Testimony of Kate Coventry, Senior Policy Analyst Performance Oversight Hearing on the DC Department of Behavioral Health, DC Council Committee on Health

Chairman and members of the Committee, thank you for the opportunity to testify today. My name is Kate Coventry, and I am a senior policy analyst at the DC Fiscal Policy Institute. DCFPI is a nonprofit organization that promotes budget choices to address DC’s economic and racial inequities and to build widespread prosperity in the District of Columbia, through independent research and policy recommendations.

I would like to focus my testimony on the need for services for low income residents with traumatic brain injuries (TBIs), also known as acquired brain injuries (ABIs). The fiscal year (FY) 2021 budget includes $698,000 to allow some behavioral health outpatient providers to offer enhanced services for these injuries as well as autism spectrum disorders. This is a great new public investment, but more is needed to ensure that Department of Behavioral Health-certified provider organizations are able to provide these services to a larger number of residents in need. I ask the Department of Behavioral Health to work with the Department of Health Care Finance to include these services in the upcoming rate study and make any necessary rulemaking.

TBIs Have Significant Negative Effects

TBIs are injuries resulting from a blow or jolt to the head, or a penetrating injury to the head, that disrupts the function of the brain.[1] TBI in adults is associated with an increased risk for substance misuse, major depression, anxiety, and unemployment.[2]

TBIs can negatively affect self-regulation and executive functioning. Self-regulation refers to a person’s ability to manage behavior associated with stress and anxiety. For a person with TBI, this might entail difficulty waiting or taking turns; difficulty calming down; or feeling overwhelmed in new places. Executive functioning refers to higher-order brain functions associated with setting goals, organizing, remembering, following directions, and focusing attention. People with TBIs can become easily confused or forgetful; have difficulty learning new information; filling out forms; and using public transportation. Some have difficulty problem-solving, and others have problems with judgment and decision-making. After experiencing a TBI, people may have trouble keeping track of time, making plans, making sure to complete plans or assignments, applying previously learned information to solve problems, analyzing ideas, and looking for help or more information when needed.

Vulnerable Populations Are Particularly at Risk

People who are homeless are at high risk of acquiring a TBI: 50 to 80 percent of them have sustained at least one brain injury prior to homelessness, national statistics show.[3] The DC rate is elevated as well. In 2010, 199 DC homeless individuals were surveyed and nearly two-thirds had a TBI.[4]TBI may be a risk factor for becoming homeless, research shows.[5] Homeless individuals are also at a higher risk of acquiring a TBI because they are more likely to be victimized by assault, experience trauma, and have substance use disorders that can cause falls.[6]

A 2016 survey of 159 adult DC behavioral health clients found that approximately 50 percent had a history of TBI.[7]Additionally, active duty military personnel are at very high risk. Domestic violence survivors are also at high risk because “the head and face are among the most common targets of intimate assaults.”[8] And finally, TBI is a common co-occurring disorder among people who are diagnosed with a major mental illness and who have a history of substance misuse and criminal justice involvement.

DC Residents with TBIs Are Not Getting the Services They Need, with Devastating Implications

Right now, DC behavioral health providers generally do not screen, identify, or treat the symptoms of TBI because TBI is not an official billable diagnosis in DC’s behavioral health system, and there is no system to train mental health providers. Community-based providers cannot receive payment for services provided to treat TBI, whether it is a standalone diagnosis or co-occurring disorder. This results in DC residents with TBIs not getting the care that they need. The new investment of $698,000 to allow some outpatient providers to offer enhanced services for both TBIs as well as autism spectrum disorders is a great first step but more is needed to reach all residents in need

The lack of services has terrible implications for individuals with TBI. Research has found that people with cognitive impairments like TBI may be falsely considered non-compliant and then get expelled from programs because these impairments prevent them from fully participating in the services. Or they are banned from sites because of “disruptive behavior or failure to comply with prescribed treatments.”[8] To the untrained eye, problems with executive functioning can look like lack of motivation, laziness, disregard for others, and a reluctance to engage in social activities. Given that a 2010 survey of 12 DC homeless service providers found that only one provider had received any training on TBIs, it is likely that many homeless individuals with TBI are being excluded from mainstream homeless services.[9]

The Department of Behavioral Health should work with the Department of Health Care Finance to include these services in the upcoming rate study that will look at the health care costs associated with covered benefits in the effort to adjust payment rates to providers. We also ask DBH to work with Department of Health Care Finance to make any rulemaking needed to implement TBI services.

Thank you, and I am happy to answer any questions.

[1]Traumatic Brain Injury & Concussion,” Center for Disease Control and Prevention.

[2] Suzanne Polinder, Juanita A. Haagsma, David van Klaveren, Ewout W. Steyerberg, and Ed F van Beeck, “Health-Related Quality of Life after TBI: A Systematic Review of Study Design, Instruments, Measurement Properties, and Outcome,” Population Health Metrics (February 17, 2015).

[3] Jennifer L. Highley and Brenda J. Proffit, “Traumatic Brain Injury Among Homeless Persons: Etiology, prevalence, and severity, Health Care for the Homeless Clinicians’ Network,” revised June 2008

[4]Findings from the District of Columbia Traumatic Brain Injury Needs and Resources Assessment of Homeless Adult Individuals, Homeless Shelter Providers, TBI Survivors and Family Focus Group, TBI Service Agency/Organizations,” DC Department of Health, revised August 2010.

[5] Jane Topolovec-Vranic, Naomi Ennis, Angela Colantonio, Michael D. Cusimano, Stephen W. Hwang, Pia Kontos, Donna Oucherlony, and Vicky Stergiopoulos, “Traumatic brain injury among people who are homeless: a systematic review,” BMC Public Health, 2012.

[6] “Findings from the District of Columbia Traumatic Brain Injury Needs and Resources Assessment”

[7] Amy Burkowski, David Freeman, Faiza Majeed, Jennifer “Niki” Novak, Paul Rubenstein, and Celeste Valente, “Traumatic Brain Injury in the District: The Ignored Injury: A Paper Examining the Prevalence of TBI in the District and the Need for Services,” revised July 2018.

[8] “Findings from the District of Columbia Traumatic Brain Injury Needs and Resources Assessment”

[9] Ibid.