From screening to success stories: Importance of early detection of brain injury

Brain injury (BI) is more prevalent than commonly recognized and frequently goes undiagnosed. Traumatic mechanisms include blows to the head and nontraumatic mechanisms include internal events such as stroke, aneurysm, brain tumor and loss of oxygen to the brain.¹ Individuals served by Medicaid, especially those facing behavioral health challenges, legal involvement, substance use recovery or housing instability, are at increased risk for a BI, as these circumstances heighten the likelihood of sustaining an injury that could result in BI. An estimated 60% of people involved with the criminal legal system have experienced a BI, seven times the rate of the general population.² Due to the complexity of BI symptoms and the varying needs of patients, it is imperative that individuals with BIs obtain early screening and that providers are trained to recognize BI-related challenges.

The role of managed care organizations

Managed care organizations (MCOs), such as UnitedHealthcare Community & State, can make a significant impact on improving BI care through comprehensive care coordination. MCOs can do this by expanding screening efforts in primary care and behavioral health settings as well as by connecting individuals with appropriate rehabilitation and support services. MCOs can also provide resources for families and caregivers and enhance cross-system collaboration to ensure continuity of care. Through these efforts, MCOs can help to bridge the gap in services and improve health outcomes for individuals with BIs.

Understanding the impact and symptoms of BI

The Centers for Medicare & Medicaid Services (CMS) recently classified BI as a chronic condition, which reinforces the need for screening and sustained, integrated care. Effective services need to cover a range of possible symptoms. The immediate effects of BI may include loss of consciousness, seizures, intense headaches, dizziness, coma and death.³ Long-term impacts extend across several domains:

• Cognition: Difficulty with memory, decision-making and reasoning
• Senses: Issues such as double vision, loss of taste, ringing in the ears or chronic pain
• Communication: Challenges with speaking, reading, writing and expressing thoughts
• Behavior: Problems with social interactions, relationships and emotional regulation
• Emotions: Increased risk of depression, anxiety, mood swings and irritability

Research suggests that repeated BIs may increase the risk of neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s disease and chronic traumatic encephalopathy.

The power of early detection and why BI screening matters

Screening for both historical and current symptoms of BI is essential to understanding how to support individuals and their unique needs. Best practices include trauma-informed, evidence-based tools like the Online Brain Injury Screening and Support System (OBISSS), a self-report questionnaire that is simple to administer and cost-effective. Screening helps ensure that care plans are personalized, support systems are in place and referrals are timely. In addition to the promotion of screenings, it’s important to promote the benefits of medical care as well. Findings published in the Brain Injury international research journal shows that of 1381 survey respondents who determined they had a BI through screenings, approximately 42% did not seek medical attention, highlighting the importance of connecting individuals to appropriate care.⁴ States such as Massachusetts and Colorado are leading the way in BI screening and care efforts across diverse populations, including individuals in recovery, domestic violence shelters, aging services and reentry programs.

Massachusetts: Expanding screening across multiple populations

The state of Massachusetts (MassAbility) is implementing the OBISSS across several populations to improve BI screening and support. In substance use recovery programs, screening efforts have revealed that over 90% of individuals tested positive for a potential BI. This finding has led to more effective treatment planning, improved support group discussions and enhanced participant education.

Specialty courts and community-based reentry programs are also incorporating BI screening to better assist individuals as they reintegrate into society. Similarly, prisons and jails are piloting screening initiatives to identify individuals who may require additional support after their release. Efforts extend to older adult support programs, where screening is being integrated into services for aging populations. Additionally, Massachusetts is working with the Department of Public Health to implement BI screening in domestic violence shelters. This initiative ensures that shelter providers receive proper training and are equipped to offer appropriate support to individuals affected by intimate partner violence.

To support these agencies, Massachusetts provides training, technical assistance, job aides, data reports and collaborative networking opportunities. The Brain Injury and Behavioral Health Communities of Practice (CoP) serve as a platform for professionals to share knowledge, discuss challenges and refine their approaches to BI screening, ultimately strengthening the effectiveness of these programs.

Colorado: Statewide screening and building a support framework

Colorado Department of Human Services has made significant strides in implementing OBISSS, providing statewide access to all residents and practitioners. This allows individuals across the state to benefit from BI screening and support. To further assist with implementation, the state facilitates quarterly CoP meetings, which help agencies navigate the challenges of BI screening and integration.

In addition to statewide access, Colorado has targeted sector-specific initiatives, focusing on populations such as those within the criminal legal system, juvenile justice, intimate partner violence survivors and offenders, tribal communities, veterans, older adults and child welfare services. These initiatives ensure that BI screening efforts are tailored to meet the unique needs of each group.

Additionally, Denver Community Corrections has developed the Brain Injury Informed Practices Guide, a framework that helps agencies incorporate BI-informed care into their services. This guide supports a more systematic and effective approach to addressing the needs of individuals with brain injuries throughout Colorado.

Addressing barriers within the Medicaid population

Research consistently shows that the impact of BIs disproportionately affects individuals enrolled in Medicaid, largely due to barriers in accessing timely and appropriate care.⁵ Compared to those with private insurance, Medicaid members and uninsured individuals are significantly less likely to receive necessary BI procedures or inpatient services such as rehabilitation and have higher in-hospital mortality rates.

One population most acutely affected by BI is individuals experiencing homelessness. Studies show that nearly 80% of people experiencing homelessness have a history of BI, compared to just 12% in the general population.⁶ This stark contrast highlights the need for systematic BI screening and intervention within Medicaid programs.

To help address these disparities, 23 states currently administer 27 Medicaid home and community-based services (HCBS) BI waiver programs.⁷ These waivers are designed to expand access to long-term services and supports, yet many operate on a limited scale.

NASHIA: Advocating for integrated BI support

UnitedHealthcare Community & State is currently working in coordination with the National Association of State Head Injury Administrators (NASHIA) as thought collaborators to strengthen support systems for individuals with BI. As a voluntary membership organization founded by state government employees, NASHIA supports the development and administration of public programs for individuals with BI.⁸ Through its efforts, NASHIA provides guidance on best practices, monitors national trends and contributes to policy development, while advocating for integrated BI support across behavioral health, housing and legal systems. By promoting collaboration between government agencies, health care providers and advocacy groups, NASHIA helps ensure that individuals with BI have access to comprehensive services that fully enable their recovery, independence and overall well-being.

The impact of increased BI awareness and screening can be seen through the following success stories that highlight how early identification and tailored support can change lives.

• Completing full recovery program: A client at a recovery program was on the verge of being removed due to complex needs. Screening identified BI, allowing for treatment plan modifications, improved group meeting structures and new referrals. These adjustments enabled the individual to remain in the program and sustain recovery.
• Avoiding incarceration: A woman in a Colorado treatment court faced revocation and a long prison sentence. Screening revealed short-term memory impairments due to BI. By adopting a personalized strategy, taking notes in colored ink to distinguish self-written instructions, she successfully completed her program and avoided incarceration.
• Improving care through screenings: In the Denver County Jail, over 90% of women screened positive for BI. Screening led to improved care coordination and the development of a best practices guide for agencies.
• Performing self-screening: A professional in the field used OBISSS for self-screening in a trauma-informed manner. The insights gained helped her manage symptoms and improve workplace success.

UnitedHealthcare Community & State is committed to addressing the comprehensive health and social needs of Medicaid populations, including individuals with BI who require specific care across multiple government systems. UnitedHealthcare supports NASHIA’s efforts to improve BI awareness, care coordination, screening protocols and cross-system collaboration, ensuring that individuals receive the right services at the right time. The focus on community-based care, rather than institutionalization, aligns with our mission to provide holistic, person-centered care that improves long-term outcomes. Through continued investment in screening, rehabilitation and supportive services, individuals living with BIs can have an improved quality of life.

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