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The complexities of a TBI case

February 1, 2011
by Gary A. Enos
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Funding silos cause many clients to fall through the cracks

If a client presents with a behavioral health problem and a co-occurring traumatic brain injury (TBI), success likely will hinge on a yeoman effort by an individual care provider assisting the client. Systemically, few publicly funded service systems around the country appear to be built around the need to integrate services for individuals who have these multiple problems.

Erik Roskes, MD, a forensic psychiatrist in Maryland, has seen these treatment challenges firsthand in his state, and suspects the situation looks much the same elsewhere. Roskes, who serves as chief psychiatrist in the Maryland Department of Public Safety and Correctional Services, says funding silos for addiction, mental health and brain injury services create complexities that can frustrate even the most intrepid service providers working with these multiple issues.

“It's a very complex set of funding mechanisms, and it invites people to say, ‘This is not our problem-this is your problem.’”

“Addiction has one funding mechanism; mental health has another. For brain injury, depending on your age, you'll either go into the adult TBI system or if you're 22 you'll go into the [developmental disabilities] system,” says Roskes, who emphasizes that his opinions are separate from the official position of state government. “It's a very complex set of funding mechanisms, and it invites people to say, ‘This is not our problem-this is your problem.’”

Case study

Roskes pens a blog for The Crime Report (, and in a December 2010 posting he related the story of “Zack,” a composite of several patients he has encountered. Zack had been an occasional drug user in early adulthood, but that use escalated significantly after he suffered a traumatic brain injury in a fall he sustained at a construction site.

Zack was eligible for state-funded services for adult-onset TBI, but he refused to stay in that service system and insisted on living independently. He later would get into trouble with the law as a result of a worsening substance use problem. Zack would go back and forth between the court system and the community for a while, until he was eventually sent to a hospital emergency room for evaluation. But the hospital psychiatry unit would not admit him because the staff there said his problems were related to the brain injury and not a behavioral health disorder.

“Psychiatric hospitals are not equipped to treat TBIs,” comments Roskes. “Addiction treatment centers are probably not good for this purpose either. TBIs are a different ballgame; they're not a mental illness. They're a behavioral disturbance with a different focus.”

Zack would remain in the hospital ER for two weeks before being sent to a state psychiatric facility. There it was determined that in order for him to receive services appropriate to his condition, he would have to be sent to a TBI unit at a publicly funded rehabilitation hospital. The state psychiatric hospital staff would work many hours to facilitate a timely transfer to such a unit-with the implication being that without this extra effort, Zack simply would have continued to fall through the cracks of a fragmented service system.

“The next steps include ensuring that [Zack] has long-term care Medicaid and then identifying the proper program for his ongoing treatment and rehabilitation,” Roskes wrote in his blog posting. He added in his essay, “How many Zacks are there in jails and prisons? How can society get them needed care, treatment, and rehabilitation in order to avoid these terrible outcomes?”

Roskes emphasizes in his posting how the disjointed nature of service systems requires individual providers to be resourceful and persistent in trying to locate the proper services for multiple-problem clients.

“It's an incredibly time-consuming process,” he says. “A lot of clinicians are not interested in fighting those battles.”

Convergence of symptoms

Roskes says several factors point to the notion that if a treatment program serving individuals with TBI is not sufficiently integrating substance use services, it is falling short of meeting many clients' needs. For one, he says past surveys have shown a high prevalence of intoxication at intake to some of these hospital-based brain injury programs.

In addition, considering that impaired impulse control constitutes a common problem in the brain-injured client, “What will that do [for] a person who has an addiction issue?” says Roskes.

In his work with court-mandated clients in Maryland, Roskes has seen and overseen efforts in integrated care on a case level. But from where he sits, he says he does not see great evidence of integration at the systems level in his state, nor has he heard much about such efforts in other states' systems.

“We have these silos. Some people are getting three services from three separate funding streams,” Roskes says. “Science says that integrated care is better, but practice hasn't caught up.”

Roskes would like to see more of a system with no wrong door to treatment, but for now he says separate funding streams make it too easy for one provider to transfer a patient elsewhere. “The only place where they can't say no [to a client] is jail,” he says.

Addiction Professional 2011 January-February;9(1):18-20