevant for health care workers and their
relationship with clients. The Ohio Department of Transportation hosted the in-person
training. Over 250 people connected online and participated in the training. The first
training is available online and is being promoted to the health care community. The
second training is being prepared. Current thinking is to have the second training in
August or September, hopefully again with the Ohio Department of Medicaid mandatory
training. This will depend on if the training spot is taken, as the training needs to happen
this autumn.
An adaptation of the OSU-TBI-ID will be included in the Long-term Care
Questionnaire. LOTISS is the new care management system and the Long-term Care
Questionnaire will be a part of that system. The adapted OSU-TBI-ID is a single question
split into three parts. The first screen will be done by telephone operators on the 1-800
number. They will determine what next level of care is appropriate. The goal is to make
the process as simple as possible for consumers without them having to go through too
many layers of services. Workers running the phones may need training regarding why
they are administering certain questions. The Balancing Incentives Program and No
Wrong Door have single entry points that are used to refer consumers to the correct place.
Those performing the screens will not be specifically trained in TBI, but they will be
trained for the screen. The strategy is to elaborate existing resources and get involved in
the existing resources around Ohio.
Ask the Expert and Frequently Asked Questions are available at
u.osu.edu/tbiexpert/tbi-aging. There is also Resource Facilitation available with a social
worker at Ohio State. These resources provide support to case managers and allow them
to continue gathering information after the training.
Youth Concussion - The Ohio Brain Injury Program had a promising conversation
with Commissioner Moore about High School RIO and creating a program for Ohio
specific data. Issues will need to be settled soon, but the push on this program is being
shared.
Veterans - Information on the Star Behavioral Health Providers program can be
found at www.starproviders.org. The program is geared toward training community
health providers in veteran service needs. There are three tiers of this training and Ohio
currently has funding for Tier 1. Two Tier 1 trainings have been completed as of this
meeting. Five hundred individuals have signed up for the trainings or are on the waitlist.
The evaluations have had an average of five out five. It is hard to meet the demand, but
that is good problem to have with the program. Work is going into gaining more funding
for the program. The first phase of the program involves training providers before
building a registry of providers. Applications have already been coming in for the
registry, which will be launched in June. Military service members, as well as family
members, will be able to find providers with the training to understand their particular
needs. The Ohio National Guard has printed brochures that will be going into the hands
of service members and family in a large awareness campaign.
The Ohio Brain Injury Program requested funds in the line item to keep Laura
VanArsdale in the Star Behavioral Health Providers program and to have a return of the
TBI module to the Ohio 2015 Behavioral Risk Factors Surveillance System. We will find
out about the line item by July 1st. There is a high demand for the Star Behavior Health
Providers training and registry, which may drive the acquisition of funding to produce
Tier 2 trainings. It helps that there is a strong focus on the evaluation component and the
evaluation scores have been phenomenal. There is clear evidence of the impact of the
trainings and the demand for them. The number of people served will be tracked which
will help promote the need for funding. There may be some potential for funding on the
national level from sources such as the Wounded Warrior Project.
The Ohio Brain Injury Program did receive the Ohio State Outreach Grant for the
joint project between the Ohio BIP, the Ohio State School of Social Work, WETA, and
Give an Hour. The project did not receive full funding, so it will have to be scaled back,
but it is the first step to providing training at the first level of education.
Ohio Department of Medicaid Waiver Presentation
Dan Arnold introduced the committee to Laura Leach and Hope Roberts. Laura
Leach started her career working with direct care before moving into policy at the state
level. Working on the state level can be limited due to funding issues and bureaucratic
red tape. Hope Roberts previously worked in a community-based practice as a social
worker. She was a PASSPORT case manager with the Department of Aging. She moved
into a provider oversight team that ensured that providers of services on the Department
of Aging Medicaid waivers were following guidelines. After that, she moved to work at
the state level with the Department of Aging where collaboration between departments
had been the approach to her work. She joined the Department of Medicaid in September
and works in policy. For the first time in the state’s history, the Department of Medicaid
has its own cabinet level department. The eligibility system is designed to be easy for
consumers to use it. HOME choice has been quite successful with 6,000 residents having
re-entered the community. Ohio has committed to helping people live in the setting of
their choice. Waivers are being used to meet this goal. Consumers have the opportunity to
hire the person that they want to deliver their services. Consumers have direct input into
how they want to receive care. The federal government gives states different models for
waiver development. The design of the waiver matches the voices of the consumers and
provides the outcomes that match as well. There are managed care models as well as fee
for service models. When designing a waiver, they have to identify who and how many
will be served, where the waivers will operate in the state, and what model will the
waiver follow. For the Balancing Incentives Program, there is both an adult and a child
assessment. The final component of the waiver is proof of compliance. Partnership is
necessary to keep the waivers functioning in Ohio.
For the PASSPORT waiver, licensed social workers and registered nurses do the
assessments and the physicians certify the level of care. The Area Agencies on Aging are
the PASSPORT administration agencies. There are challenges such as when an elderly
person is suffering from physical ailments and developmental disabilities as a consumer
can only be on one form of waiver.
There are Department of Developmental Disabilities (DD) waivers as well as
Ohio Department of Medicaid (ODM) and Ohio Department of Aging (ODA) waivers.
Enrollment on the traditional waivers is going down. If a person is dual eligible for
Medicare and Medicaid and lives in one of the 29 counties where the waiver is available,
s/he will be transitioned to the MyCare Ohio waiver. There is an ongoing effort to align
multiple waivers in policy and practice. Self-directed services from the Choices waiver
have been put into PASSPORT. Similar to PASSPORT, the Transitions Carve-Out
Waiver (TCOW) has served those 60 and older. However, there two waivers did not offer
the same individual cost limit or service packages. As a result, PASSPORT has added
services that were on the TCOW and revised the individual cost limit to be consistent
with TCOW. Due to these changes, the individuals served on the TCOW will move to
PASSPORT. This move began in February 2015 and will be completed in June 2015. The
TCOW will officially close on June 30th. It has been ensured that no one will lose
services, providers, etc. As people move from TCOW they will now have access to selfdirected services with PASSPORT. Consumers who are using independent providers will
have the option of exploring whether have to see if their current providers are still
available under PASSPORT as independent providers. If a consumer hires family
members, the requirement elements are the same. Only an adult is able to provide
services to a family member or relative.
The Brain Injury Advisory Committee wants to integrate into the system, rather
than running parallel to it. This is the same goal as with the integration of the waivers. It
makes more sense to join together then to have two groups doing the same thing.
The Individual Options Waiver was studied to determine the population served
and if the design services allow consumers to keep their providers in the most cases
possible. There is adult foster care and adult family living, but consumers prefer shared
living as the terminology. They have heard from individuals that in some cases, health
care staff has to travel to watch the consumer take their pills. This is complicated when
individuals live in a rural area. In order to address this situation, remote monitoring
service is now an option. There are individuals that need assistance and/or prompts for
daily living such as making popcorn, but these individuals did not want to be waiting for
hours for a staff member to travel to their homes. This is where remote monitoring comes
into play. It could also be used for individuals who struggle with seizures. Individuals are
able to live independently without a staff member having to be there constantly.
Planning and assessing needs for services is nursing-based and nurses perform
these tasks in accordance with the state policy. The DD Waivers place planning and
assessing into the hands of the local county boards. There is slightly more local control
for the DD waivers, because they are partially funded by county levies. Local county
boards are the case managers that assist with the plans. Medicaid has contracted with
CareSource, Care Star and the Council for Older Adults in Cincinnati. The Department of
Aging contracts with the PASSPORT Administrative Agencies for planning and
assessing for PASSPORT and Assisted Living. There is a wide range of differences from
county to county. Franklin County may have more people on waivers and have a more
automated format than smaller counties which may have only five people on a waiver and
use a handwritten format.
Onsite visits are used to see if waivers are being implemented appropriately.
Individual needs for care vary widely as well and case managers will work with family to
determine when and where services will be needed. The engagement of staff has been
beneficial for the waivers. The services are waiver specific and there are some differences
in services between waivers. In order to align waivers such as the Ohio Home Care
Waiver with PASSPORT, you would have to align the services and test how they work
before integrating them. The CMS federal regulation says that individuals receiving
services need to be served in the most integrated setting. There needs to be meaningful
community integration. Public comment is open for at least 30 days on the waivers. Next
year, the Ohio Home Care Waiver is being renewed so that will be the point when public
comments will be needed. Entire waiver documents will be posted online for feedback.
DD waivers have historically had a long waiting list, because they are driven by county
board funding. Due to the waitlist, 3,000 slots have been added to the IO waiver in the
last year. Most people waiting for the IO waiver are on the emergency list, but the
additional 3,000 slots will be available for non-emergency consumers.
For the DD waivers, one of the new services in all of the DD waivers will be
employment services (competitive, sheltered, etc.). These will be called the Adult Day
Services. Advocacy groups are working on these right now. The stream for the DD
programs are sometimes to the state’s advantage such as with the recession in 2008,
because their funding was not cut when state funding was cut, so not everyone would
want that to change. IO waiver nursing services will be paid by Medicaid, which will
help to stretch the funding for the DD waivers. There are attempts to collaborate to
provide funding in the best way possible to get the services that are needed. DD waivers
are for those of any age.
Strategic Planning: First Draft
The committee was introduced to the framework for the 2015-2020 strategic plan.
This will be a joint plan for the Ohio Brain Injury Program and Brain Injury Advisory
Committee. The goal is to plan for five years, but renew in three years.
Population surveys have been popular in several states and one was completed in
Ohio some years ago. However, the responses really only make up a convenience sample.
The responses simply reinforce what is already being thought. A proper Needs
Assessment is not possible with such low response rates.
We have inferred needs, generalized from other states and national data. Key
informants have been telling us about perceived needs. Hopefully, in the future, we will
be in a better position to work more systematically. Inferred needs should continue to be
used in planning. There needs to be agreement on what direction this process should take
and where the focus should be.
We have to do this planning in the context of limited resources. We have 125,000
dollars to do this planning. The plan must be strategic and not duplicate what others are
already doing. Existing resources (state department programs, available grants, etc.)
should be leveraged.
When thinking of brain injury from a public health standpoint, we need to decide
if we are focusing on primary, secondary, or tertiary prevention. Primary and secondary
prevention are not currently the main target as these preventions already have much work
being done for them. Our current target is tertiary prevention.
There is a major emphasis on data, because we must have data to do planning and
evaluation. We are behind on checking data and analyzing what it tells us. There is a need
for a workforce of informed providers. Educating providers is a major need across several
states. We will seek system change for specific issues. There are limits such as this
program is being relatively small. For moderate to severe TBI, we have around $10
available per person with TBI. This is not much money, but there are some areas that are
desperate for change and need issues addressed.
Incidence data will be used for planning and evaluation. This will include data on
persons receiving medical care in the ED and those hospitalized as collected by the Ohio
Department of Health and the Ohio Department of Public Safety. Youth sport is an area
in which there is a need for incidence of untreated TBIs. There is both need and
opportunity in this area. There has been some indication that acquiring a mild TBI in
childhood may have long-lasting effects that carry over into adulthood. The public is
focused on this area as well, so now is a good time to address this issue. There is not
much data available on prevalence. Adult population estimates should be developed for
history of TBI from the Ohio BRFSS. There is one year’s worth of data to be analyzed.
Youth population estimates need to be developed for history of TBI from the Ohio
YRBSS and/or Ohio BRFSS (which is not limited to sports). A method should be
developed for estimating those with disability due to TBI. There are those that may have
a need for long-term supports. All state services should screen for a history of TBI. It is
reasonable that if we were to ask a state department for how many individuals have a
history of TBI that they would be able to provide that number. All departments that
deliver services to individuals should be screening for TBI.
Regarding the workforce, there is a high turnover rate in the health care field
which makes training something that must be done constantly. The best way to do this
would be to have pre-service training that has the prospect of changing the workforce
permanently. Continuing education is a helpful learning tool so in-service trainings would
continue, but pre-service training is a must in order to get ahead of the workforce and
make sure that consumers are receiving proper care. Our focus will be on seven
professions: medicine, nursing, psychology, social work, counseling, education, and
criminal justice. Some, but not all, therapists are aware of the needs of those with a TBI.
There is already training for therapists, so they must be approached differently. A preservice training would not reach everyone currently practicing in the field, but more
trained professionals would be entering the field over time.
System change is key for specific issues. Return-to-Learn is adopting the best
practices for students returning to school following an injury. Community living is one of
the most important needs that are being addressed by the HRSA grant. There is the need
to make sure that brain injury symptoms are accommodated for when receiving
behavioral health treatment. A handout was given to the group consisting of the 10
strategic directives for 2015-2020.
Return-to-work was considered for system change, but ultimately not chosen. It
would be helpful to have Opportunities for Ohioans with Disabilities (OOD) start
screening everyone for TBI, because it is a challenge to decide what changes to make
without knowing the numbers of who needs served. The method of screening would need
to be discussed as OOD looks at the functional disability. Perhaps a screen for executive
functions would be appropriate. There may be some people who are being discriminated
against due to executive function deficits that are not being taken into account. There is
an issue with the differences in the languages that are being used.
It would wonderful to see TBI being addressed across all agencies at the state
level. There is a current focus on physical disabilities over mental deficits. It may be a
good idea to screen for deeper functions rather than for screening for TBI, because there
are many people who do not realize that they have executive function deficits.
Medications may also impact a person’s awareness of physical and mental issues. Only
later in time do many TBI patients recognize that they have more than physical ailments.
The Recovery to Work initiative was the first time the major departments came together
to focus on a goal. The language being used to describe problems impacts how things
work and finding TBIs later on showed mental barriers to return-to-work. When a
disability impacts motivation and motivation is a requirement to receive treatment, there
is an inherent issue. Something that is impacted by the disorder should not determine if a
consumer receives services. It is important to see who is receiving services, who drops
out, and who succeeds.
Comments were given on the 10 strategic directives for 2015-2020. For number
ten it was noted that a chaotic family or bad environment could negatively impact a
patient. This would also be an issue under number nine. This is something to consider in
the treatment of clients.
For number one, data is necessary to receive funding at the state level. The coding
regarding substance abuse is important, because if that information is not provided, then
there cannot be an accurate assessment of needs and thus funding will be weak.
For number two, youth TBI should be the focus, but we should leverage the
public awareness of Sports TBI. Mild TBI is under-reported in youth.
There are several other areas of unreported TBI that we want to capture such as
those from adult abusive situations (domestic violence, elder abuse, etc.).
The significance of TBI is not recognized in Ohio, which is highlighted by the
lack of data available. Eventually there will have to be a discussion on the topic of
financing from the public sector and having the public sector recognize that TBI
awareness is an issue that needs to be supported. The Ohio Brain Injury Program does not
get the public attention that other programs get, such as the Injury Prevention Program.
These programs receive more attention as well as more funding, as can be seen with the
reports they publish. We do not yet have the answer for how to address this at the
community level, but it is clear that Ohio does not provide the money or services that are
needed for people with TBI. There are a lot of factors that are driven by money. Brain
Injury impacts the community in a way that many other things do not.
With the inclusion of the screening in the Long-term Questionnaire, we should be
able to go to state departments and show them what is happening while telling them that
they need to screen for TBI as well. If the state departments start using the screening,
then we could encourage all providers to do the screening as well. It could be indicated
that if the screening is in one system, then it needs to be in all systems. The BIP screening
is an access point for increasing awareness and utilizing screening tools elsewhere.
There are longitudinal studies such as the Model Systems study, but this study
only collects data on patients that are 16 and older. Three children’s hospitals in Ohio are
working on a similar project with three other hospitals in Texas and Australia, but this is
not national data. The Ohio Brain Injury Program is working with the CDC to develop a
nationwide registry of kids who have a TBI. This is a long-term process that cannot
happen immediately. The timing of the HRSA grant connected well with the changing
structures of state department policies. The state departments are trying to streamline the
state infrastructure. Reform measures are taking place. There are several departments that
are making forward strides. The Brain Injury Program is tagging along to provide help
and support wherever possible.
The Star Behavioral Health Program is now setting precedence. The goal is to
elaborate on TBI in Ohio as the original program out of Purdue only provides a basic
overview of the subject in Tier 3 trainings. Additions can be made to the trainings in
order to promote anything we think would be beneficial. TBI resources are able to be
promoted along with the Star program. Collaboration has been a key component of
success in this program. The Department of Defense has focused most of its attention on
acute care rather than long-term living.
There are certain initiatives with state departments that do not receive the
attention they deserve. There has to be internal connections between agencies in order to
make a strong pull for the Brain Injury Program. Getting the TBI screen into the state
system would be monumental. The screen is a pre-assessment to the OSU-TBI-ID. It is
not the most detailed screen, but the initial screen would lead to the more detailed
assessment to get a better idea of lifetime history. It is easier to slip the screen into
structures that are already in place rather than creating an entirely new structure.
There was not time for the workgroup summaries. Anyone interested in a
workgroup can email Monica Lichi regarding the workgroups.
The meeting was adjourned.