Special Report: Focus on TBI Programs

TBI patients who’ve abused substances need support

Linking patients to crucial services

A Columbus, OH, rehab program provides a special service to meet the unique needs of patients who have suffered a traumatic brain injury (TBI) and who have a history of substance abuse.

Called TBI Network, the nine-year-old program provides case management and alcohol and drug treatment services to TBI patients.

"Our philosophy is that after a brain injury, people should not use substances at all, because there are many behaviors and conditions of brain injury that look just like those associated with substance abuse problems," says Marty Wolfe, LISW, TBI Network program manager. TBI Network is part of the outpatient rehabilitation services provided by The Ohio State University.

The program has had some positive outcomes. In a survey conducted last year of patients who had been discharged three months previously, 71% of the TBI Network patients remained abstinent from substance use, 71% were productive, and 47% met life satisfaction goals. At discharge, all of these cases had met 100% of the goals, Wolfe says.

The program typically has 140-150 clients, with a caseload of 25 clients per case manager. The network typically receives 250 new referrals each year, Wolfe says.

Although the program originally was funded by grants at its inception in 1992, now it receives revenue by billing drug and alcohol case management services through three payers: Medicaid, a county board that manages drug and alcohol mental health funds, or the Bureau of Vocational Rehabilitation.

"We don’t turn people away because of their inability to pay," Wolfe adds.

Services provided by TBI Network include the following:

  • Referral and screening. Patients are referred from the university’s rehabilitation and TBI service as well as by substance abuse providers in the community, Ohio’s criminal justice system, other community mental health centers, and physicians.

TBI Network screens patients to meet three criteria. First, they must live in the community, which usually only includes Franklin County. If the patient is in a nursing home outside of the county, he or she must anticipate returning to the community soon. Secondly, the patient (who must be age 18 or older) must have had a brain injury that causes some kind of cognitive problem. Finally, the patient must be diagnosed as having a substance abuse problem, Wolfe says.

  • Case management assessment. Each new patient is assigned to a case manager who will guide the patient through the program from intake to closure.

The program’s staff will assess, plan treatment, and provide for closure in the case. Although a team among the 11 employees has been involved in each case, the program is evolving to reduce the number of people with whom patients interact, Wolfe adds.

"People with cognitive problems have difficulty understanding why they are interacting with so many different people, so we’re trying to cut that down," Wolfe says.

Case managers assess a patient’s substance use, social functioning, involvement in the criminal justice system, employment history, medical situation, and other issues in his or her life.

  • Treatment. The treatment plan typically includes abstinence, Wolfe says.

"Many people with TBI have reduced inhibitions, cognitive memory problems, and visual problems — which all are the same with TBI and substance abuse," Wolfe adds. "So it’s putting yourself in double jeopardy if you have a head injury and use substances."

Case management is the primary treatment, and the program links clients to a variety of services in the community. Case managers advocate for their special needs, Wolfe says.

For example, if a patient needed intensive long-term drug and alcohol treatment, the program would refer the patient to another agency and stay involved in the process, forming a treatment team if possible, he says.

"So we facilitate communication between those folks dealing with the client and focus on what the client’s needs are at any one time," Wolfe says. "Many substance abuse programs use case management, but we look at that as our treatment."

Individual counseling and group education are included in the TBI Network’s treatment plans.

  • Referrals to community resources. TBI Network is certified by the Ohio Department of Drug and Alcohol Treatment at the lowest level of care. When patients need more intensive care, the program will refer them to an inpatient treatment facility.

"We would start by working with the client to help the client understand why treatment is needed and how we do the referrals and how we will help with the process," Wolfe explains.

"Part of our whole concept here is that if a program already exists in the community, then we don’t do it," he adds. "Our clients need a number of providers who work in a coordinated way and who each understand what piece they’re focusing on."

Once the patient is admitted into another program, TBI Network staff will provide a wraparound service of staying in touch with the patient and the outside program staff to make certain that the patient’s brain injury is understood. TBI Network staff also help other providers working with the TBI patient understand how to help the client learn as much as possible, Wolfe adds.

Financial resources are another area of referral. "Clients typically have financial problems, and they often come to us unemployed," Wolfe says. "We refer them to financial assistance programs, and if they have no money for medical care, we try to link them to local jobs and family services and Medicaid."

When patients haven’t had any medical follow-up care, the program will refer them to a community medical service or to physicians working through The Ohio State University.

Program makes mental health referrals

Sometimes TBI patients who abuse substances will have a history of depression or other mental health problems, requiring a referral to a mental health agency.

"These problems are intermingled, and pretty soon you see this whole map of problems the individual has, and we work very much in referring the patient to treatment for the mental health problem," Wolfe says.

  • Developing a purpose. The program’s philosophy is that for patients to maintain sobriety, they will need to lead productive lives with a meaningful purpose.

This is difficult for patients to accomplish when they are not working, so TBI Network staff will refer patients to local vocational rehab services and by other means help patients gain some level of productivity, Wolfe says.

"Some folks don’t want to or can’t go back to work, and so we focus on volunteer services," Wolfe says. So if a patient is afraid of losing Social Security benefits or has had physical and mental limitations that prevent him or her from returning to full-time employment, he or she can at least volunteer to help some local charitable organization.

"People with a brain injury need some kind of schedule or regimen," Wolfe says. "We have one job specialist on our staff, so if a patient is going to the Bureau of Vocational Rehabilitation, we can assist in helping the patient look at what their employment activities might be."

  • Monitoring substance use. TBI Network case managers monitor patients to see how they are handling issues of substance use. They check to learn whether patients are attending Alcoholics Anonymous meetings and to determine whether they are receiving any social support for their abstinence.

"We help them develop a relapse prevention plan," Wolfe says. "What’s unusual about our program is that typically, when you leave one substance abuse treatment program, that agency closes your case, but we don’t close the case; we stay open and involved while they’re involved with other programs."

  • Discharge planning. Patients are discharged based on three criteria: abstinence, productivity, and life satisfaction.

Occasionally there will be clients who are abstinent from drug or alcohol use and who have strong family support, but who do not want to be productive. So that client’s case might also be closed, so long as the patient is satisfied with his or her life.

"The other reason to close a case is if the client says, I’m not interested in changing; I’m working now, but I’m still smoking pot, and I’m happy,’" Wolfe explains. "We say, "We think you will at some point need us again, but we’ll discharge you for now.’"

Life satisfaction is measured using a six-point Life Scale questionnaire, which is measured at intake, monthly for three months, and then every three months until discharge.

"Every three months, we review the treatment plan with the client to see if the client has met the goals that the client set," Wolfe says. "If the client hasn’t met the goals, we look at why not and whether we need additional goals in that particular area." nNeed More Information?

  • Jennifer Bogner, PhD, Associate Professor of Physical Medicine and Rehabilitation, The Ohio State University, OSU Hospital Dodd Hall, 480 West 9th Ave., Columbus, OH 43210. Telephone: (614) 293-3830.
  • Marty Wolfe, LISW, Program Manager, TBI Network, 106 McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210. Telephone: (614) 292-4559.