Wyoming assessment of rehabilitation needs

Of the population reporting an employment disability, an estimated 10,563 individuals (34.1%) were unemployed at the time of the census (Table 6). By comparison, unemployment rates for members of the general Wyoming population actively seeking work have been approximately 4% in recent years (4.4% in May 2003; 3.7% in May 2004: 3.2% in April 2006; see http://doe.state.wy.us/lmi/LAUS/TOC.HTM).

Table 6: Sex by Age by Disability Status by Employment Status (Civilian Non-institutionalized Population 16 to 64 years) Source: 2000 Census and 2003 WYARN
Group	16 - 20 Years	21 – 64 Years	Total 16 - 64
Male Population	19,772	138,489	158,261
With Employment Disability	1,238	15,164	16,402
Employed	903	10,316	11,219
Not Employed	335	4,848	5,183
Female Population	18,761	138,837	157,598
With Employment Disability	1,125	13,425	14,550
Employed	754	8,416	9,170
Not Employed	371	5,009	5,380
Total Population	38,533	277,326	315,859
With Employment Disability	2,363	28,589	30,952
Employed	1,657	18,732	20,389
Pct. Employed	70.1%	65.5%	65.9%
Not Employed	706	9,857	10,563
Pct. Not Employed	29.9%	34.5%	34.1%

Population of Special Concern: Brain Injury
According to the Centers for Disease Control and Prevention, Wyoming has the highest brain injury mortality rate in the nation. Wyoming’s mortality rate is approximately 1.7 times the national average. (http://www.cdc.gov/ncipc/StateProfiles/sip_wy.pdf).
Wyoming, like many states, does not require a brain injury registry. Lacking this mandate, it is difficult to accurately determine annual incidence rates and total numbers of people with brain injury. However, according to a recent report published by the Division of Developmental Disabilities within the Wyoming Department of Health entitled “Brain Injury Needs Assessment and Infrastructure Improvement Plan”, there are between 9,876 and 15,000 people with brain injury in Wyoming (Table 7). The primary cause of brain injury in Wyoming is motor vehicle accidents.

Table 7: Incidence of Traumatic Brain Injury (TBI) in Wyoming Source: Brain Injury Needs Assessment and Infrastructure Improvement Plan, Wyoming Department of Health

Number of TBI hospitalizations per year: 448 to 648 Number of male TBI hospitalization per year: 305 to 441 Number of female TBI hospitalizations per year: 143 to 207 Total number of people with a TBI related disability: 9,876 to 15,000

The same report outlines the results of a mail survey sent to 504 Wyoming residents with brain injury in January 2006. The largely multiple choice survey asked questions about cause of injury, extent of injury, age at injury, degree of recovery to-date, type of health care coverage, kinds of services utilized, kinds of services needed but not available, etc. In addition to the multiple choice questions, respondents were encouraged to provide open-ended narrative comments.

Survey results indicate that motor vehicle crashes were the primary cause of brain injury among survey respondents. Tied for the second leading cause of injury were falls and stroke/disease. The survey also asked about age at injury, the length of time since injury, extent of injury, and recovery to-date. Results indicate a fairly consistent number of injuries per age group up to age 50 (Table 8). Then injuries become less common. The percent of respondents indicating they were injured at various ages is as follows: age 0 to 10 (12.9%); age 11 to 20 (17.4%); age 21 to 30 (13.5%); age 31 to 40 (16.1%); age 41 to 50 (15.5%); age 51 to 60 (9.0%); age 61 to 70 (.6%); over age 70 (3.2%). The average length of time since the injury was 11.7 years.
According to the report, 7.7 percent indicated that their brain injury was “mild”; 16.1 percent said their injury was “moderate”; 27.1 percent said their injury was “moderately severe”; and 47.1 percent said their injury was “very severe” (Table 8).
As for recovery to-date, respondents indicated the following: 16.1 percent indicated that there had been very little recovery yet; 58.1 percent said there had been “moderate” recovery; 19.4 percent said there had been “almost complete” recovery; and 3.9 percent indicated that there had been “complete” recovery (Table 8). These results are important because they indicate recovery is possible. Sometimes complete or almost complete recovery is possible.
The survey also asked questions about life styles changes. Survey results indicate that a brain injury is very often a life changing event. It can have a significant impact on finances. For example, while 51.6 percent indicated that their annual income before the injury was $0 to $20,000, 80.6 percent indicated that their after injury income, at the time of the survey, was $0 to $20,000 (Table 8). The injury also had an impact on employment and career plans. Nearly 40 percent of respondents indicated they are currently not able to work at all (Table 8). Another 35.5 percent said they had to make major adjustments to career plans.
Living arrangements and marital status were also impacted by the injury. Respondents reported the following current living arrangements: 27.1 percent live alone; 18.1 percent live with parent(s); 27.7 percent live with a spouse; 4.5 percent live with a roommate; 4.5 percent live in an assisted living facility; 7.1 percent live in a boarding/group home; 1.3 percent live in a rehabilitation facility; 1.3 percent live in a nursing home (Table 8). Ten of the fifty-one respondents who were married at the time of their injury were divorced at the time of the survey.
Respondents were asked about the services that they had utilized since the injury. The most utilized service was physical therapy (Table 8). About seventy percent of respondents had used this service. Speech/language therapy, occupational therapy, psychological counseling and neurological services were used by about fifty-five percent of the respondents. Forty percent used transportation services, and thirty-six percent had used vocational rehabilitation. Other services were used by smaller percentages of respondents.
When asked which services most need to be improved in their community, neurological services, vocational rehabilitation and psychological counseling received the greatest responses (Table 9). The report concludes “This appears to indicate that respondents place a priority on services that can restore their psychological and financial well-being. Other support services are important but are at a lower priority level.”
As indicated above, the survey encouraged respondents to provide open-ended comments. Many took time to do so (see select comments, Table 10). Comments show that a brain injury is almost always a life changing event. To varying degrees, it will impact emotional well being, cognitive ability, career plans, economic security, marital status, and personal independence. Respondents expressed an intense frustration that while all these things are happening to them, the service delivery infrastructure is not responding. Many indicated that it is difficult to navigate through the infrastructure because very few people are in a position to coordinate services. In many communities, no one is available to “connect the dots”.

Table 8: Results of Brain Injury Survey of 155 Wyoming Respondents* Source: Brain Injury Needs Assessment and Infrastructure Improvement Plan, Wyoming Department of Health
Initial Extent of Injury				# of Responses		Recovery To-date				# of Responses
Mild				12		Very little yet				25
Moderate				25		Moderate				90
Moderately Severe				42		Almost complete				30
Very Severe				73		Complete				6
Health Insurance Now				# of Responses		Health Insurance Then				# of Responses
Have private insurance				29		Had no coverage				29
Have Medicaid				41		Had minimal coverage				21
Have Medicare				52		Had pretty good coverage				33
Have no coverage				22		Had very good coverage				58
No answer or other				11		No answer or other				14
Marital Status Now				# of Responses		Marital Status Then				# of Responses
Single				65		Single				80
Married				44		Married				51
Separated				2		Separated				0
Divorced				37		Divorced				20
Current Employment				# of Responses		Career Impact of Injury				# of Responses
Employed full-time				14		Able to continue previous plans				4
Employed part-time				29		Had to make minor adjustments				12
Unemployed but looking				22		Had to make major adjustments				55
Unemployed, not looking				60		Not able to work				61
No answer or other				30		No answer or other				23
Income Now				# of Responses		Income Then				# of Responses
$0 to $10,000				91		$0 to $10,000				57
$10,001 to $20,000				34		$10,001 to $20,000				23
$20,001 to $40,000				12		$20,001 to $40,000				38
$40,001 to $60,000				6		$40,001 to $60,000				12
More than $60,000				0		More than $60,000				12
Alcohol/drugs Now				# of Responses		Alcohol/drugs Then				# of Responses
Is not a problem				137		Was not a problem				116
Is moderate problem				7		Was a moderate problem				19
Is considerable problem				2		Was a considerable problem				11
No answer or other				9		No answer or other				9
Living Arrangement						Services right after Hosp. Dis.
Live alone				42		Rehab				91
Live with parent(s)				28		Home health care/aide				35
Live with spouse				43		In-home personal care				28
Live with roommate				7		In-home housekeeping				14
Live in assisted living				7		Day care				8
Live in boarding/group home				11		Boarding/group home				13
Live in rehab facility				2		Assisted living				6
Live in nursing home				2		Nursing home				11
No answer or other				13		I used no services				18
Need Personal Care?				# of Responses		Who Helps with Personal Care?				# of Responses
Need no assistance				95		Parent or family member				15
Need small amount of assistance				27		Spouse				12
Need Moderate amount assistance				18		Friend or neighbor				1
Need quite a lot of assistance				13		Paid caregiver				24
No answer or other				3		No one				95
Services Utilized Since the Brain Injury
Physical therapy	109		Vision therapy		27		Legal assistance	46	Case management		49
Speech/language therapy	88		Home health care/aide		36		Advocacy services	32	Long-term care waiver		17
Occupational therapy	88		In-home personal care		23		Independent living	25	ABI waiver		42
Psychological counseling	89		Chore services		27		Housing assistance	28	DD waiver		2
Neurological services	82		Medication mgmt.		39		Day care	15
Substance abuse treatment	16		Caregiver respite		18		Boarding/group home	20
Vocational rehabilitation	56		Transportation		62		Assisted living	13
Residential rehabilitation	30		Financial mgmt. assist.		49		Nursing home	7
*Note some numbers do not add to 155 because some respondents provided more than one answer or no answer
Table 9: Services that are in Most Need of Improvement in Your Community Source: Brain Injury Needs Assessment and Infrastructure Improvement Plan, Wyoming Department of Health
Physical therapy	17	Vision therapy			13		Legal assistance	18	Nursing home		2
Speech/language therapy	14	Home health care/aide			9		Advocacy services	18	Case management		12
Occupational therapy	15	In-home personal care			10		Independent living	12	Long-term care waiver		7
Psychological counseling	31	Chore services			21		Housing assistance	12	ABI waiver		10
Neurological services	38	Medication mgmt.			3		Emergency med. services	9
Substance abuse treatment	7	Caregiver respite			14		Day care	4
Vocational rehabilitation	34	Transportation			22		Boarding/group home	6
Residential rehabilitation	13	Financial mgmt. assist.			15		Assisted living	10

Table 10: Comments Provided by Survey Respondents Source: Brain Injury Needs Assessment and Infrastructure Improvement Plan, Wyoming Department of Health

Hospital discharge information is so poor. Haven't found one person that is informed about services. When I returned from surgery, the only support group that was available in our community was for battered wives. There is little or no understanding of services by TBI person or family. You have to go to Billings or Casper for most neurological tests and doctors. No substance abuse service is available locally. Psych counseling that is appropriate for TBI is non-existent. The seriousness and long-term implications of TBI is under rated. There are great frustrations by patient and family and friends. Getting information out is a real problem compounded by a lack of appropriate information from the hospitals. I challenge you to make this project and information count and not just be another futile attempt. In over 20 years and several boards/agencies, I am really skeptical. "Talk is cheap" Help!

I believe the biggest problem is what seems to be a total lack of continuity in case management, as well as ongoing follow-up for an extended period of years in most cases. Generally, most family members responsible for securing services for their survivor with brain injury don't have the slightest idea where to go to obtain the necessary information. We seem to be expected to automatically know which governmental agency is responsible for what. In the 14 years since my daughter's injury, I have gone from DVR, to Easter Seals, to Social Security, to Department of Family Services, to a local Psychologist recommended by DVR, back to DVR, back to Easter Seals. Presently she is involved with Life Quest in Sheridan. Someone assigned to "permanently" manage her case would be a great asset and utilize the services available much more efficiently. What I have observed is that all of the above entities take her to a point, then close her file if they feel she is successful at that point. As in most cases of brain injury, without ongoing follow-up, she subsequently has failed to continue on her own. This has resulted in having to basically start all over again with one of the above entities, which seems terribly ineffective. This is the biggest issue I have encountered as the care-giver for a brain injured individual over the last 14 years. If it is frustrating for a healthy person, it must be devastating to a survivor to have to deal with governmental agencies.

I believe there should be someone within the hospital system that is knowledgeable about TBI to give pertinent information to family members to guide them thru the transition. Unless you've been through some type of TBI you have no idea.

I live in Cheyenne because Casper does not have any type program for TBI. They lump the DD with TBI, and there is a big difference. It would be much more convenient if I could live in Casper. Relatives must go back and forth to Cheyenne every other weekend to spend time with me. Also, I am having a difficult time getting into employment. I am limited but I do believe I am employable and would be much happier with a work schedule.

Brain injury rehab services in our county are terrible! There is a lack of trained individuals, lack of professional services familiar with brain injury, lack of quality residential services, absolutely no structured day habilitation, and incredibly poor case management, just to mention a few.

The brain injury waiver needs to be widened to include the vast majority of ABI folks who appear high functioning, but can't hold a job, and desperately need many of the above mentioned services!!! Vocational rehab needs to be told that they cannot insist that an ABI individual go to school full time in order to qualify for voc rehab funds! They have done this to me over and over, no joke! I'm glad to see the support groups developing around the state. These are absolutely critical!

My employer (State of Wyoming) fired me after three weeks due to brain injury. I have needed help but have had to ask friends to help me and pay them. I never knew that there was any help out there. When I applied for the ABI waiver a few years ago, the lady said I was not qualified because they had people who were worse off than me.