Chairman and members of the Committee, thank you for the opportunity to testify today. My name is Kate Coventry, and I am a senior policy analyst at the DC Fiscal Policy Institute. DCFPI is a nonprofit organization that promotes budget choices to address DC’s economic and racial inequities and to build widespread prosperity in the District of Columbia, through independent research and policy recommendations.
I would like to focus my testimony on the need for services for residents with traumatic brain injuries (TBIs), also known as acquired brain injuries. I ask the Department of Behavioral Health and the Committee on Health to work with advocates and providers to meet this need. DC behavioral health providers generally do not screen, identify, or treat the symptoms of TBI because TBI is not an official billable diagnosis in DC’s behavioral health system, and there is no system to train mental health providers. The most direct path to ensuring DC residents with co-occurring TBI and behavioral health conditions receive needed treatment would be to allow behavioral health service providers to bill for services rendered even when TBI is the primary diagnosis.
TBIs Have Significant Negative Effects
TBIs are injuries resulting from a blow or jolt to the head, or a penetrating injury to the head, that disrupts the function of the brain.[1] TBI in adults is associated with an increased risk for substance misuse, major depression, anxiety, and unemployment.[2]
TBIs can negatively affect self-regulation and executive functioning. Self-regulation refers to a person’s ability to manage behavior associated with stress and anxiety. For a person with TBI, this might entail difficulty waiting or taking turns; difficulty calming down; or feeling overwhelmed in new places. Executive functioning refers to higher-order brain functions associated with setting goals, organizing, remembering, following directions, and focusing attention. People with TBIs can become easily confused or forgetful; have difficulty learning new information; filling out forms; and using public transportation. Some have difficulty problem-solving, and others have problems with judgment and decision-making. After experiencing a TBI, people may have trouble keeping track of time, making plans, making sure to complete plans or assignments, applying previously learned information to solve problems, analyzing ideas, and looking for help or more information when needed.
Vulnerable Populations Are Particularly at Risk
TBIs can happen to anyone, but there are people who face a greater risk of acquiring a TBI. National statistics show that 50 to 80 percent of homeless individuals have sustained at least one brain injury prior to homelessness.[3] Research suggests that TBI may be a risk factor for becoming homeless.[4] Homeless individuals are also at a higher risk of acquiring a TBI because they are more likely to be victimized by assault, experience trauma, and have substance use disorders that can cause falls.[5] In 2010, 199 DC homeless individuals were surveyed and nearly two-thirds had a TBI.[6]
A 2016 survey of 159 adult DC behavioral health clients found that approximately 50 percent had a history of TBI.[7] Additionally, active duty military personnel are at very high risk. Domestic violence survivors are also at high risk because “the head and face are among the most common targets of intimate assaults.”[8] And finally, TBI is a common co-occurring disorder among people who are diagnosed with a major mental illness and who have a history of substance misuse and criminal justice involvement.
DC Residents with TBIs Are Not Getting the Services They Need, with Devastating Implications
DC behavioral health providers generally do not screen, identify, or treat the symptoms of TBI because TBI is not an official billable diagnosis in DC’s behavioral health system, and there is no system to train mental health providers. Community-based providers cannot receive payment for services provided to treat TBI, whether is a standalone diagnosis or co-occurring disorder.
The lack of services has terrible implications for individuals with TBI. Research has found that people with cognitive impairments like TBI may be falsely considered non-compliant and then get expelled from programs because these impairments prevent them from fully participating in the services. Or they are banned from sites because of “disruptive behavior or failure to comply with prescribed treatments.”8 To the untrained eye, problems with executive functioning can look like lack of motivation, laziness, disregard for others, and a reluctance to engage in social activities. Given that a 2010 survey of 12 DC homeless service providers found that only one provider had received any training on TBIs, it is likely that many homeless individuals with TBI are being excluded from mainstream homeless services.[9]
DC Can Look to Other Jurisdictions for Effective Service Models
DC should allow providers to bill for screenings and a wide range of services. There are a number of other jurisdictions that have implemented effective services that DC could build upon:[10]
- Screening and Accommodations in both healthcare and behavioral health settings. It is essential that DC create a system of TBI screening and provide accommodations at its medical and psychiatric intake sites, including hospital emergency departments, jails, drug treatment programs, in-patient psychiatric units, core service agencies, and the Comprehensive Psychiatric Emergency Program (CPEP).
- Day programs provide individualized skills training, cognitive rehabilitation, and work reentry. They provide the opportunity for participants to relearn life skills, such as how to interact in social settings, negotiate public transportation to get to appointments, or how to cook a simple meal.
- Case management assists the consumer to address basic needs, such as keeping appointments, developing a therapy and medication schedule, and accessing public benefits.
- Residential Programs with specially trained staff.
DCFPI urges the Department of Behavioral Health and the Committee on Health to work with advocates and providers to create a robust system of TBI screening and programming.
Thank you, and I am happy to answer any questions.
[1] “Traumatic Brain Injury & Concussion,” Center for Disease Control and Prevention, http://www.cdc.gov/traumaticbraininjury/
[2] Suzanne Polinder, Juanita A. Haagsma, David van Klaveren, Ewout W. Steyerberg, and Ed F van Beeck, “Health-Related Quality of Life after TBI: A Systematic Review of Study Design, Instruments, Measurement Properties, and Outcome,” Population Health Metrics (February 17, 2015), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342191/
[3] Jennifer L. Highley and Brenda J. Proffit, Traumatic Brain Injury Among Homeless Persons: Etiology, prevalence, and severity, Health Care for the Homeless Clinicians’ Network, revised June 2008, http://www.nhchc.org/wpcontent/uploads/2011/12/TBIAmongHomelessPersons_2008.pdf.
[4] Jane Topolovec-Vranic, Naomi Ennis, Angela Colantonio, Michael D. Cusimano, Stephen W. Hwang, Pia Kontos, Donna Oucherlony, and Vicky Stergiopoulos, “Traumatic brain injury among people who are homeless: a systematic review,” BMC Public Health, 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538158/pdf/1471-2458-12-1059.pdf
[5] “Findings from the District of Columbia Traumatic Brain Injury Needs and Resources Assessment of Homeless Adult Individuals, Homeless Shelter Providers, TBI Survivors and Family Focus Group, TBI Service Agency/Organizations,” DC Department of Health, revised August 2010, http ://www.nchv.org/images/uploads/DC_TBI_Report.pdf
[6] Ibid.
[7] Amy Burkowski, David Freeman, Faiza Majeed, Jennifer “Niki” Novak, Paul Rubenstein, and Celeste Valente, “Traumatic Brain Injury in the District: The Ignored Injury: A Paper Examining the Prevalence of TBI in the District and the Need for Services,” revised July 2018, http://www.uls-dc.org/media/1150/tbi-white-paper-final-7-25-18.pdf
[8] “Findings from the District of Columbia Traumatic Brain Injury Needs and Resources Assessment”
[9] Ibid.
[10]Amy Burkowski, David Freeman, Faiza Majeed, Jennifer “Niki” Novak, Paul Rubenstein, and Celeste Valente