Coordinated and adequately funded state streams for rehabilitation of newly injured persons with tbi.

Traumatic brain injury (TBI) rates are highest among families with the lowest income levels. A paucity of appropriate funding streams for low-income, recently injured TBI patients is reported to cause delays in provision of early postacute rehabilitation or to cause patients to be discharged without receiving rehabilitation. There are also reports of patients remaining in hospitals with minimal care or being returned home, both because of a lack of a discharge site. The purposes of this exploratory study were to: (1) identify model aspects of existing publicly supported and administered programs for postacute individuals with TBI; (2) present results of a survey measuring to what extent state Medicaid programs fund postacute rehabilitation services for recently injured patients with TBI; (3) present results of interviews with trauma center social workers affiliated with the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems projects to determine whether and how delays in receiving Medicaid coverage occur; and (4) make recommendations for improved systems of care for postacute individuals with TBI.

The New York experience.

Under the Medicaid program, the provision of dental services is optional; presently 45 states cover some type of dental care for Medicaid recipients. This article reviews the 22-year history of the Medicaid dental program in New York, and compares that program to those in other states. Finally, the implications of the New York plan's latest innovation is discussed: requiring all residential health care facilities to provide dental services to all patients.

Dental record documentation in selected ambulatory care facilities.

Having recognized the differences in financial incentives between institutional providers and private practitioners participating in the Medicaid program, the New York State Health Department developed a streamlined mechanism of prior approval for 13 selected institutional providers of dental care. As part of the evaluation of this process, a retrospective audit of 316 dental records was conducted to assess the level of documentation present in the dental record. A followup audit was conducted 3 months after implementation of a plan to correct any deficiencies identified. More than 50 percent of the facilities were unable to present all the records requested at the time of the initial audit. Few of the audited records were free of deficiencies, and documentation of the results of the intra-oral examination was lacking in most facilities. The followup audit demonstrated statistically significant improvement in the level of record documentation. These results demonstrate that, even when good recordkeeping procedures were identified and agreed to by these institutional dental providers, performance was inadequate. However, the study also demonstrates that adequate records can be kept if sufficient incentives are provided. Efforts to evaluate retrospectively the delivery of dental care that are dependent on the dental record as a primary data source are unlikely to succeed unless incentives to encourage good recordkeeping are incorporated. Further research is needed to develop appropriate incentives that would operate in other practice settings.