Service Coordination/Case Management is a process of linking clients with the services they want and need. It is a method that analyzes client and family needs and assesses area resources in order to provide, procure, purchase, and coordinate services for persons with a traumatic head or brain injury. Case management/service coordination generally consists of the following functions: (1) intake; (2) service planning; (3) service coordination; (4) service monitoring/quality assurance; (5) supportive counseling; and (6) advocacy.
Many programs and payment systems provide case management services. Case management may be offered while the person with a head injury is in a hospital and/or rehabilitation facility. The hospital and/or rehabilitation facility may provide this service while the patient is hospitalized. The insurance company or health management organization may also employ a case manager to manage the health and medical needs of the patient.
A number of state programs offer case management or service coordination services. For persons with a traumatic head injury a service coordinator may be a vital service in order to obtain and coordinate the array of rehabilitation, social, vocational and support services which may be needed.
The Department of Health and Senior Services, through the Division of Community and Public Health offers service coordination through the Special Health Care Needs Unit for persons from birth to 21 who qualify medically and financially. The Unit, through its head injury program, also provides service coordination for adults with a traumatic head injury. For persons injured prior to age 22 they may also be eligible for case management services through the Department of Mental Health, Division of Mental Retardation and Developmental Disabilities.
The Missouri Department of Health and Senior Services Adult Head Injury Program is located in the Division of Community and Public Health, Special Health Care Needs Unit. The program provides assistance in locating, coordinating and purchasing rehabilitation and psychological services for adults who have reached their 21st birthday, who have survived a traumatic brain injury.
Traumatic brain injury is defined in 192.735 RSMo as a “sudden insult or damage to the brain or its coverings, not of a degenerative nature. Such insult may produce an altered state of consciousness and may result in a decrease of one (1) or more of the following: mental, cognitive, behavioral or physical functioning resulting in partial or total disability. Cerebral vascular accidents, aneurysms and congenital deficits shall be specifically excluded from this definition.”
The Department of Health and Senior Services Head Injury Program provides two types of services:
- Service Coordination
- Rehabilitation Services
1. Service coordination is free of charge to all individuals who are medically eligible for the program regardless of income. Service coordination includes:
- Evaluation and assessment of needs
- Information and education about the cause and effects of traumatic brain injury and preventing secondary conditions
- Development of a service plan to meet the identified needs
- Assistance in locating and accessing resources and services such as medical care, housing, counseling, transportation, rehabilitation, vocational training, and cognitive/behavioral training
Currently, there are nine service coordinators throughout the state to provide this service.
2. Rehabilitation services are available to individuals who are medically eligible for the program and whose income is 185% of Federal Poverty Guidelines or lower. Certain limitations may apply.
The Head injury Program Service Coordinator will assist the client to apply for any other payment resources before submitting requests for use of Program funds to purchase these services. All clients must be enrolled with the Special Health Care Needs Unit before services can be authorized. All services must have prior authorization before provision of services. Services include:
- Neuropsychological Evaluation and Consultation
- Behavioral Assessment Counseling
- Adjustment Counseling
- Comprehensive Day Program
- Transitional Home and Community Support
- Pre-Vocational/Pre-Employment Training
- Supported Employment/Follow Along
- Special Instruction
- Physical Therapy Evaluation/Treatment
- Occupational Therapy Evaluation/Treatment
- Speech Therapy Evaluation/Treatment
- Transportation
Program Service Delivery Model
The Program utilizes a person-centered approach that places the participant and family at the center along with the Head Injury Program Service Coordinator to facilitate the assessment, planning and service delivery efforts for each individual.
The Service Coordinator, together with the individual and family or significant others, develops a Program Service Plan. The Program Service Plan outlines a long-term projected outcome goal, such as return to work or independent living, and the steps to achieve this goal. These steps may include referral for any public programs, development of skills through rehabilitation services or development of other supports that will assist the individual to reach the maximal level of independent community functioning. The Service Coordinator documents the Program Service Plan, assures that the client and family wishes are included in the plan, obtains their signatures of agreement, and provides them with a copy of the plan.
Together, the Service Coordinator and family identify key people to form the Person Centered Planning Team. The planning team that works with the individual will always include: the participant, the Head Injury Program Service Coordinator, involved family member(s), significant other(s), and/or the legal guardian. Other members will be added at appropriate times given changing needs as the participant moves through services toward functional independence. The Service Coordinator actively assures the ongoing coordination and functioning of the planning team. The Service Coordinator assures that at least an annual review of the Program Service Plan is scheduled.
For further information call 1-800-451-0669.
