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June 2016

Annual Evaluation ReportJUNE 2015 – MAY 2016

Nebraska’s TBI Implementation

Partnership Grant

Nebraska Brain Injury Advisory CouncilShaping the Future of Brain Injury

DearReader:Traumaticbraininjury(TBI)isaseriouspublichealthproblemintheUnitedStates.TheCentersforDiseaseControl(CDC)reportsapproximately1.7millionpeoplesustainaTBIannually,andeachyearTBIcontributestoasubstantialnumberofdeathsandcasesofpermanentdisability.ATBIiscausedbyabump,blow,orjolttotheheadorapenetratingheadinjurythatdisruptsthenormalfunctionofthebrain.MostTBIsaremildandtheireffectsdiminishovertime,butevenamildTBIcanresultinpermanentcognitive,physical,andbehavioralchanges.Individualsexperiencingmoderatetosevereinjuriesmayrequirelife-longsupportsforhousing,work,andcommunityliving.ManyNebraskansimpactedbyTBIstillstruggletoaccessappropriateservicestomeettheirneeds.NebraskaVocationalRehabilitation(VR)andtheBrainInjuryAdvisoryCouncilremaincommittedtobuildingacomprehensive,multidisciplinary,easilyaccessiblesystemofcareforindividualsexperiencingbraininjuryandtoensuringawarenessandtrainingforpartnersinthesystem.NebraskaVRservesasleadagencyforaU.S.DepartmentofHealthandHumanServicesTBIImplementationPartnershipGrantwhichprovidesfundingforstatestobuildinfrastructureandcreatesystemschangetobetterservetheircitizenswithbraininjuries.TheBrainInjuryAdvisoryCounciladvisesNebraskaVR,theDepartmentofEducation,SpecialEducation,andtheDepartmentofHealthandHumanServices(DHHS)inimplementinggrantobjectivesandgoalsundertheNebraskaStatePlanforSystematicServicesforIndividualswithBrainInjuries.StatePlangoalsfor2013-2018areto:��Increaseawarenessandknowledgeaboutbraininjury��Increaseaccesstocommunityresourcesforindividualswithbraininjury��Increasefundingforservices��PromoteindividualizedservicesforpeoplewithbraininjuryFormoreinformationabouttheNebraskaStatePlanforSystematicServicesforIndividualswithBrainInjuries,pleasevisittheBrainInjuryAdvisoryCouncil’swebsiteatwww.braininjury.ne.gov.Thisreportsummarizesgrant-fundedprojectoutcomesforFY2015-2016.NebraskaVRandtheBrainInjuryAdvisoryCouncillookforwardtoworkingwithourpartnersandstakeholderstobuildbetterfuturesforNebraskanswithbraininjuryandtheirfamilies.

Sincerely,

KeriBennett,M.S.Ed,CBISNebraskaVRProgramDirectorforABITBIGrantProjectDirector

Thisprojectwassupported,inpartbygrantnumber90TBSG0013-01-00,fromtheU.S.AdministrationforCommunityLiving,DepartmentofHealthandHumanServices,Washington,D.C.20201.Granteesundertakingprojectsundergovernmentsponsorshipareencouragedtoexpressfreelytheirfindingsandconclusions.Pointsofvieworopinionsdonot,therefore,necessarilyrepresentofficialAdministrationforCommunityLivingpolicy.

TableofContents

ExecutiveSummary........................................................................................................................1

ProjectPurpose..............................................................................................................................3

GrantObjectives.............................................................................................................................3

DisseminationofInformation........................................................................................................4

InformationandReferral................................................................................................................6

ResourceFacilitationCaseManagement.......................................................................................7

ResourceFacilitationCommunityOutreach.................................................................................12

TBITrainings.................................................................................................................................13

TBIScreenings..............................................................................................................................20

PARTNERTool...............................................................................................................................23

CostofTBIAnalysis......................................................................................................................26

SurveillanceData..........................................................................................................................29

Appendix......................................................................................................................................33

Reportpreparedby:

402.477.5407 [email protected]

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ExecutiveSummaryThepurposeofNebraska’sTBIgrantproject(fundedbytheU.S.DepartmentofHealthandHumanServices)istoincreaseaccesstorehabilitationandotherservicesforindividualswithTraumaticBrainInjury(TBI)andtheirfamiliesbyimplementingactivitiesrelatedtoeachofthefollowingcomponents:1)InformationandReferralServices;2)ProfessionalWorkforceDevelopmentTrainings;3)ScreeningforTBI;and4)ResourceFacilitation.Activitiesfromyear2(June2015-May2016)aresummarizedbelow.DisseminationofInformation

• 11,712lettersweredeliveredtoindividualsontheTBIRegistry.• 12,177hitstotheNebraskaBrainInjuryAdvisoryCouncilWebsite(thisnumberalsoincludes

hitstotheAssistiveTechnologyPartnershipsofNebraska).• NumerousmaterialsdistributedattheAnnualBrainInjuryConference.• 10informationcampaignsconductedthroughConstantContactwith231to243recipientsfor

eachcampaign.InformationandReferral

• 377TBI-relatedcallsfrom131individualswerefieldedbytheBrainInjuryAllianceofNebraska.• 40informationandreferralserviceswereprovidedtoindividuals(someduplication)by

DisabilityRightsNebraska.• 27informationandreferralserviceswereprovidedtoindividualsbyHotlineforDisabilities.

ResourceFacilitationCaseManagement

• DesignedprograminYear1.• Providedinformation/intakeandreferralservicesto18individuals,someofwhomwillmove

intocasemanagement.• Providedcasemanagementservicesto14individuals,11ofwhosecasesstillremainopen.

ResourceFacilitationCommunityOutreach

• 209outreachactivitieswereconductedbyResourceFacilitators,withanestimatedreachof3,870individuals.

TBITrainings

• Atotalof222individualsreceivedtrainingfromoneoffiveTBItrainingsthatwereoffered.• Trainingparticipantsfromallfivetrainingsgavepositivefeedback,indicatinganincreasein

knowledgeinareassuchasTBIprevention,causes,and/orrecovery;waystoidentifyaTBI;andwaystoserveindividualswithaTBI;amongotherareas.

TBIScreenings

• Atotalof558elderlyadultsinruralNebraskawerescreenedbyAAAcoordinators,86ofwhomhadapositivescreenforbraininjury.Ofthe86withpositivescreensforabraininjury,75werepreviouslyundiagnosedwithabraininjury.

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PARTNERTool• ThePARTNERToolwasrepeatedin2015tomeasurethecollaborationofkeystakeholdersand

partnersaroundTBIinNebraska.• Thelevelsofperceivedtrust,value,power/influence,andotherindicatorsremained

consistentlystrongfrom2014to2015,indicatingthecontinuationofcollaborativestrength.CostofTBIAnalysis

• UsingaCDCtoolknownasWISQARS,theestimatedmedicalandworklosscostsduetoTBIsinNebraskain2013wasdeterminedtobeover$800million.Notethatmanyofthesecostsaresustainedovermultipleyears,especiallyworklosscosts.

• The15-19and20-24year-oldagegroupshadthehighestcostsduetoTBIinthestate,duetothehighnumbersofinjuriesandthehighaverageworklosscostsfortheseagegroups.

SurveillanceData

• Deaths,hospitalizations,emergencydepartmentvisits,andTBIRegistrydatacontinuetobemonitored.

• TherateofdeathsduetoTBIhasremainedrelativelystable,whiletheratesofhospitalizationsandemergencydepartmentvisitsduetoTBIhaveincreasedsubstantiallysince2000.

• SurvivorsofaTBIareplacedonaregistry.FromJanuary2015throughSeptember2015therewere9,733newcasesintheTBIregistry.Therewereonaverage1,081newcasesofTBIpermonthduringthisnine-monthperiod.

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NEBRASKA’STBIIMPLEMENTATIONPARTNERSHIPGRANTYEAR2EVALUATIONREPORT

(June1,2015throughMay31,2016)June2016

ProjectPurposeThepurposeofNebraska’sTBIgrantproject(fundedbytheU.S.DepartmentofHealthandHumanServices)istoincreaseaccesstorehabilitationandotherservicesforindividualswithTraumaticBrainInjury(TBI)andtheirfamiliesbyprovidinginformationandreferral,professionaltraining,TBIscreeningandresourcefacilitationservices.The$1,000,000four-yeargrantwasawardedtoNebraskaVRinJuneof2014.Thetargetpopulationidentifiedfortheproject’sstrategiesischildren,youth(includingstudentathletesatriskforconcussion)andtheelderlywhoexperienceTBIorareatriskforTBI.KeriBennett,withNebraskaVRistheprojectdirector.

GrantObjectivesTheTBIimplementationgrantprojectfocusesonfivecoreareaswhichprovidesthebasisforthegrantobjectives:1. Enhanceandexpandexistinginformationandreferralservicestoreachchildren,youthandelderly

withTBI,theirfamilymembersandtheprofessionals,serviceproviders,andagencystaffwhoservethem,providingeducationalresourcesandreferraltoappropriateservicesandsupportsasrequested.

2. Providetrainingtokeyprofessionals,serviceprovidersandagencystaffservingchildren,youthandtheelderlyonthepotentiallong-termcognitive,physical,emotionalandbehavioraleffectsofTBI(includingconcussionormildTBI),andresultingimplicationsforhousing,work,andcommunityliving.

3. Teachprofessionals,serviceprovidersandagencystaffservingchildren,youthandtheelderlytoimplementsimplemethodstoscreenindividualsforTBIatthepointofprogrameligibilityandserviceneedsplanning.

4. Developasustainablemodeltoimplementresourcefacilitationforthechildren,youth,andelderlywithTBIandtheirfamilymemberswhorequireassistanceinnavigatingcomplexservicesystemstomeettheirneedsandachievetheirgoals.

5. Developaplanandidentifypotentiallong-termfundingsourcesforsustainingkeyTBIserviceinfrastructureelementsbeyondgrantfunding,withafocusonthetargetedpopulationsofchildren,youth,andtheelderlywithTBI.

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DisseminationofInformationThedisseminationofinformationconductedbytheNEVRTBIprogramisorganizedunderthreemainheadings:NebraskaBrainInjuryRegistryLetters,NebraskaBrainInjuryAdvisoryCouncilWebsite,andMaterialsDistributedattheBrainInjuryConference.Figure1containsasummaryoftheinformationdisseminatedundereachofthesethreeareas.

Figure1 DisseminationofInformationSummary:June1,2015–May31,2016

NebraskaBrainInjuryRegistryLetters

Ø Registrylettersmailed:12,868Ø Lettersreturnedundeliverable:1,156Ø Totalregistrylettersdelivered:11,712

NebraskaBrainInjuryAdvisoryCouncilWebsite*

Ø 12,177websitehitsØ 6,389uniquevisitors(seefullsummarybelow)

MaterialsDistributedatBrainInjuryConference(March31andApril1,2016)

Ø LashBrainInjuryTipCards-240Ø OnlineTBITrainingCoursepostcards-50Ø ProviderTrainingManuals-25Ø Screeningbrochure/tools-25Ø Registrybrochures-25Ø CDCSeniorFallPreventionbrochures-150Ø TheCostofTBI-25Ø BIRegistryReports-20Ø BIRSSTTeamContactlist-10Ø Councilapplications–resultedinanewBIAdvisory

CouncilmemberfromNorthPlatte.

ConstantContactStatistics

Ø Conducted10distinctinformationcampaignsthroughConstantContactduringthegrantyear.

Ø Therewerebetween231and243recipientsforeachConstantContactcampaignthatwassentout.

*ItappearsthatanalyticsfortheBrainInjuryAdvisoryCouncilwebsitehavebeenlumpedinwithanalyticsfromtheAssistiveTechnologyPartnershipofNebraska.Atthispoint,thereisnothingthatcanbedonetoseparateanalyticsfromthetwosites.

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ChangestotheNebraskaBrainInjuryRegistryLetterTheregistryletterandbrochurewereredesignedinordertoexpandtheinformationandmakethemmoreuserfriendly.Aperforatedsymptomchecklistwasaddedtothebrochure.Itisdesignedtobecompletedanddiscussedwithaphysician.ResourcesandtrainingforhealthcareprofessionalsandalinktotheAffordableHealthCareActarenowlisted.AlogoforPartnersforBrainInjurywasdesignedtodepicttheregistrypartnershipofNebraskaDepartmentofHealthandHumanServices,theBrainInjuryAdvisoryCouncil,andtheBrainInjuryAllianceofNebraska.MaterialsweretranslatedandprintedinSpanishwithotherlanguagesavailableuponrequest.Brochuresweredistributedattheannualbraininjuryconference,toNebraskaVRstaff,braininjurysupportgroups,andothers.Atotalof11,712lettersweredeliveredduringthegrantyear(June1,2015throughMay31,2016)toindividualswhoenteredthebraininjuryregistry.NebraskaBrainInjuryAdvisoryCouncilWebsiteAnalyticsAnalyticsfortheNebraskaBrainInjuryAdvisoryCouncilWebsitearelimitedduetothefactthatthatanalyticsfromtheAssistiveTechnologyPartnershipofNebraskahavebeencombined,andareunabletobeseparatedatthistime.Nevertheless,keyhighlights(forbothsitescombined)include12,177hitsfrom6,389uniquevisitors(Figure2).

Figure2 AnalyticsfortheNebraskaBrainInjuryAdvisoryWebsite*(June1,2015–May31,2016)

Websitehits: Ø 12,177Uniquevisitors Ø 6,389

Newusers: Ø 6,041(49.6%)Averagesessionduration: Ø 3:28

Averagenumberofpagespersession: Ø 2.8Bouncerate(Percentagewhonavigate

awayafterviewingonlyonepage): Ø 49.3%

Channels(howvisitorscametothesite):

Ø Direct:42.6%Ø Organicsearch:34.4%Ø Referral:21.5%Ø Socialmedia:1.4%

*ItappearsthatanalyticsfortheBrainInjuryAdvisoryCouncilwebsitehavebeenlumpedinwithanalyticsfromtheAssistiveTechnologyPartnershipofNebraska.Atthistime,thereisnothingthatcanbedonetoseparateanalyticsfromthetwosites.

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InformationandReferralInformationandreferralservicesforsurvivorsofTBIareconductedbythreeorganizations:TheBrainInjuryAllianceofNebraska(BIA),DisabilityRightsNebraska,andHotlineforDisabilities.Betweenthesethreeorganizations,404informationandreferralserviceswereconductedduringthegrantyear(notethatduplicationoccurs–someindividualsreceivemultipleinformationandreferralservices)(Figure3).

Figure3 InformationandReferralSummary:June1,2015–May31,2016

BrainInjuryAlliance(BIA)ResourceFacilitationInformationandReferral(formerlyknownasTBIOmbudsperson)

Ø Received377callsrelatedtoTBIfrom131individuals

(survivors,familymembers,professionals,andothers)Ø 289(76.7%)ofallcallsresultedinalinkagetoa

resource

DisabilityRightsNebraska

Ø Conducted40informationandreferralservicesfor

individualswithaTBI(someduplicationoccurs).

HotlineforDisabilities

Ø Conducted27informationandreferralservicesfor

individualswithaTBI.

Total Ø 404informationandreferralserviceswereconductedinthisgrantyear

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ResourceFacilitationCaseManagementResourceFacilitationCaseManagementconductedbytheBrainInjuryAllianceofNebraska(BIA)involvesclose,potentiallylong-term,one-on-oneinteractionbetweenabraininjurysurvivorandaresourcefacilitator.TheResourceFacilitatorassiststhesurvivorinnavigatingresourcesintheircommunity,evaluatingprogresswiththesurvivorandfamily/caregivers,andsettingandachievinggoals.Atthistime,resourcefacilitationservicesareopentoallsurvivorsofbraininjuryintheLincolnandOmahaareas.AtthebeginningofYear1,thereweretwoResourceFacilitators(oneservingtheLincolnarea,theotherservingtheOmahaarea).TheindividualservingtheLincolnarearesignedfromherpositionmid-waythroughtheyear.MovingintoYear2,twonewResourceFacilitatorshavebeenhiredtoserveLincolnandOmaha.TheindividualformerlyservingOmahawillmoveintoanewrolefocusingmoreonmanagerialdutiesandcommunityoutreachefforts,whilestillstayinginvolvedasaResourceFacilitator.Inaddition,GinaSimanekcontinuestocoordinateallstatewideinformationandreferralactivitiesfortheBIA(herworkisdocumentedinthesectiondirectlyabove).GinaanswersthebulkofthecallscomingintotheBIAandprovidesreferralstotheresourcefacilitatorswhenthesituationcallsforit.InYear1,aftergettingtheprogramofResourceFacilitationCaseManagementdesigned,thetwoResourceFacilitatorsprovidedinformation/intakeandreferralservicesto18individuals(someofwhomwilleventuallymoveintocasemanagement),andcasemanagementservicesto14individuals(11ofwhomstillhaveopencasesatthetimeofthisreport)(Figure4).

Figure4 ResourceFacilitation:Year1Summary

Information/IntakeandReferral:Ø 18(someofthesewill

moveintocasemanagement)

CaseManagement Ø 14(11casesremainopenatthistime)

ClientDemographicsFigures5through9presentdemographicinformationofcasemanagementclients.

Figure5 AgeofCaseManagementClients(n=12)

0-12 13-18 19-26 27-40 41-50 51-64 65-74 75+ Average Missing/Unknown

1 0 3 2 2 1 3 0 41.7 2

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Figure7 CauseofInjurytoCaseManagementClients(n=14)

Caraccidents/struckbyacar 3Caraccidentsandassault 1Fall 2Gunshotwound 2ArterialVascularMalformation(AVM) 1Bombblast 1Surgeries 1Meningitis/Encephalitis 1Accidents/incidents(unspecific) 2

TBI,8MultipleTBI,2

ABI,1

MultipleABIs,1

TBI(Concussion),2

Figure4.TypeofInjuryforCaseManagementClients(n=14)

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Figure9AdditionalDemographicsofCaseManagementClients(n=14)

Ø Gender:Male–8,Female–6Ø Veterans:3Ø Employmentstatus

o Currentlyemployed:1o Currentlyunemployed:4o Retired/disability/notapplicable:9

Ø Locationo Lincoln/LancasterCounty:4o OmahaMetroArea:10

ClientNeedsDataonclientneedshasbeenprovidedfor14casemanagementclients.Belowisasummaryoftheneedsidentifiedbytheseclients.Onaverageeachcasemanagementclienthashad6.7distinctneeds(Figure10).

Figure10 CaseManagementClientNeeds(n=14)Housingassistance 7Neurobehavioralneeds 7Educationandemployment 7Socialsupport 7Transportation 5In-home/ADLsassistance 5

Alone,3

Family/friends,10

Institution,1

Figure8.LivingArrangementofCaseManagementClients(n=14)

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Medicalspecialist(rehabdoctors,neurologist,psych) 5

Coping 5Concussion/MTBIevaluations 4Mentalhealthservices 4Legalservices 4Other 4Food 3Financialassistance/information 3Sleep 3AgingafterBI 3Alternativetherapies 2Vision 2Fatigue 2Substanceabuse 2Violence/angermanagement 2Clothing 1Insurance 1Coma/disordersofconsciousness(DOC) 1Seizures 1BIResearch 1Statistics 1Pediatric/schoolsupport 1Assistivetechnology 1Averagenumberofneedsperclient 6.7

TheMayo-PortlandAdaptabilityInventoryTheMayo-PortlandAdaptabilityInventory(“shortversion”)isatoolusedtoascertainneedsofindividualswhohavesufferedabraininjury.Thetoolmeasuresself-care,residence,transportation,employment,andotherbasicneeds.Thistoolisbeingusedasapre-postassessmentwithcasemanagementclients.ThehopeisthatimprovementwillbeseeninsomeareasafterworkingwithaResourceFacilitator.Todate,eight“pre”Mayo-PortlandAdaptabilityInventorieshavebeencollected.Nopost-datahavebeencollectedyet.The“short-version”oftheMayo-Portlandincludeseightinventoryitemswithaminimumscoreof0andmaximumof30.ThelowerthescoreontheMayo-Portland,thegreatertheindependence,andthelesserinterferencefrominjuries,foranindividualwithaTBI.Theaverage,healthyadult,wouldlikelyhaveascoreofzeroornearzero.

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Figure11presentstherangeofMayo-Portlandpre-scores.Theaveragepre-scorefortheeightindividualswhohaveparticipatedintheinventoryis17.3,substantiatingthevarietyofindividualneedsofthecurrentcasemanagementprofile.

Figure11 Mayo-PortlandAdaptabilityInventoryScores(n=8) 0-5 6-10 11-15 16-20 21-25 26-30 Average

Pre 0 1 2 3 2 0 17.3

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ResourceFacilitationCommunityOutreachInadditiontoofferinginformationandreferralservicesandcasemanagement,theBrainInjuryAllianceofNebraska(BIA),alsoconductscommunityoutreachtopromoteandraiseawarenessfortheResourceFacilitationprogram.Duringthisgrantyear(June2015throughMay2016),theBIAconducted209outreachactivitieswithanestimatedreachof3,870individuals.FurtherinformationaboutthenatureofthesecommunityoutreachactivitiesiscontainedbelowinFigures12and13.

Otherincludeshostingbooths,interviews,specialevents,eventplanning,orientation,networking,andotheractivities

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44

4

23

87

40

Training(attendedbyRF)

Communitymeeting(attendedbyRF)

Communityoutreach/training(givenbyRF)

Presentation- Education

Informationexchange(betweenRFandanindividualor…

Other

Figure12.ResourceFacilitationCommunityOutreachActivity(June'15- May'16)

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169

23

10

1

Presenting

Attending

Facilitating

Coordinating

Training

Figure13.BIAMember'sRoleinCommunityOutreachActivities(June'15- May'16)

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TBITrainingsAtotaloffiveTBItrainingswereofferedthisgrantyeartoabroadarrayofprofessionals,individuals,andfamilymembers.ThesetrainingsfocusedonvarioustopicsrelatedtoTBIsuchasTBIprevention,causesandrecovery;servicesforsurvivorsofaTBI;andhowtoassistTBIsurvivors;amongnumerousothertopics.ThedatesandparticipantsofthesefivetrainingsaredetailedbelowinFigure14.Figure14 TBITrainings:DatesandParticipants

Date(s) ParticipantDescription NumberofParticipants

OnlineTBIModules OngoingVariousprofessionalsandfamilymembersservingindividualswithTBI

25(unique)Introtraining:14

Pediatrictraining:5Adulttraining:12

Substancetraining:4

BrainInjuryRegionalSchoolSupportTeams(BIRSST)Symposium

February2016

Primarilyschool-basedprofessionals(schoolnurses,athleticdirectors,athletictrainers,counselors,psychologists,etc.),aswellasahandfulofcommunity-basedserviceproviders

76

OllieWebbCenterTBITraining March2016

Directsupportstaff(jobcoaches,DDprofessionals,educators,etc.)andmanagement

14

GetSchooledinConcussions(BIRSST-sponsored) April2016

Schoolstaff,includingathletictrainers,counselors,nurses,principals,andothers

36

NebraskaAssociationofServiceProviders(NASP)TBITrainings(fouridenticaltrainings)

May2016

Directsupportstaff,licensedmentalhealthcounselors,nursingstaff,socialworkers,andnumerousotherserviceprovidertypes

71

Total - - 222

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AdditionalTrainingActivitiesChallengingBehaviorandExecutiveFunctionSixBIRSSTmembersandtheBrainInjuryAdvisoryCouncil’sSpecialEducationrepresentativeattendedtrainingon"ChallengingBehaviorandExecutiveFunction"inColorado,andaresharingwhattheylearnedbydeveloping20-30minutetrainingmodulesforNebraska’sBIRSSTmembersandclassroomteachers."CollaborationwithDHHSInjuryPreventiononHealthcareProviderTrainingModulesNebraskaVRhassupportedtheworkoftheDHHSInjuryPreventionProgramanditspartnerstocreateonlinemodulesforhealthcareprofessionalsonthetopicofconcussions.TheDHHSInjuryPreventionProgramhasdevisedatotalofninemodulesdealingwithvariousaspectsofconcussions,includingidentification,recovery,compliancewithstatelaw,andotherareas,focusingprimaryontheyouthpopulationandsports-relatedconcussions.NebraskaVRsupportedtheworkofModules4,5,and6.Thesethreemoduleswerecompletedduringthisgrantyearandarescheduledtobeofferedtohealthcareprofessionalsinthecomingyear.Post-TrainingEvaluationSurveyResultsPost-trainingevaluationsurveyresultsaredisplayedinFigures15through21belowforallfivetrainingsconductedinthisgrantyear.Ingeneral,grant-fundedtrainingsuseastandardpost-trainingevaluationsurvey.However,duetothenatureandobjectivesofsometrainings,certainitemsonthestandardizedsurveyarenotusedwitheverytraining.Thefiguresbelowshowtheresultsfromeachsurveyitemonthestandardizedsurveybytraining.Ifatrainingisleftofffromafigure,thisisbecausethesurveyitemwasnotapplicabletothattraining.Seetheappendixforaversionofthestandardpost-trainingevaluationsurvey.Thepost-trainingevaluationsurveyshadverypositiveresults.Examplesofsomeofthemanypositivehighlightsfromthecombinedtotalofalltrainingsinclude96.7%oftrainingparticipantsreportingthattheirknowledgeofTBIprevention,causes,and/orrecoveryincreasedasaresultofthetraining(Figure15),99.4%reportingthattheirknowledgeofwaystheycanidentifyindividualsthathaveaTBIandmeettheirneedsincreasedasaresultofthetraining(Figure18),and98.5%reportedbeingsatisfiedorverysatisfiedwiththetraining(Figure21).

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100%94.4% 97.1% 96.7%

OllieWebbCenterTBITraining(n=14)

GetSchooledinConcussions(n=36)

NASPTBITrainings(n=70) Total(n=120)

Figure15.KnowledgeofTBIprevention,causes,and/orrecoveryincreasedasaresultoftraining

100%

92.9%88.9%

97.1% 95.5%

BIRSSTSymposium(n=37)



NASPTBITrainings(n=70)

Total(n=157)

Figure16.KnowledgeofwaysaTBIcanbedetectedincreasedasaresultofthetraining

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92.3%97.2% 97.1% 96.6%



NASPTBITrainings(n=70) Total(n=119)

Figure17.Knowledgeofservicesand/orprovidersthatmaybeabletohelpwithrecoveryafterTBIincreasedasaresultofthetraining

100% 100%97.2%

100% 99.4%





Total(n=165)

Figure18.KnowledgeofwaystheycanidentifyindiviualsthathaveaTBIandmeettheirneedsrelativetotheirpractice,and/orrefer

elsewhereincreasedasaresultofthetraining

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Figure20 AmongthoseanticipatingthattheywillbemoreabletoassistindividualswithTBI,etc.(seeFigure19directlyabove),reportedwaysinwhichtheywillbebetterabletoservethem


GetSchooledinConcussions

(n=35)


Total(n=115)

Ihaveinformationtoprovidetoindividuals/familiesaboutTBI

69.2% 85.7% 83.6% 82.6%

Ihaveinformationtoprovidetoindividuals/familiesaboutlocalresources/services

53.8% 48.6% 80.6% 67.8%

IcanmoreeasilyrecognizesymptomsofTBI 69.2% 51.4% 71.6% 65.2%

IcanbetterinteractwithindividualswithTBIinthecourseofmywork

76.9% 68.6% 74.6% 73.0%

IknowwhattodowhenIencounteranindividualwithTBIinmywork

69.2% 57.1% 68.7% 65.2%

94.4% 92.9%97.2% 95.7% 95.7%

OnlineTBIModules(n=18)




Total(n=138)

Figure19.Asaresultofthistraining,theyanticpatebeingmoreabletoassistindividualswithTBIandtheirfamiliesinaccessingthe

servicestheyneed

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NebraskaAssociationofServiceProviders(NASP)TBIProjectTheNASPTBITrainings(includedintheabovepost-trainingevaluationsurveyresults)werepartofalargerprojectdirectedtowardscommunity-basedproviderswhoserveindividualswithbraininjury.Thisprojectisdescribedinmoredetailbelow.Purpose:Thepurposeoftheprojectwastobuildcapacityamongdevelopmentaldisabilityserviceproviderstoserveindividualswithbraininjury.Capacityincludesawarenessofneed,knowledgeoffundingstreams,trainingonserviceprovision,andadvocacyforMedicaidwaiversupport.ActivitiesCompleted:Activitiescompletedincludedastakeholdersmeetingtoanalyzeawarenessandneed,collectionandsummaryofdata,developmentandexecutionoffourtrainings,andmeetingsleadingtorecommendationsregardingMedicaidwaiverredesigntobetterserveindividualswithbraininjury.Outcomes:OutcomesincludedcompletionofinformationalmemosformembersoftheNebraskaAssociationofServiceProviders,asummaryofrecommendationsforMedicaidwaiverredesign,completionoftrainingstatewide,andthedevelopmentofaresourcetoolkitfordevelopmentaldisabilityserviceproviders.Conclusions:Severalconclusionscanbedrawnfromthisproject.First,thereisadisconnectbetweentheneedordemandforservicesforindividualswithbraininjuryandagenciesthatcanprovideservicesandtheopportunitiesforfundingfortheservices.Second,relationshipsmustbedevelopedbetween

94.9%98.4% 100% 100% 98.6% 98.5%

OnlineTBIModules(n=18)


OllieWebbCenterTBITraining

(n=14)

GetSchooledinConcussions

(n=36)


Total(n=199)

Figure21.Satisfiedorverysatisfiedwiththetraining*

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servicecoordinatorsfortheAgedandDisabledWaiver,resourcecoordinators,anddevelopmentaldisabilityserviceproviders.Third,developmentaldisabilityserviceprovidershavesome,butnotall,ofthecapacitiesandskillsetsneededtoserveindividualswithbraininjury.NextSteps:Torespondtolessonslearned,severalnextstepsaresuggested.First,tobetterunderstandthedisconnectbetweenthedemandforservicesandfundingandserviceproviders,moredataanalysisshouldbecompleted.DevelopmentaldisabilityserviceproviderscouldbeprovidedwithcapacitybuildingfundingtodeveloprelationshipsandsetupthesystemsneededtobecomeAgedandDisabledWaiverproviders.Second,pilotprojectscouldbedevelopedtodirectindividualswithbraininjuryidentifiedbyresourcecoordinatorstotargeteddisabilityserviceproviders.Third,individualizedstaffdevelopmentcouldbedevelopedtofilltheorganizationalgapsfordisabilityserviceproviderstoserveindividualswithbraininjury.Additionaltrainingcouldbeprovided.Finally,additionalworktoidentifycommunitybasedservicesavailableundertheAgedandDisabledWaivercouldprovidemorecommunitybasedsupportsforindividualswithbraininjury.

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TBIScreeningsScreeningandIdentificationofElderlyIndividualswithBrainInjurythroughtheAreaAgencyonAginginRuralNebraskaPurposeThescreeningprojectfocusedontheneedforroutinebraininjury(BI)screeningsforahigh-riskagegroup,those65yearsandover.Theresearchersutilizedascreeningtoolwithelderlyindividualsinarurallocation.DatawascollectedfromservicecoordinatorsemployedbytheAreaAgencyonAgingatthreelocationsinruralNebraska:NorthPlatte,Scottsbluff,andKearney.Theresearchersprovidededucationaboutbraininjuryandmeasuredtheeffectivenessoftheeducationwithatrue/falsepre-andpost-survey;trainedtheservicecoordinatorstoadministeraspecificbraininjuryscreeningtool(theOSU-TBI,seetheAppendixforthetool);interviewedafocusgroupofservicecoordinatorsabouttheeffectivenessofthetrainingandtheirfeelingsofpreparednessinusingthescreeningtool.Theservicecoordinatorsthenadministeredthescreeningtoolandtheresearchersacquireddataregardingthenumberofpositivebraininjuryscreensattainedbythem.Finally,theresearchersconductedafollow-upinterviewwithservicecoordinatorsapproximately3-4monthsaftertheeducational/trainingsessionregardinginformationabouttheirperceptions,preparedness,anduseofthescreeningtoolwithclients.ParticipantsThereweretwogroupsofparticipantsforthisstudy.GroupAconsistedof24servicecoordinatorsemployedbyanAreaAgencyonAgingatthreelocations.Theseparticipantswererecruitedforthisprojectbecauseoftheiremploymentresponsibilitiesthatincludedevaluatingelderlyindividualsforhealthcareservices.GroupBconsistedofclientsseekingservicesthroughtheAreaAgencyonAging(N=558,43%male).TheywerescreenedforbraininjurybyGroupAwiththeOSUTBI-IDscreeningtoolandtheirresultswereenteredintoade-identifieddatabase.Results:ServiceCoordinators(GroupA)Preliminaryanalysisofthepre-posttestsindicatedthatGroupAparticipants(N=24)increasedtheirknowledgeofbraininjuryintheareasofrecoveryprocess,BIsequelae,anddisordersofconsciousness.TheresearchersaskedGroupAfollow-upquestionsregarding:1)educationalsessiononbraininjury;2)previoustrainingsessiononuseofscreeningtool;3)screeningprocesswithclientswiththebraininjuryscreeningtool.Thefollowingthemesemergedfromtheinterviews.Caseworkers…1)learnedmoreabouttheirclientsthroughthescreeningprocess;2)statedadjustmentstheywouldmaketothescreeningformforeaseofadministrationanddatacollection;3)describedthehelpfulnessofeducationandtrainingsessionsonbraininjuryandscreeningtool;4)describedtheirlackofpriortrainingonbraininjuryandpositiveeffectsofthistraining;5)expressedenthusiasmforthescreeningtool’sfitwiththeirexisting

21

screening/intakeprocedures;and6)expressedadesiretoknowabouttreatmentoptionsandreferralprocesstospeechlanguagepathologiststoprovidemorecompleteservicesforclients.Results:ScreeningData(GroupB)Atotalof558elderlyadultswerescreenedbytheAAAservicecoordinators.Ofthese,86(15%)hadapositivescreenforbraininjury(BI)(Figure22).

Figure22 BrainInjury(BI)ScreeningResults

TotalNumberScreened

HaveInjuriesPotentiallyCausingaBI

PositiveScreenforBI

Number 558 201 86PercentageofTotal - 36% 15%

Amongthosewithpositivescreens,thevastmajority(87%)hadbeenpreviouslyundiagnosedwithBI(Figure23).

Figure23 UndiagnosedBrainInjuries(BI)(amongthosewithpositivescreens)

PositiveScreenforBI

PreviouslyUndiagnosedwith

BINumber 86 75Percentage - 87%

Amongthosewithpositivescreens,22%hadtwobraininjuriesand15%hadthreeormorebraininjuries(Figure24).

Figure24 NumberofBrainInjuries(amongthosewithpositivescreens)(n=86)

1injury 2injuries 3ormoreinjuries63% 22% 15%

Amongthosewithpositivescreens,36%wereage65oroveratthetimewhenthebraininjuryoccurred(Figure25).

22

Figure25 AgeatTimeofBrainInjury(amongthosewithpositivescreens)(n=86)

0-4 5-14 15-24 25-44 45-64 65+5% 10% 19% 19% 12% 36%

Amongthosewithpositivescreens,themajority(75%)wereidentifiedashavingamildbraininjury(Figure26).

Figure26 SeverityofBrainInjury(amongthosewithpositivescreens)(n=86)

Mild Moderate Severe75% 20% 5%

Themajority(66%)ofthosewithapositivescreenreportedatleastsomelossofconsciousness(Figure27).

Figure27 LossofConsciousness(amongthosewithpositivescreens)(n=86)

NoLossofConsciousness

LossofConsciousnessfor

LessThan30Minutes

LossofConsciousnessfor30Minutesto24

Hours

LossofConsciousnessforMoreThan24

Hours34% 41% 20% 5%

EarlyChildhoodBrainInjuryScreeningsThreeEarlyChildhoodPlanningRegionTeamsbeganusingtheSAFEChildScreenforBirththrough2years(developedunderapreviousTBIgrant)withchildrenbeingscreenedforIndividualswithDisabilitiesAct(IDEA)PartC(birththroughage-2)servicesfromMay15throughAugust15thandaredocumentingthenumberofscreensadministeredandthenumberofpositivescreens.ThisdatawillbereportedafterAugust15,2016andwillbeincludedinnextyear’sAnnualTBIGrantreport.Thecompletedscreenformwillbeplacedineachchild’seducationalfileregardlessoftheoutcomeofthescreen.AllSAFEChildscreenforms(Birth–2Years;Ages3-Kindergarten;Grades1–5andSAFEStudent–MiddleandHighSchool)havebeentranslatedtoSpanishandVietnamesealongwiththeParentBrochuresforfamiliesofscreenedchildrenaged0throughhighschool.”

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PARTNERToolOneoftheaimsoftheTBIprojectistoincreasethecollaborationamongthekeystakeholdersorpartners.Partnershipsareanimportantelementforreachingtheoutcomesoftheproject.Asameasureofthelevelofcollaborationandeffectivenessofthepartnerships,thePARTNERtoolwasselectedtobeadministeredtokeypartnerseveryyearaspartofthegrantevaluation.ThePARTNERtoolhasbeenconductedtwice(December2014andDecember2015)with13projectpartners.Followingaresomekeyhighlightsfrombothyearsofadministration.Ingeneral,itcanbeconcludedthatthestrengthofthecollaborationhasremainedconsistentacross2014and2015(Figure28).Figure28 PARTNERToolSummary

2014 2015Collaborationhasbeensuccessfulorverysuccessfulatreachingitsgoals

7outof10(3noresponses) 10outof13

Topthreeaspectscontributingtothesuccessofthecollaboration

1. Havingasharedmission,goals

1. (tied)Exchanginginfo/knowledge

3. Bringtogetherdiversestakeholders

1. Exchanginginfo/knowledge

2. Bringingtogetherdiversestakeholders

2. (tied)Informalrelationshipscreated

Topthreemembercontributionstothecollaboration1. Info/feedback1. (tied)Community

connections3. Paidstaff

1. Info/feedback2. Community

connections2. (tied)Advocacy

Topthreeoutcomesofthecollaborativework

1. Publicawareness2. Improved

communication2. (tied)Increased

professionalTBIknowledge

1. Improvedcommunication

1. (tied)Publicawareness

1. (tied)Improvedresourcesharing

Densityscore(percentageoftiesinthenetworkinrelationtothetotalnumberofpossibleties) 65% 63%

Degreecentralizationscore(thelowerthescorethemoresimilarthemembersareintermsoftheirconnectionstoothers–i.e.,moredecentralized)

41% 44%

Trustscore(100%occurswhenallmemberstrustothersatthehighestlevel) 85% 84%

Value

(Scale:1

-4) OverallValueScore 3.28 3.33

Power/influencevaluemeasure 3.14 3.34Levelofinvolvementvaluemeasure 3.45 3.30Resourcecontributionvaluemeasure 3.24 3.35

Trust

(Scale:1

-4) OverallTrustScore 3.57 3.55

Reliabilitytrustmeasure 3.70 3.66Insupportofmissiontrustmeasure 3.43 3.42Opentodiscussiontrustmeasure 3.58 3.58

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NetworkMapsfromthePARTNERToolFigures29and30showthenetworkmapsfromthe2014and2015PARTNERTooladministrations.EachlinerepresentsanetworkbetweentwodifferentorganizationscollaboratingaroundtheissueofTBI.Morelinesindicatemorecollaboration.Therearethreelevelsofcollaboration:

• CooperativeActivities:involvesexchanginginformation,attendingmeetingstogether,andofferingresourcestopartners.Example:InformsotherprogramsofRFArelease.

• CoordinatedActivities:includescooperativeactivitiesinadditiontointentionaleffortstoenhanceeachother'scapacityforthemutualbenefitofprograms.Example:Separategrantingprogramsutilizingsharedadministrativeprocessesandformsforapplicationreviewandselection.

• IntegratedActivities:inadditiontocooperativeandcoordinatedactivities,thisistheactofusingcommonalitiestocreateaunifiedcenterofknowledgeandprogrammingthatsupportsworkinrelatedcontentareas.Example:Developingandutilizingsharedprioritiesforfundingeffectivepreventionstrategies.Fundingpoolsmaybecombined.

Figure29.2014NetworkMap

All(100%) CooperativeOnly(49%)

CoordinatedOnly(30%) IntegratedOnly(14%)

25

Figure30.2015NetworkMapAll(100%) CooperativeOnly(48.1%)

CoordinatedOnly(21.52%) IntegratedOnly(21.52%)

26

CostofTBIAnalysisTheWeb-basedInjuryStatisticsQueryandReportingSystem(WISQARS)isaprojectoftheCentersforDiseaseControlandPrevention(CDC).WISQARSprovidesvaluableinformationonthetopicofinjuryintheUnitedStatesintheformofdatareportsandquerysystems.TheCostofInjuryReportsapplicationwasusedinthistodeterminethecosts(bothmedicalandworkloss)associatedwithtraumaticbraininjury(TBI)inNebraskain2013.TheCostofInjuryReportsApplicationprovidesanaverageestimatedcostforaTBIbyageandgender.ThedatainthissectionrepresentthecostsforTBIsthatweresustainedin2013.Thecostspresentedinthisreportshouldnotbeunderstoodasbeingaccruedentirelyin2013.BothmedicalandworklosscostsassociatedwithTBImayextendthroughoutanindividual’slifetime.InthetragicincidenceofadeathduetoTBI,theaverageworklosscostscanextendbeyondamilliondollars.Furthermore,worklosscostsarecalculatedastheamountofworklostbyanindividualwhosustainedaTBI.TheworklosscostsdonotincludetheworklossacquiredbyparentsandcaregiversofTBIsurvivors.Formoreinformation,seethefullreport,availablebycontactingKeriBennett([email protected]).Figure31presentsthetotalnumberofemergencydepartmentvisits,hospitalizations,anddeathsduetoTBIinNebraskain2013.Basedonageandgenderbreakdownsofthesedata,atotalcost(includingbothmedicalandworklosscosts)ofTBIsinNebraskaoccurringin2013wasdeterminedtobeover$800million.Totalscostsarealsobrokendownbygenderandageinsubsequenttablesinthissection(Figures31through36).

Figure31 Emergencydepartmentvisits,hospitalizations,anddeathsduetoTBIinNebraska(2013)

EDVisits Hospitalizations Deaths10,672 1,701 344

(Source:NebraskaTBIRegistryandNebraskaVitalStatistics,2013)

Figure32 ThetotalestimatedcostofTBIbyemergencydepartmentvisits,hospitalizations,anddeathsinNebraska(2013)

EDVisits Hospitalizations Deaths TotalMedicalCosts $52,112,808 $144,396,731 $3,991,653 $200,501,192WorkLossCosts $42,440,973 $313,433,021 $245,735,663 $601,609,657TotalCosts $94,553,781 $457,829,752 $249,727,316 $802,110,849

(Source:NebraskaTBIRegistry,2013;NebraskaVitalStatistics,2013;andWISQARSCostofInjuryReports,2013)

27

Figure33 ThetotalestimatedcostofTBIbygenderinNebraska(2013)

Male Female Unknown TotalMedicalCosts $124,003,990 $76,483,303 $13,899 $200,501,192WorkLossCosts $468,023,686 $133,570,610 $15,361 $601,609,657TotalCosts $592,027,676 $210,053,913 $29,260 $802,110,849


Figure34ThetotalestimatedcostofTBIbyemergencydepartmentvisits,hospitalizations,anddeathsinNebraska(2013)

EDVisits Hospitalizations Deaths TotalMedicalCosts $52,112,808 $144,396,731 $3,991,653 $200,501,192WorkLossCosts $42,440,973 $313,433,021 $245,735,663 $601,609,657TotalCosts $94,553,781 $457,829,752 $249,727,316 $802,110,849

(Source:NebraskaTBIRegistry,2013;NebraskaVitalStatistics,2013;andWISQARSCostofInjuryReports,2013)Figure35 ThetotalestimatedcostofTBIbygenderinNebraska(2013)

Male Female Unknown TotalMedicalCosts $124,003,990 $76,483,303 $13,899 $200,501,192WorkLossCosts $468,023,686 $133,570,610 $15,361 $601,609,657TotalCosts $592,027,676 $210,053,913 $29,260 $802,110,849


Figure36 ThetotalestimatedcostofTBIbyageinNebraska(2013)

MedicalCosts WorkLossCosts TotalCosts0to4 $8,608,985 $19,376,743 $27,985,7285to9 $4,483,412 $9,261,424 $13,744,83610to14 $5,175,412 $12,008,411 $17,183,82315to19 $12,888,350 $55,776,947 $68,665,29720to24 $14,718,566 $80,781,016 $95,499,58225to29 $11,265,844 $62,743,240 $74,009,08430to34 $11,028,560 $63,354,373 $74,382,93335to39 $6,548,191 $32,560,928 $39,109,11940to44 $7,941,884 $43,168,884 $51,110,76845to49 $9,960,390 $47,408,984 $57,369,37450to54 $10,796,746 $57,731,808 $68,528,55455to59 $10,511,581 $28,160,101 $38,671,68260to64 $10,878,622 $24,011,898 $34,890,52065to69 $11,760,112 $21,151,736 $32,911,848

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MedicalCosts WorkLossCosts TotalCosts70to74 $9,881,674 $7,949,955 $17,831,62975to79 $15,179,508 $11,298,109 $26,477,61780to84 $14,386,541 $9,660,148 $24,046,689

85andover $24,486,814 $15,204,952 $39,691,766Total $200,501,192 $601,609,657 $802,110,849

(Source:NebraskaTBIRegistry,2013;andWISQARSCostofInjuryReports,2013)

29

SurveillanceDataDeaths,Hospitalizations,andEmergencyDepartmentVisitsFigures37through39presentratesofdeath,hospitalization,andemergencydepartmentvisitsduetoTBIfrom2000through2014.TherateofdeathsduetoTBIhasremainedrelativelystable,whiletheratesofhospitalizationsandemergencydepartmentvisitsduetoTBIhaveincreasedsubstantiallysince2000.Asignificantcontributortotheseincreasesinhospitalizationsandemergencydepartmentvisitsmaybeduetotheincreasedawarenessofconcussions.

(Source:NebraskaDeathCertificates,2000-2014)

(Source:NebraskaHospitalDischarge-E-Code,2000-2014)

18

15

2018 18

1718 18

19 1917 17

2018

1718 18

1918 18

0

5

10

15

20

25

Figure37.AgeAdjustedDeathRateDuetoTraumaticBrainInjuryinNebraskaper100,000Population

5245 46

5045 48

5257

6266

78 7988

8177

6368

7579 81

0

25

50

75

100

Figure38.AgeAdjustedHospitalizationRateDuetoTraumaticBrainInjuryinNebraskaper100,000Population

YearlyRates 5-YearAverages


30

(Source:NebraskaHospitalDischarge-E-Code,2000-2014)

TBIRegistrySurvivorsofaTBIareplacedonaregistry.TBIRegistrydataareshownbelowinFigures40through43.FromJanuary2015throughSeptember2015therewere9,733newcasesintheTBIregistry.Therewereonaverage1,081newcasesofTBIpermonthduringthisnine-monthperiod.Notethatthesedataonlycoverapartialyearandarepreliminary.Thoseage15–19werethemostcommonagegroupintheTBIregistryduringthistimeperiod,accountingfor1,092cases.Amongthoseundertheageof45,TBIsaremoreprevalentamongmales.However,amongthoseage45andoverTBIsaremoreprevalentamongfemales.TheleadingcauseofTBIduringthisnine-monthtimeperiodwasfalls,accountingfor47%ofallTBIs.Notethatthefullcalendaryear2015dataarenotyetfinalized.ChangesareoccurringtothewaydataarecollectedduetohospitalsswitchingfromtheICD-9totheICD-10codingsystem.

240 241264 261 251

273

338

394 412

487518 517 529 549 557

430466

493520 534

0

100

200

300

400

500

600

Figure39.AgeAdjustedEmergencyDepartmentVisitRateDuetoConcussionsinNebraskaper100,000Population


31

Figure40.ReportedcasesintheTBIRegistrybymonth,Jan.2005–Sept.2015*

*CountsforthemonthofSeptemberarepreliminary

(Source:NebraskaTBIRegistry,2015)

Figure41.TBIRegistryCasesDistributedbyPatientAge-Group,Jan.2015–Sept.2015


32

Figure42.NumberofTBIRegistryCasesDistributedbyAgeandGender,Jan.2015–Sept.2015


Figure43.TBIRegistryLeadingCausesofInjurybyPercentofCases,Jan.20015–Sept.2015


33

Appendix

34

TBIGrant–TrainingQUESTIONS

TrainingEvaluation

Date:_____________ Profession:_____________________________Didyourknowledgeinthefollowingareasincreaseasaresultofthistrainingevent?

1. TBIprevention,causesand/orrecovery Ÿes ¨No2. WaysaTBIcanbedetected(screeningtools,orwarningsignsthatshould

promptareferralforscreening) Ÿes ¨No

3. Servicesand/orproviderthatmaybeabletohelpwithrecoveryafterTBI Ÿes ¨No4. WaysthatI,inmyprofessionalrole,canidentifyindividualsthatmayhave

TBI,meettheirneedsrelativetomypractice,and/orreferthesestudentselsewhereforneededservices

Ÿes ¨No

5. Asaresultoftoday'straining,doyouanticipatebeingmoreabletoassistindividualswithTBIandtheirfamiliesinaccessingtheservicestheyneed?

Ÿes ¨No

6. Ifyouanswered“Yes”toquestion#5,inwhatwaysdoyouthinkyouwillbebetterabletoservethispopulation?Pleasecheckallthatapply.¨ Ihaveinformationtoprovidetoindividuals/familiesaboutTBI¨ Ihaveinformationtoprovidetoindividuals/familiesaboutlocalresources/services¨ IcanmoreeasilyrecognizesymptomsofTBI¨ IcanbetterinteractwithindividualswithTBIinthecourseofmywork¨ IknowwhattodowhenIencounteranindividualwithTBIinmywork

7. Howsatisfiedareyouwithtoday'straining?¨Verysatisfied ¨Satisfied

¨Neithersatisfiednordissatisfied

¨Dissatisfied ¨Verydissatisfied

OPTIONAL:8. Howconfidentdoyoufeelinusingthematerialsandmethodsprovidedattoday'strainingtotrain

someoneelse?¨Veryconfident ¨Confident

¨Neutral

¨Notconfident ¨Notconfidentatall

9. Aftertoday'straining,howconfidentdoyoufeelinassistingindividualswithTBI?¨Veryconfident ¨Confident

¨Neutral

¨Notconfident ¨Notconfidentatall

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