This report presents the analysis, findings, and recommendations of the Institute of Medicine’s (IOM) Committee on Traumatic Brain Injury with regard to the Federal TBI Program administered by the Health Resources and Services Administration (HRSA). The HRSA TBI Program is a congressionally mandated program intended to facilitate the development of state-level infrastructure and service delivery systems for individuals with TBI and their families, particularly with respect to family or consumer support, return to work, housing or supportive living personal assistance services, assistive technology and devices, behavioral health services, substance abuse services, and traumatic brain injury treatment and rehabilitation (Title 42 U.S. Code, Ch. 6A, 2003). The effectiveness of the HRSA TBI Program was recently called into question in a federal Office of Management and Budget (OMB) Program Assessment Rating Tool (PART) review report (OMB, 2005). In its critique, OMB found fault with the TBI Program, citing that it had neither long-term health outcomes measures nor regular independent evaluations of the program’s effects on TBI patients and their families.

To address these criticisms, HRSA contracted with the IOM in the spring of 2005 to conduct a study: (1) to assess the impact of the HRSA Program on how state systems are working or failing to work in support of individuals with a TBI; and (2) to advise HRSA on how it could improve the program to best serve individuals with TBI and their families (Box 1-1). The IOM appointed an 11-member Committee on Traumatic Brain Injury to assess the impact of the HRSA TBI Program and make recommendations to HRSA. Committee members were selected for their expertise in neurology, neuropsychology, cognitive and physical rehabilitation, clinical medicine and nursing, epidemiology, program evaluation, behavioral health, social work, and personal TBI experience.

The underlying premise of the HRSA TBI Program is that grants to states that meet certain requirements will facilitate the creation of infrastructure and increased capacity for serving individuals with TBI. This study is not intended as a technical evaluation of the HRSA TBI Program’s impact on either the delivery of TBI-related services or on person-level outcomes—such an analysis is not feasible given currently available data. Rather, the study’s focus is on whether the TBI Program has led to an expansion in state systems infrastructure as a precondition for better serving persons with TBI and their families.

The committee used a qualitative study method to assess the program’s impact. Qualitative methods are often used to investigate developing institutions and systems as well as to assess the impact of government programs (Caudle, 1994; Sofaer, 1999; Newcomer and Scheirer, 2001; World Bank