Brain Injury Advisory Committee

BIAC meeting minutes 10-24-2013

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Brain Injury Advisory Committee

Meeting Minutes

Date: January 16, 2014

Place: 1739 North High Street

Columbus, Ohio 43210

Attendance

Members: Daniel Arnold,Steven Cuff, Rhonda Evans, Julie Fasick-Valley, Julie Johnson, Barry Knotts, Cody Linder, Bonnie Nelson, Donna Owens, Diana Pollock, Stephanie Ramsey, Denise Schaad, Kathy Stachowski, Adreana Tartt, Grace Williams, Marlon Williamson

Brain Injury Program Staff:John Corrigan, Monica Lichi, Hannah Thompson, Laura VanArsdale

Guests: Michael J. Bush, Kirstin Hildebrant, Suzanne Minnich, Anna Prebis, Tom Prebis,Schuyler Schmidt

Welcome and Introductions

Stephanie Ramsey opened the meeting and asked attendees to introduce themselves.

Stephanie Ramsey, on behalf of the BIAC, thanked Marlon Williamson for his work as the outgoing Chair. Marlon Williamson briefly explained how he became involved with the BIAC and expressed his appreciation for being able to take part in the BIAC.

Old Business

Review/Approval of Minutes.

Grace Williams motioned to approve the October minutes. Marlon Williamson seconded. Motion passed.

New Business

Update on the Brain Injury Program

John Corrigan began new business with an update on the Brain Injury Program. He described the progress being made in each of the five areas of emphasis.

• Establishing the Brain Injury Program at Ohio State – The quarterly BIAC meetings have been set. Working Groups have, or will, set up monthly telephone meetings.John Corrigan is meeting with the Summit County TBI Collaborative on February 21st. Funds have been processed. House Bill 361 is being evaluated to determine what role the Brain Injury Program or the Brain Injury Advisory Committee may have in it. HRSA grants were announced with a deadline of March 7th.
• Youth Concussion – The Ohio Department of Health was able to get a Youth Sports Concussion module into Ohio’s 2014 Behavioral Risk Factors Surveillance System. This will give us the ability to look at parameters related to the new Return-to-Play law. Later in the meeting, Steven Cuff, MD, would present on youth sports concussion.
• Community Integration – The Brain Injury Program met with Dan Arnold, ODM, about additional services in the Ohio Home Health Care Waiver. A written request was submitted for additional services in the Ohio Home Health Care Waiver. In regards to the proposed trainings for case management providers participating in ODM’s Balancing Incentives Program, there will be a large conference in the fall for hospice and home care providers that the BIP submitted a proposal to present.
• Incidence and prevalence – In addition to the youth sports concussion module there will also be a TBI Lifetime History module in Ohio’s 2014 Behavioral Risk Factors Surveillance System. Collaborating with ODPS, CDC and NIDRR to compare two methods of projecting long-term outcomes for Ohioans who received rehabilitation for TBI. The Brain Injury Program, with ODPS, is advocating for a follow-up component for the Ohio Trauma Registry. The Trauma Registry includes all ages. This follow-up component could be done post-injury by telephone at 6 months, 1 year, 2 year, etc. This follow-up component would be done for all trauma etiologies, not just TBI.
• Service Members – The Brain Injury Program is working with ODMHAS and the Veterans’ Court in Cleveland with implementing TBI screening. There was training on January 24 at MetroHealth. The morning was spent on TBI while the afternoon was spent on military culture and placing military culture in behavioral health services. The Brain Injury Program, Give An Hour and BIAA are providing a webinar on February 26th for behavioral health professionals that will include special targeting of Ohio providers.Give An Hour is a private organization that is providing service members with behavioral health services from the community. Behavioral health professionals in private practice take one hour each week to give pro bono support to service members. OSU Outreach grants are being evaluated for a joint project with the School of Social Work and Give an Hour. The Brain Injury Program, with the Ohio National Guard, is looking for funding to bring the Star Behavioral Health Providers (SBHP) registry project to Ohio. This has been difficult so far due to the large expense associated with bringing SBHP to Ohio.

HRSA State Grants – John Corrigan gave an explanation of the HRSA State Grant deadlines and requirements. The HRSA State Grant applications are due on March 7th, which is prior to the next Committee meeting. Communication regarding the HRSA grant application will be done electronically. The start date for the grant is June 1, 2014.It is expected that there will 21 awards at up to $250,000 per year for four years. There is a requirement of a 33% match ($125,000 per year). A successful grant will need a partnership between the Brain Injury Program and another partner. We will be able to use the state line item for some of the match money, but not all of it. The match can also be in-kind. In the past, much of the in-kind match has come from OSU via unrecovered F&A. Suzanne Minnich pointed out that the Ohio General Assembly has given some of the match in the past. Barry Knotts mentioned a potential to help with the in-kind match. John Corrigan said that we can cover about half of the total match, but will need a partner for the other half.

All Applications for the HRSA State Grant must address 4 common barriers to accessing care seen across States:

• A lack of information of services and supports with little or no assistance in accessing them (information and referral services)
• A shortage of health professionals who may encounter individuals with TBI but lack relevant training to identify or treat the resulting symptoms, including physicians, nurses, school staff, coaches, athletic trainers, social workers, psychologists, child care providers, domestic violence/homeless/emergency shelter staff, law enforcement, and assisted living facility personnel (professional training)
• The absence of a TBI diagnosis, or the assignment of an incorrect diagnosis (screening)
• Critical TBI services are spread across numerous agencies resulting in services being difficult for families to identify and navigate (resource facilitation)

John Corrigan said that the Brain Injury Program is thinking of something more data oriented, but is unsure how this will work with the four barriers. It may be necessary to choose a subpopulation to focus on and decide how to weave the four barriers together for this subpopulation.

Denis Schaad remarked that perhaps the BWC would be a good choice due to BWC case management following patients more closely. There are a lot of people who do not have an initial diagnosis of TBI.

John Corrigan said that other subpopulations to consider were youth with concussions and the homeless population. John suggested that BIAC members and guests email him their thoughts on choice of a target population. He will compose a shorter list of ideas to send out to the Committee. In the future planning will be gone through more thoroughly and will be more detailed, but the time constraint will not allow for such planning in regards to the HRSA State Grant.

Denise Schaad asked if the list of suggested populations was written into the grant and if additions, such as car accidents, could be made to the list. John Corrigan answered that is was created from the grant wording and that additions such as car accidents could be added as a population.

Julie Johnson brought up that perhaps there was something that has already been looked at or something on which data has been collected that can be continued. Barry Knotts commented that maybe it could be something built on a needs assessment. Stephanie Ramsey said that on the 2012 BIAC report there were carry over items that could be looked over for material that might be useful. John Corrigan is working on a national grant with Aging and DisabilityResource Centers which could be a good connection with something that is already being started. There is a national dataset, but not an Ohio specific dataset. Julie Johnson said that the Department of Aging may be able to provide money. Laura VanArsdale gave Return-to-Learn as an option. Bonnie Nelson mentioned that Ohio has committed to a CBIRT proposal to NIDRR that was due January 28. This proposal was focused on Columbus and Toledo with the Return-To-Learn Policy and setting up infrastructure in schools.

New Strategies for Financing the Life – Costs of Severe Injuries

This presentation was given by guest speaker Michael J. Bush. The key to life care is that injuries do not end after discharge; long-term problems arise such as decreased household income and support needed to complete daily tasks. While there are living homes for disability patients after discharge, many TBI survivors cannot afford these services. Outpatient rehabilitation is expensive and difficult to maintain due to a lack of insurance coverage. A portion of the Affordable Care Act, which was to support disability care, was not passed. Disabled persons need a constant stream of income over their lifetimes. The question is whether a risk pool could be generated. It would have to be affordable, but also have an adequate payout stream. Michael and his team decided there should be a fixed stream of money rather then a system of reimbursement for services.

Economic viability issues include each insurance company having its own plan and people not buying this kind of insurance.

Qualification criteria would be based on a study done at Craig Hospital in Denver. There are four levels of TBI based on a Functional Independence Measurement (FIM) or a Disability Rating Score (DRS). Level 1 and 2 have moderate to full recovery after TBI. Level 3 and 4 would be the set of people who would need coverage. These TBI survivors require assistance with all activities or are totally dependent.

There should be an immediate payout for required changes to the home followed by a monthly benefit that increases annually to match the rise in inflation.

Michael’s goal in presenting to the BIAC was to relay the ideas and receive feedback on them. The first step is to get someone interested and then to move on to getting approval by the state. The role of the BIAC could be to build the product and/or support the product. Perhaps the BIAC could earn annuity from insurance companies for endorsing a product.

Potential methods of selling this type of coverage include bundling it with life or medical insurance. This has been successful when tested in schools with student athletes.

Denis Schaad asked if it would work better to take the money for this insurance out of taxes. Michael J. Bush stated that insurance similar to this has been successful in New Zealand with a government backer. However, a government backer would be almost impossible on the national level in the United States. There have been some moves forward, such as in Michigan and Massachusetts, but it has been a slow process.

Legal settlements are another way to package the coverage, but the time to reach a settlement is usually uncertain.

Insurance is regulated on the state level. Years ago there was an attempt to get funding through the Ohio legislature which turned into a political battle.

One problem with coverage could be risk taking behavior. The risk taking behavior that often leads to trauma also invades other life choices such as buying insurance. This could mean that people who take risks do not buy insurance and only those who do not need coverage will have it. Despite this, it would be better to have the option available. Brain injury could happen at anytime.

A good demographic for this product would be parents. It could be packaged with home owners insurance and children would be covered for life. There is now a higher survival rate after these injuries. This type of insurance may not have been necessary in the past, but it is becoming more of a necessity.

Insurance companies will not offer it if they cannot make money on it. If it is positioned well in an already existing policy that people are going to buy then maybe an insurance company would be interested in it. Michael said that this product could be economically viable. He asked his own insurance company to search for this type of product and his insurance company was unable to find any.

Just as with life insurance, there would a variety of options as well as changes in coverage over time. Grandparents would be another good target demographic. They may be looking for ways to better take care of grandchildren and in a more financially stable position to buy this insurance. They may be more aware as to what would happen to a grandchild if an injury were to happen.

Anna Prebis asked if this insurance would interfere with Medicaid. Michael would want this to be a replacement for Medicaid that would provide better for the injured person.

The insurance industry will have to be involved in getting this product off the ground.

This is only the first step.

Youth Sports Concussion Training

This presentation was given by BIAC member Steven Cuff, MD. Concussion laws are important due to players not telling coaches about symptoms, lack of concussion education, continued play after concussion, etc. The positive effect of Return-to-Play can be seen by the increase in concussion visits, increase in ED visits for Sports Related Concussions, and increase in NCH Sports Medicine head injury visits. This may seem like a contradiction, but it could mean that coaches and parents are paying closer attention to concussion symptoms and are seeking treatment more often. A similar trend was seen after the Lystedt Law in Seattle was passed. An increase of awareness can lead to an increase in reporting.

An internal study at Nationwide’s Children Hospital showed that continuing to play after injury leads to a longer duration of symptoms. More concussions happening in games than practices could be due to less contact, less intensity, and more focus on skills training during practice. The theory of males simply reporting less than females does not have much validity. Until we know what leads to prolonged symptoms and more severe symptoms, it is difficult to create new policies, place restrictions on play, or make changes to play.

A concussion evaluation is made up of a physical exam, the BESS (Balance, Error, Scoring, System) test, and neurocognitive testing. None of the individual tests can establish a concussion diagnosis. It is better to have a baseline test that future tests can be compared with after a possible concussion. By having a baseline done prior to any concussions, it is possible to see if there are any significant changes that may indicate a concussion. Some schools will have student athletes complete these tests once a year to establish a baseline.

After a concussion, athletes will need physical and mental rest that includes no electronics. Short term and long term effects of concussion are being discussed with parents and students. There is a lot of push back from both parents and students, but it is getting better. Parents are more likely to be on board if they are not hearing the information for the first time. Coaches need to be educated about concussion and the need to keep parents informed of any incidents that could have caused a concussion.

Studies show that a majority of injured athletes are not getting better within a week. Athletes need to be made aware that recovery time varies, but that it usually takes longer than a week.

Prior to being able to return-to-play, exertion is slowly added into the athlete’s routine. After their first concussion, when they are asymptomatic, an athlete will progress back to play over a five day period. Athletic trainers can be a good resource for the return-to-play process, because they may be in the best position to help kids and recognize concussion symptoms.

The acute phase of recovery should be complete rest. Scouts and scholarships can impact how a student feels about not playing. The risk and benefits differ for different types of people.

Concussion clinics are mostly in major hospitals (NCH, OSU Wexner MC, Cincinnati, and Cleveland). It would be beneficial to publicize a list of resources for where people can go for concussion treatment.

While there have been concussion patients with LOC or PTA, but who did not show any symptoms, this is rare. It is sometimes the case that symptoms do not appear until activity occurs.

Information and programs are given to schools to help implement return-to-learn protocols. If students are not able to do schoolwork they may be held out of school for a period of time. Accommodations can be made with schools so students will be able to lay their heads down if needed, have longer time for tests, wear sunglasses, avoid gym class, and have a decreased workload. There is less push back now than in the past.