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Objective: To articulate a framework for supporting individuals with behavioral challenges following brain injury, to describe a state-funded clinical intervention program established to provide community support to individuals with challenging behaviors following brain injury using such a framework, to present data from which it can be concluded that such a program is cost-effective, and to offer policy recommendations., Design: Retrospective analysis of cost data and living arrangements for individuals with behavioral challenges served for a period of 3-4 years through the New York State Home and Community-Based Services Traumatic Brain Injury (HCBS-TBI) Waiver program and the State Behavioral Resource Project., Subjects: 80 individuals with TBI and severe behavioral challenges that included criminal behavior, physical threats, assault and physical aggression, sexually inappropriate behavior, substance abuse, refusal to participate in intervention programs, and psychiatric disturbances, all of whom were at least 2 years postinjury (X = 7.33 years postinjury)., Results: The majority of individuals (82% of the 1996 cohort; 89% of the 1997 cohort) with challenging behaviors were living successfully in their home communities 3-4 years after the initiation of behavioral supports. In addition, the costs of serving these individuals decreased in the first year of community integration and for that last year that a cost analysis was completed., Conclusions: Many individuals with behavioral impairments can be supported successfully in community settings, so long as those supports are flexibly implemented to meet the changing needs of those individuals. Moreover, even with intensive supports, it is cost-effective to serve this population in the community.

This article examines Medicaid waivers to provide services to adults with traumatic brain injury (TBI) who are Medicaid eligible in the community and who would otherwise be placed in nursing homes or who meet nursing home levels of care. Medicaid waivers for individuals with TBI were addressed through a review of six TBI Waivers (Colorado, Idaho, Kansas, New York, Rhode Island, and Vermont). A summary of the services covered by the waivers is provided. Review of the data suggests two processes, obtaining a waiver and implementing a waiver. Four characteristics were linked to obtaining waivers (a) social-medical-political climate, (b) similarity to other waivers, (c) ability to strengthen access and reduce barriers, and (d) expenditure of resources. Similarly, four theoretical characteristics were posited to be associated with managing waivers: (a) cost effectiveness, developmental process of waiver implementation, (c) ability to improve access and reduce barriers, and (d) expenditure of resources to manage the waiver.