Jenny Quigley-Stickney RN MSN MHA CCMJordan Hospital & Tufts Medical Center

Case Management Society of New EnglandMay 2, 2011

Acute onset of injury ED admission Triage to Trauma Center Critical Care Unit Medical Surgical Unit Transition to Rehabilitation Center

Determination of patients prognosis and level of care

Evaluation of cognitive and functional recovery

Fiscal resources Family support and provisions for care

LTAC admission criteria Acute Rehabilitation admission criteria Skilled level of care and admission

criteria Home Rehabilitation care

LTAC provides acute medical care and rehabilitation for ELOS of 30 days or more

Acute Rehabilitation care (IRF) ELOS of 20-31 days

Skilled level of care ELOS 2 weeks to 100 days

LTC in nursing home private pay, MH or LTC

policy for additional nursing and 24 hour care

Assist with reviewing insurance and determine additional needs for insurance

Assist with accessing resources for LTC policies, STD, LTD and need for FMLA

Assist in accessing SSI and SSDI resources

Introduce Mass. Brain Injury Association and resources

Complete SHIP application and acknowledgement of new Brain injury

Complete PCA application if eligible

Criteria for safe transition to the communitybased on FIM, cognition and behavioral

management of the TBI survivor Supervision provided in skilled level of care,family through FMLA, PCA program, LTC

policies and private pay HHA Discharge to home with home care oroutpatient rehabilitation, Skilled level of care,

Foster care and TBI Group homes

Insurance coverage Fiscal availability and Private funds LTC plans Family availability for supervision and

handson care Family understanding on TBI and

managementof behavior , cognition and substance abuse

issues

Supervision Management of Behavior, Cognition andsubstance abuse issues Fiscal challenges for care provision Gaps in care from rehabilitation discharge

and safe management of the survivor in the

community Case management assistance withmodifying care plan as the survivor copes

with challenges living in the community

Electronic devices for safety monitoring Development of outcome criteria for

Transitions of Care Development of Day Programs for brain

injured survivors Increased development of group homes

designed to retrain survivors for re-learning

and independent living.