Early Referral

Traumatic Brain Injury

A Streamlined Method That Works For People

The TBI Grant Project work team discovered that using a person-centered philosophy and collaborative approach can result in efficiently delivered services and better outcomes for people

What are the components of an efficient system?

• An early referral to the right entry point
• provides a planned transition from the hospital to the community
• The customer/family has connected with community resources before hospital discharge so they know who to call to find appropriate assistance rather than bouncing around from agency to agency applying for available services
• A planned transition right from the hospital means that:
• the customer spends less time finding services and more time on the services needed for rehabilitation
• medical records are available for service planning 30-60 days earlier
• service coordinators can often identify community resources instead of state funded services
• service coordinators can save time and effort by making sure individuals are eligible and ready for state services
• potential overall Medicaid and general health care dollar savings occur when individuals access medical care in a planned manner
• hospital discharge planners know of options for community placement rather than institutional placements, potentially improving the outcome
• hospital discharge planners can receive a 90-day follow up report on the status of the patient from the TBI coordinator