	Background

TBI is the injury most likely to result in death or permanent disability. Medicaid, Vocational Rehabilitation, and ILS Programs Provide Services to Adults With TBI

Federal funding is available for medical and social support services under Medicaid, vocational rehabilitation services provided through state VR agencies, and for independent living services. With the exception of nursing facility care, most services provided under the standard Medicaid program are medically oriented. To provide long-term home and community-based services for broad groups of Medicaid beneficiaries—such as the elderly disabled or physically disabled, including adults with TBI—states generally have used 1915(c) waivers. States Target Medicaid Services to Small Groups of Adults With TBI

States generally use Medicaid home and community-based waivers to target Medicaid services to small groups of adults with TBI. VR and ILS Provide Services to Reintegrate Adults With TBI Into the Community

VR and ILS—Department of Education programs administered by the states—provide services to disabled adults, including adults with TBI, to support their reentry into the community. Both programs are financed by a combination of federal and state funds—totaling roughly $2.5 billion in 1996—and receive referrals from a variety of sources. VR provides vocational rehabilitation services to individuals with disabilities, including adults with TBI, to prepare them for and support them during their transition to employment. State-Financed Programs Provide Services to Adults With TBI

Five states that we contacted—Arizona, Florida, Massachusetts, Missouri, and Pennsylvania—have developed programs funded exclusively by the state to provide services to a generally small number of adults with TBI.These programs—which obtain services from other programs and pay only for services that cannot be financed otherwise—are more flexible than Medicaid waiver programs. Despite State Efforts to Provide Services, Certain Individuals Are Likely to Confront Substantial Barriers

Some adults with TBI encounter substantial barriers in accessing services that will support their reintegration into the community. Although the states we contacted have developed strategies to expand such services, a small number of individuals relative to the number of adults with TBI are generally served by these programs. These experts most frequently identified three groups: individuals who are cognitively impaired but lack physical impairments, individuals without personal advocates, and individuals with problematic behaviors. People without social support systems or whose social support systems fail also fall into this category. Individuals With Problematic Behaviors

People with problematic behaviors—such as aggression, destructiveness, or participation in illegal activities—generally do not have the skills required to return to the community and usually require expensive treatment in residential environments with a great deal of structure. Without treatment, these individuals are the most likely to become homeless, be committed to a mental institution, or be sentenced to prison. Based on state reports of the number of individuals who sustain a TBI in a year, the gap between the number receiving long-term services and the estimated number of disabled adults with TBI remains wide. Additional copies are $2 each.
Why GAO Did This Study

Pursuant to a congressional request, GAO reviewed federal and state efforts to provide services the individuals with traumatic brain injury (TBI), focusing on the: (1) primary federal and state programs that provide adults with TBI services to help them function more independently; (2) strategies that states have developed to enhance access to TBI-related services; and (3) circumstances believed to be most frequently associated with difficulty in obtaining services.

What GAO Found

GAO noted that: (1) adults with TBI receive services to facilitate their reintegration into the community primarily from three federal-state programs: Medicaid, vocational rehabilitation (VR), and Independent Living Services (ILS); (2) Medicaid provides medical, rehabilitation, and social support services to poor individuals with disabilities; (3) VR agencies provide services to individuals with disabilities to prepare them for and support them during the transition to employment; (4) ILS programs provide skills training to individuals with disabilities to facilitate their independence in the community; (5) all three programs are financed by a combination of federal and state funds and serve a range of individuals with disabilities, only a small number of whom have a TBI; (6) because most of the services covered by standard Medicaid programs are medical, all states have expanded Medicaid services through home and community-based waivers, which permit them to offer additional services--such as homemaker services, adult day care, and nonmedical transportation--to persons at risk of institutionalization; (7) these Medicaid waivers generally target long-term community-based services to a broad population, such as the physically disabled or disabled elderly; (8) recognizing the difficulties adults with TBI experience in accessing services, each of the states GAO contacted have developed various strategies to target services to adults with TBI; (9) five target Medicaid services specifically to limited numbers of adults with TBI; (10) despite these strategies, service gaps are likely--the number of adults with TBI who are provided services remains small relative to estimates of the total number; (11) according to program representatives and experts, those most likely to have difficulty accessing services are: (a) individuals with cognitive impairment but who lack physical disabilities; (b) individuals without an effective advocate to negotiate the social service system or without a social support system; and (c) individuals with problematic or unmanageable behaviors, such as aggression, destructiveness, or participation in illegal behaviors; and (12) without treatment, individuals with problematic or unmanageable behaviors are the most likely to become homeless, institutionalized in a mental facility, or imprisoned.