Number of people served in the rehabilitation program that reach their maximum potential and, with continued needs for services, successfully transition to Choices for Care Long Term Services, TBI specialized Long Term Services, or TBI Case Management Services. Transition from TBI rehabilitation provides an opportunity for improvement; individual outcomes and program goals would be improved if individuals requiring long term services are more effectively identified and transitioned to the long- term services that best meet individual needs. Historically, some individuals remained in the rehabilitation program for indeterminate periods of time without transitioning to long term services. Annual monitoring of individuals’ programs is essential to maintain and guide a focus on rehabilitation to maximize individuals’ potential and provide education to individuals and their families, while identifying and assessing the areas of need for ongoing long term services and how to meet these needs.

DAIL Adult Services Division, DVHA Department of Vermont Health Access, TBI Providers, Choices for Care Providers.

• A clear focus on rehabilitation goals, strategies, and progress.
• A clear understanding of long term needs and services.
• Clear transition processes that ensure that people's needs are met.

• Maintain TBI rehabilitation service focus on rehabilitation goals, strategies, and progress.
• Ensure long term services focus on long term care needs rather than intensive rehabilitation goals and strategies.
• Refine a written transition process across programs to define the roles of each division and create a clear and more streamlined transition process.
• Educate and support individuals, guardians, families, and providers about long term care needs and the transition process.