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Conflict Free Case Management, a Model for Quality and Cost Effectiveness The Challenges of Long Term Brain Injury Rehabilitation in a Rural Southeastern State Experiencing Prolonged Financial Distress

 

T. Wells*
Department of Aging and Independent Living, Cabinet for Health and Family Services,
Frankfort, KY 40621
*Corresponding Author: Department of Aging and Independent Living, Cabinet for Health and Family Services, email: toniaa.wells@ky.gov


ABSTRACT

Conflict Free Case Management, a Model for Quality and Cost Effectiveness:  The Challenges of Long Term Brain Injury Rehabilitation in a Rural Southeastern State Experiencing Prolonged Financial Distress is a brief purveying the success and challenges of an evolving program initiated in 1998 by the Commonwealth of Kentucky General Assembly creating the Kentucky Brain Injury Trust Fund (TBITF) and the Board of Directors.  Services provided to qualifying individuals include:  

1. Case management;

2. Community residential services;

3. Structured day program services;

4. Psychological and mental health services;

5. Prevocational services;

6. Supported employment;

7. Companion services;

8. Respite care;

9. Occupational therapy; and

10. Speech and language therapy

Keywords: traumatic brain injury, Commonwealth of Kentucky, case management, financial distress

INTRODUCTION

Traumatic brain injury (TBI) is a significant health problem in Kentucky. In 2007, over 4,500 brain injury cases were reported by Kentucky hospitals as acute care admissions or fatalities. This did not include the numerous individuals treated in outpatient facilities, emergency rooms (ERs), and contiguous states. In 2008, preliminary reports of outpatient ER data estimated over 27,000 individuals had been diagnosed with brain injuries. Statistically, it has been determined, within Kentucky, the number of individuals sustaining brain injuries is rising. According to the Kentucky Injury Prevention and Research Center’s 2007 data, 6,248 Kentucky residents survived an injury of the brain (i.e.: TBI, acquired brain injury (ABI), spinal cord injury (SCI), but had significant deficits after sustaining the injury (Figure 1 and Figure 2).  Unfortunately, 2,751 Kentuckians died the same year from a brain injury.  On average, brain injury has played a role in the death, or hospitalization, of 23 (12 TBIs, and 11 ABIs, or SCIs) state residents per day. 

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Figure 1:  Kentucky Brain Injury Cases by County, Non-Fatal and Fatal, 2007.

 

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Figure 2:  External Cause of Brain Injury, Fatal and Non-fatal, 2007.

In 2008, the Kentucky Hospital Association (KHA) began collecting electronic records for outpatient encounters from Kentucky hospitals, including ER visits.  Based on preliminary 2008 data, the number of non-fatal TBI cases for Kentuckians treated and released each year, from ERs, was somewhere between four and six times the number of inpatient hospitalizations. Accordingly, over 7,000 individuals were seen in an ER and diagnosed with a brain injury in the first six (6) months of 2008.  It is estimated; therefore, approximately 15,000 individuals annually, are diagnosed in a Kentucky ER, and discharged, with a brain injury.  Data collection has been improved and as the 2010 data has been examined more closely, the number appears to be over 25,000 individuals diagnosed with a TBI.  This number is far above initial estimates. 

Attempting to address the health crisis, the Kentucky Traumatic Brain Injury Trust Fund (KY TBITF) was created by the General Assembly in 1998 to provide services to children and adults with ABIs and TBIs across the Commonwealth.  Kentucky Revised Statute (KRS) 42.320 designates the Trust Fund receive 5.5 percent (5.5%) of court costs collected by all circuit clerks statewide.  In addition, KRS 189A.050 specifies that eight percent (8%) of the Driving under the Influence (DUI) service fees shall be credited to the TBITF.  This statue also includes a cap of $3.25 million to the Trust Fund.  Funding to the Trust Fund has been increased minimally since its inception.  The number of individuals served by the Trust Fund, however, has increased more than 30 times in the past ten years.  Moreover, the Trust Fund Board of Directors has a mandate (KRS 211.470 to 211.478) to investigate the needs of people with brain injuries and to identify gaps in services, as well as assist in the development of services for people with brain injuries.  For administrative purposes, the KY TBITF Board of Directors is attached to the Kentucky Cabinet for Health and Family Services, Department for Aging and Independent Living (DAIL).  A Benefit Management Program (BMP) was established by the Board in April 2001 to govern the operation of the TBITF. The Kentucky Administrative Regulation (KAR) 910 KAR 3:030 established the responsibilities of the BMP and the procedures for obtaining a benefit from the Trust Fund.

In accordance with the regulations, the BMP is required to:

  • establish a toll-free number;
  • engage in public information activities;
  • provide case management services to eligible applicants and recipients;
  • accept applications for benefits from the Trust Fund and distribute benefits to recipients based upon an approved service plan; and
  • establish a Service Plan Review Committee for the purpose of reviewing service plans for approval.

A private case management firm was selected by the Board in 2001 to administer the BMP.  This selection process was a significant milestone for state programs in that a private for profit corporation was selected to work closely with the Commonwealth and other funding sources.  Since the inception of the Program, 3,890 clients have been admitted and attended with case management services.  The growing number of referrals with no increase in funding, over the years, has been a significant concern for the TBITF. 

METHODS

Over the past ten years, the TBITF has been transformed into one of the most innovative programs in the Commonwealth, merging external funding sources and resources with federal, state, and local programs.  The primary goal of the TBITF is to provide case management services, at no cost to the clients, in order to assist them in remaining in their home communities.  The BMP must, however, ensure the Trust Fund remains a funding source of last resort.  The case managers need, therefore, to be innovative in accessing the available natural supports in the communities.   Case managers assess the applicant’s eligibility for a benefit, identify the applicant’s needs for services and supports and assist in the development of service plans and requests.  The case manager also monitors the delivery of services and supports to the recipient; and educates applicants, recipients, and family members. 

The following benchmarks for the program have emerged, defining its success:

A.  Identification of case managers who are well trained, certified, have advanced degrees and meet the following criteria (non-mandated):licensure as a Registered Nurse, or MS in Social Work, or Vocational Rehabilitation; minimum of 3 years experience in nursing, vocational, or other related health care field;

  1. occupational health, public health, home health, critical care, vocational counseling, or other equal experience;
  2. five days formal training, including classroom, and field training in case management;
  3. additional formal training for catastrophic case management;
  4. mandatory certification at the time of eligibility as either Certified Disability Management Specialist (CDMS), Certified Case Manager (CCM), or Certified Rehabilitation Registered Nurse (CRRN); and
  5. six hours of brain injury specific continuing education unit training annually. 

B.   Identification of Lead Case Manager/Care Coordinator who: 

  1. assures clients are not involved with any other program;
  2. assures that anyone who contacts a vendor, or the DAIL agency, receives immediate screening, intake, and assistance;
  3. assures needs are identified and referrals are made immediately to the appropriate parties. (There is no "wrong door" for the individual, reducing calls and improving consumer service);
  4. assures a universal plan of care is developed and a case manager is assigned which avoids a duplicate number of case managers assigned to the same case; and                                          
  5. oversees financial/program eligibility determination, program applications, ordering of services, data monitoring and collection, and quality assurance. 
  6. Case managers who are located in communities with the injured individual and are, therefore, familiar with local resources and able to access both public and private funding sources. 
  7. Conflict free case management available through a privately owned company providing innovative medical consulting, disability management and cost containment services.  The case management provider is not affiliated with any other vendor (financially or otherwise) nor does it deliver other services the TBI clients may need. 
  8. Utilization of case managers who are knowledgeable about multiple insurance  types, public funding (federal, state, and local), non profit resources, local resources, and charity organizations.  The TBITF has learned that resources are essential to providing quality rehabilitation services with limited money.  The ability to track cost savings by individual, county, and service has provided essential data used to build resource information and make funding decisions. Ability to work with clients as needed, and not based on strict criteria, or unnecessary guidelines.  While the TBITF has budgeted money on an annual basis for case management, the BMP has the ability to utilize the money as needed for each individual.  Case Management services are reimbursed hourly and a detailed service log is required by activity and client.  This allows each case manager to utilize the case management dollars by need, not by regulated activities.  Monthly fluctuations in case management hours are detailed below (Figures 3 and 4). 

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Figure 3: FY 2008-2009 case management hours by month.

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 Figure 4: FY 2009-2010 case management hours by month. 

RESULTS

Through the BMP, the TBITF has provided over 210,495 case management hours to 3,890 individuals between January 2001-May 2011.

The Trust Fund Program has saved over $4,993,645.26, since August 2001, by the BMP case managers obtaining needed resources from other community options and natural supports.

The Trust Fund has been able to meet its goals with minimal funding increases in the past ten years. 

The TBITF case management program has become an exemplar model for case management throughout the Kentucky Health and Family Services Cabinet, implementing the principles of:

  • conflict free case management;
  • avoidance of duplicated services;
  • utilization of natural and local resources;
  • cost savings to the state through identification of other resources; and
  • exceptional consumer services that are client need based and easily accessible.


DISCUSSION

The TBITF realizes the significance of the problem of TBI in Kentucky.  The individuals served by the Trust Fund represent only 1% of those affected by brain injury in 2009.  Figure 5 depicts all hospitalized TBI injuries in Kentucky in 2006 and those individuals referred to the TBITF in the same year. The TBITF provided services to 1,423 of the total 7,247 brain injured individual’s hospitalized inpatient in 2006.  The maximum number of referrals allowed by budgetary constraints was served.

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Figure 5:  All hospitalized TBI injuries in Kentucky in 2006 and those individuals referred to the TBITF in the same year.

Kentucky, like most other states is currently suffering from a severe financial shortfall.  According to the Center on Budget and Policy Priorities, Kentucky has a projected FY 2013-14 gap of $780 million dollars.  Kentucky has a two year budget and closed their FY 2012 shortfalls when they enacted the 2011-2012 biennium.  The TBITF Board of Directors works diligently to protect the Fund annually from decreased funding and realizes securing increased funding from the Commonwealth will be difficult in the next 4-5 years. 

Recognizing the ongoing military efforts overseas, the Board has begun exploring mechanisms to address the large numbers of Kentuckians returning home with brain injuries. The number of Kentucky veterans from Operation Enduring Freedom and Operation Iraqi Freedom (OEF-OIF) is not known (1.64 million nationally).  If it is estimated that among the 1.64 million OEF-OIF soldiers deployed, (the highest priority for this project) there are at least 23,780 OEF-OIF deployed from Kentucky (Kentucky = 1.45% of the national population, thus 1.45% of the OEF-OIF population).  It can be estimated, therefore, 4,518 of the deployed will have a brain injury (Tanielian & Jaycox, 2008). Kentucky has traditionally played an important role in national defense with two major military bases, Fort Knox and Fort Campbell, in the state.  The Board has sought collaboration and partnerships with federal, state and community entities to ensure the issues are identified and the needs addressed for those individuals and families affected by brain injury.

Kentucky's population grew 7.4 percent from 2000 to 2010 and became older in the process.  Kentucky demographics are modeling a world wide trend, shifting toward decreased birthrates, people living longer, and immigration.  This data trend promises to stress the TBITF further, as low birthrates and an aging populace lead eventually to economic difficulty and increased incidence based on the increased population group over 65 years of age.  The demographics of TBI in 2007 were consistent with those for 2006. The highest rates of TBI were again found among those aged 65 and over and 15-24.  The TBITF data follows the statewide trends for increased injury prevalence in this age group.

The TBITF Board works diligently to educate the public about the Trust Fund and strives to stretch every dollar to serve all of those referred to the program. Further, the Board continues to explore alternative funding sources to address the ongoing needs and ability to serve those affected by TBI.  A significant challenge for the coming years is to identify other funding sources.   The TBITF has made client focused field case management a reality, allowing clients to be served without interruption in unstable economic times through sound benchmark practices and innovative cost effectiveness.

ACKNOWLEDGEMENT

Contributors to this article:

Deborah Anderson, Commissioner, Department of Aging and Independent Living, Cabinet for Health and Family Services, Commonwealth of Kentucky
Mary Hass, Chairperson, Traumatic Brain Injury Trust Fund Board of Directors, Commonwealth of Kentucky
Shannon Beaven, Surveillance Coordinator, Kentucky Injury Prevention and Research Center, University of Kentucky
Cindy Whitehouse, RN, CCM, CEO and Managing Partner, Ascential Care Partners, LLC.

CITATIONS AND REFERENCE LIST

Kentucky Revised Statutes, Commonwealth of Kentucky, KRS 211.470-478; KRS 42.320; KRS 189A.050.
Kentucky Administrative Regulation, Commonwealth of Kentucky, 910 KAR 3:030.
Tanielian, T., & Jaycox, L. H. (Eds.). (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Center for Military Health Policy Research.
Crouch, R. (2009). Demographic Trends for State Policymakers. The Council of State Governments.
Traumatic Brain Injury Trust Fund Board of Directors, Commonwealth of Kentucky, Annual Reports 2009-2011.
Kentucky Traumatic Brain & Spinal Cord Injury Surveillance Project.  Kentucky Injury Prevention and Research Center, University of Kentucky 2009-2011.