BOX 3-1
One TBI Survivor’s Challenges in Obtaining Needed Services

Scott suffered a severe TBI at age 17 and continues to have many language, motor, behavioral, and cognitive deficits. Now, at age 33, he still uses a wheelchair and has marked disinhibition that caused him a recent arrest for public lewdness. He needs constant supervision.

Despite his problems, Scott received SIB-R testing scoresa that made him ineligible for his state’s Medicaid development disabilities waiver. Scott’s receipt of a social security death benefit from his father made him ineligible for Medicaid due to his total income exceeding a limitation. Scott is ineligible for the TBI Medicaid waiver in his state because he was younger than 22 when he sustained his injury.


The SIB-R (Scale of Independent Behavior-Revised) is a widely used assessment tool. SIB-R is used to evaluate persons’ behaviors to determine the type and amount of special assistance they may need including, for example, home-based support services for infants and children and their families, special education and vocational training for young people, and supported work or special living arrangements such as personal care attendants, group homes, or nursing homes for adults. Go to for further information.

services they need. At best, their access to services may be circumscribed by nonclinical variables such as health, disability, or accident insurance; family income; health coverage; geography; primary language for communication; and other cultural and socioeconomic factors (NIH, 1998) (Box 3-1). Over time, as persons with TBI-related impairments grow older and their personal circumstances evolve, their eligibility for services may change and they may encounter new obstacles to care.

A lucky few individuals with TBI-related impairments may obtain some needed services in a serendipitous way (Box 3-2).


As noted in Chapter 2, TBI usually begins as an acute medical problem. If the individual with the injury is covered by health insurance, initial treatment for the injury may be obtained in a hospital, physician’s office, or other acute health care setting. If the injury is severe enough to require prolonged hospitalization, individuals with no insurance or limited insurance are often covered by Medicaid.

If a person with a TBI survives, however, much of the person’s improvement is likely to occur after the acute crisis ends when health benefits may be limited. Some individuals with severe disabilities must have ongoing

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