- Report Published -
|Action Plan for the Appropriate Treatment of Persons with Brain Injuries in the Mental Health System|
|Department of Mental Health; Mental Retardation and Substance Abuse Services; Department of Rehabilitative Services|
|SJR 158 (Regular Session, 1998)|
|It is estimated that nearly 2,000 of the 10,000 people reported to the Virginia Brain Injury Central Registry each year will require long-term services and supports due to resulting physical, cognitive, and behavioral impairments. The majority of persons who survive mild to moderate brain injury are able to return to their homes and families with minimal follow-up support. Some people who sustain a brain injury require intensive specialized treatment and long-term intervention and supports to effectively address cognitive and behavioral challenges directly related to the injury. In the absence of appropriate long-term treatment and support, many people with brain injuries, especially those with challenging behaviors caused by the injury, are placed in state psychiatric facilities.|
In Fiscal Year 1998, there were 118 individuals with a diagnosis of acquired brain injury, including trauma, dementia, tumor, stroke, and other neurological disease, who resided in Virginia's state psychiatric facilities [this is the unduplicated count of all individuals with this diagnosis who were on inpatient status at any point during that fiscal year]. An analysis of patients with a diagnosis of brain injury at Western State Hospital, where the majority of these patients were treated, revealed that almost 20% had a primary diagnosis of brain injury with no mental illness or mixed diagnoses of mental illness and neurological head injury, the latter of which significantly impacted clinical presentation. This cohort is not appropriate for psychiatric hospitalization and would best be served by programs specifically designed to serve individuals with brain injury.
There is limited state funding for specialized services for individuals with brain injury. While DRS provides and administers several critical services and programs for this population, these services are inadequate to meet demand and do not reflect the full continuum of services and supports required for individuals with brain injury and severely challenging behavior. Long-term residential services represent the area of greatest need in Virginia, specifically long-term supported living options with intensive behavioral supports. Few providers in Virginia offer affordable short-term behavioral treatment and support within a secure environment for people with brain injury, and none offer long-term services that are affordable to the target group as a whole.
Woodrow Wilson Rehabilitation Center's Brain Injury Services Program is not designed to provide a full continuum of behavioral services and current admission criteria exclude individuals with severely challenging behaviors. The absence of an appropriate, secure residential setting for people with brain injuries and severely challenging behavior forces some individuals requiring intensive behavioral and cognitive retraining to seek such services outside Virginia, sometimes paid for with state dollars.
There is currently no system of care in the community for people with brain injuries and no mental illness. Both short and long-term specialized rehabilitation services for people with brain injuries and severely challenging behavior are needed to divert people from admission to state mental hospitals and to assist individuals in transitioning from state mental health facilities to their communities.
DRS is the designated state agency responsible for coordinating rehabilitative services for persons with functional and central nervous system disabilities. Given the limited available funding for specialized services for individuals with brain injury, there is not a comprehensive service delivery system in the Commonwealth to meet the specialized needs of this population. Federal regulations governing Medicaid, however, contain provisions which allow states to provide certain non-medical services by applying for and implementing a Home and Community Based Services Waiver. Fifteen states have implemented such a waiver under Medicaid for persons with brain injury to cover a range of non-medical services such as case management, structured day programming and supported living services. Such services can assist individuals with brain injury and challenging behavior to avoid institutional care.
Major Finding - and Recommendations
There are three distinct groups of head-injured persons in Virginia's state psychiatric facilities. The following is recommended for each group:
• The report proposes that DMHMRSAS continue to admit and treat people with a primary mental illness diagnosis and a co-occurring head injury that presents no significant clinical concerns.
• For people with a primary mental illness diagnosis and a co-occurring head injury that is a significant clinical factor in their treatment, the report proposes that Western State Hospital and Woodrow Wilson Rehabilitation Center's Brain Injury Services Program establish a model pilot program of consultation and staff cross-training to ensure more comprehensive treatment of the co-occurring disorders in the psychiatric setting.
• The report proposes that DMHMRSAS prohibit admissions to state psychiatric facilities of individuals with a primary head-injury diagnosis and no mental illness.
The Department of Rehabilitative Services is the designated state agency for the purpose of coordinating rehabilitative and related services to those with primary brain injuries. The report recommends that the Commonwealth support DRS in pursuing several strategies to promote the development of short and long-term residential alternatives for people with brain injuries who have severely challenging behaviors but no mental illness. Specifically,
• The Commonwealth, through DRS in collaboration with DMHMRSAS, should support the development of community-based models for the provision of services to persons with brain injuries and challenging behaviors.
• The Commonwealth should develop secure residential programs for short-term and long-term treatment and rehabilitation of individuals with the most severely challenging behaviors.
• The Commonwealth should develop long-term supported living options that will assist individuals with brain injuries to live in their own homes.
• DRS and the Department of Medical Assistance Services should pursue financing for the above residential services through a Medicaid waiver for Home and Community-Based Services targeted to Virginians with brain injury.
• DRS, in collaboration with DMAS, should study the use of dedicated brain injury units in nursing facilities, and explore strategies to expand these services where feasible and appropriate.
These recommendations lay the groundwork for achieving statewide implementation of model programs and services for people with brain injuries residing in state mental health facilities.