From November 2010 to August 2013, 161 adults with acquired brain injury in Massachusetts transitioned from long-term care settings to the community through a Medicaid-funded waiver. Most participants transitioned with minimal risk; for some, the transition resulted in an increase in risk incidents above the rest. Specifically, despite risk mitigation efforts, 11 percent of the participants accounted for more than 75 percent of the reported first year incidents.
A registered nurse Care Manager was engaged in a pilot program to address the needs of participants at the highest risk. Based on incidents or potential for incidents, 30 participants were enrolled in care management (CM). Secondary data analysis, interviews, and surveys assessed whether CM was associated with a decrease in incidents and to what extent participants and providers were satisfied with CM.
Care management was significantly associated with a decrease in incidents including hospitalizations and emergency room visits. Participants, Case Managers, and service providers were highly satisfied with the Care Manager. Focusing on a specific population with increased risk, clearly explaining the purpose of CM, and remaining flexible when addressing the complex and individual nature of risk management are important strategies to ensure an effective CM program.