TBIAC Report December 2018
10795-75104300nThe Texas Brain Injury Advisory Council 2020 Report Presented to the Texas LegislatureAs Required by1TAC Part 15, §351.825(d)(2) and Texas Government Code §531.012Texas Brain Injury Advisory Council December 2020Contents TOC \o "1-3" \h \z \u Contents PAGEREF _Toc530996739 \h 1Executive Summary PAGEREF _Toc530996740 \h 2Introduction PAGEREF _Toc530996741 \h 5Background PAGEREF _Toc530996742 \h 11Legislative Recommendations PAGEREF _Toc530996743 \h 14Non-Legislative Recommendations PAGEREF _Toc530996744 \h 21References PAGEREF _Toc530996745 \h 24Acronyms PAGEREF _Toc530996746 \h 24DisclaimerThis report was prepared by members of the Texas Brain Injury Advisory Council. The opinions and recommendations expressed in this report are the members’ own and do not reflect the views of the Texas Health and Human Services Commission Executive Council or the Texas Health and Human Services Commission.Executive SummaryWHAT IS AN ACQUIRED BRAIN INJURY?An acquired brain injury (ABI) may be either traumatic or non-traumatic. The CDC defines a traumatic brain injury (TBI) as “a disruption in the normal function of the brain that can be caused by a bump, blow or jolt to the head or a penetrating injury” (8). A traumatic brain injury suggests injury either via direct forces (ex. blow to head from object), or injury via indirect forces (ex. blast injury or high speed acceleration/deceleration forces). A non-traumatic cause of acquired brain injury may include: tumors, strokes, brain infections, or anoxic brain injury (i.e. oxygen deprivation to brain tissue). HOW DOES AN ACQUIRED BRAIN INJURY IMPACT AN INDIVIDUAL?Just as no two individuals are alike, no two brains are alike. The brain injury may cause the person to have varying levels of impairment and functional limitations. Not all symptoms are likely to be present at once and the degree of impairment may range from minimal to severe. Impairments may be short lived or may last a lifetime. These may include physical impairments such as poor mobility, problems speaking or swallowing, headaches, or fatigue; cognitive impairment such as memory loss, disorientation, poor problem solving, limited attention span; or behavioral/emotional impairments such as impulsivity, irritability, passivity, or aggressiveness. The changes after an ABI may impact an individuals’ ability to work, drive, read, write, communicate, manage their finances, take care of their children, live independently, or participate in community and social activities. Recovery is dependent upon the nature of the injury or disease, the part of the brain injured, the individual, family support, the availability of resources, and timely access to medical services and rehabilitation.ACQUIRED BRAIN INJURY INCIDENCE AND FACTSThe American Stroke Association (ASA) reported in 2019 that stroke is the 5th leading cause of death (more than 142,000) and about 795,000 Americans will have a new or recurrent stroke this year of which 87% are caused when a clot cuts off blood ?ow to a part of the brain (8). Stroke is a leading cause of disability and the leading preventable cause of disability. Data in 2020 stated more than 5.3 million Americans live with brain injury-related disabilities at a cost exceeding $82 billion annually (5). Texas leading causes of death in 2017 were heart disease (45,346), cancer (40,668), stroke (10,790), accidents (10763), and chronic lower respiratory disease (10,650) (24). Recommendations of the Texas Brain Injury Advisory Council LEGISLATIVE RECOMMENDATIONSAdd Cognitive Rehabilitation Therapy to the State Medicaid Plan.Require Texas Workforce Commission, in collaboration with the Office of Acquired Brain Injury (OABI) and Texas Brain Injury Advisory Council (TBIAC), to develop a Vocational Rehabilitation plan for individuals with Acquired Brain Injury across all levels of functioning. Adequately fund OABI including travel reimbursement costs for Texas Brain Injury Advisory Council survivor and caregiver members. Provide permanent and sufficient funding for the Comprehensive Rehabilitation Services Program.Require HHSC, in collaboration with TBIAC and OABI, to submit to the legislature a comprehensive plan to improve long term outcomes, reduce disability, and decrease long term healthcare costs for Texans with acquired brain injuries. In collaboration with the OABI, the TBIAC will evaluate recommendations for legislature regarding motorcycle helmet laws through analysis of current available data in Texas, as well as other states with more/less restrictive laws.Evaluate other states’ brain injury programs for best practices, including public education for Texans with Acquired Brain Injury. Evaluate and develop a system to ensure Acquired Brain Injury data is collected even when not listed as a primary diagnosis.Add non-traumatic brain injuries to the Brain Injury Registry maintained by the Department of State Health Services.NON-LEGISLATIVE RECOMMENDATIONSRecommend OABI pursue the federal Traumatic Brain Injury Act grant to fund the Family Navigator Program.Collaborate with OABI on current and future projects, including fact sheets, brain injury conferences, and brain injury training for first responders. Collaborate with Health and Human Services to create guidelines and best practices for the Veterans Recovery Pilot Program per H.B. 271, 85th Legislature, Regular Session, 2017, regarding Hyperbaric Oxygen Chamber Treatments. Request for proposal deadline Mar 19, selection made Nov 19, pending funding. Closed.Build a network of brain injury focused social media sites, resources, and contacts to promote education and prevention through the OABI website. Strengthen partnerships and communication with state agencies as well as other state and national brain injury organizations. IntroductionWHAT IS AN ACQUIRED BRAIN INJURY?An acquired brain injury (ABI) may be either traumatic or non-traumatic. The CDC defines a traumatic brain injury (TBI) as “a disruption in the normal function of the brain that can be caused by a bump, blow or jolt to the head or a penetrating injury” (8). A traumatic brain injury suggests injury either via direct forces (ex. blow to head from object), or injury via indirect forces (ex. blast injury or high speed acceleration/deceleration forces). A non-traumatic cause of acquired brain injury may include: tumors, strokes, brain infections, or anoxic brain injury (i.e. oxygen deprivation to brain tissue). How does an Acquired Brain Injury Impact an Individual?Just as no two individuals are alike, no two brains are alike. The brain injury may cause the person to have impaired functional abilities in some or all areas listed below. Not all symptoms are likely to be present at once and the degree of impairment may range from minimal to severe. Impairments may be short lived or may last a lifetime. Examples of impairments are listed below:Physical impairments may include: problems walking, motor weakness or paralysis, loss of coordination, tremors, poor balance, chronic pain, headaches, dizziness, mental or physical fatigue, loss of sensation, difficulty swallowing, unclear speech and inability to speak words. Cognitive/Communication impairments may include: disoriented to time, place or situation, difficulty processing information, shortened attention span, impaired decision making and problem solving abilities, difficulty understanding abstract concepts or following directions with multiple steps, memory loss, understanding others, difficulty or inability to express thoughts. Perceptual impairments may include: a change in any of the senses, however, most likely vision and disorders of taste or smell. Behavioral/Emotional impairments may include: irritability,impatience, lack of initiative, impulsive, denial of impairments, reduced tolerance for stress, inflexibility, flattened or heightened emotional response and reactions, and loss of impulse control that may result in physical or verbal aggression, or inappropriate sexual behavior. Research indicates that a brain injury is not an “event”, it is a disease condition that causes the development of other diseases. Individuals with a brain injury are at an increased risk of developing other neurological, neurodegenerative and neuroendocrine disorders, psychological and psychiatric diseases, and non-neurological disease (18). Ma (17) claims the protease calpain is responsible for the development of disorders following the event.Acquired Brain Injury Incidence and FactsUnited States and Texas ABI data on the incidence and related disability is limited. The 2015 CDC Report on TBI to the Congress made several recommendations related to improving incidence estimates. One recommendation is to include data on individuals with TBI who are not receiving medical care and identify non-hospital incidence data. Another recommendation is to generate state specific TBI estimates through the collection and compilation of health care administrative data in all states. Some of this information can be found Texas databases as well as in the CDC WONDER and WISQARS databases.Texas leading causes of death in 2017 were heart disease (45,346), cancer (40,668), stroke (10,790), accidents (10763), and chronic lower respiratory disease (10,650) (24). Cardiac arrest, stroke, and head related accidents can result in acquired brain injury. At a national level data in 2020, more than 5.3 million Americans live with brain injury-related disabilities at a cost exceeding $82 billion annually (5). The following data is provided by the Texas Emergency Medical Services (EMS) Trauma Registry and is generated by hospital patient records submitted as of 22 Sep 2018. Five Causes of Injury Resulting in a Traumatic Brain Injury (TBI), Texas 2018External Causes of injuryCountsSame Level Fall3325One Level To Another Fall1444Blunt Trauma1272Motor Vehicle Crash (MVC) (Collision)610MVC /Other/Other Transports198Stroke:The American Stroke Association (ASA) reported in 2019 that stroke is the 5th leading cause of death (more than 142,000) and about 795,000 Americans will have a new or recurrent stroke this year of which 87% are caused when a clot cuts off blood ?ow to a part of the brain (4). Stroke is a leading cause of disability and the leading preventable cause of disability due to smoking and diet. The annual direct and indirect costs was $45 billion in the United States. (31).In Texas, 42% of stroke victims had moderate disabilities at discharge in 2016-2017 as determined the modified Rankin scale. Note: Only 30.8% had a modified Rankin scale at discharge and a potential focus for hospital documentation (3).In Texas, there were 532 088 strokes with 68,327 hospitalizations (25.3 per 10.000), with total charges of $4,919,615,659 (3).Stroke is the tenth leading cause of death in children (35).There were 36 pediatric stroke cases from 2008-2017 in Texas (3).Texas county statistics can be found in appendix 1 (16).Unintentional Drowning:The last Texas EMS report concerning unintentional drowning was in 2013 with 241 non-fatal submersions 36 adult non-fatal adult submersions (2) and but allows an estimate of submersion survivors based on the deaths. In 2014, the Injury Epidemiology & Surveillance Branch, TX Department of State Health Services, identified 420 submersion events (347 from <1 to 19 years old and 61 from 20 to >75) with 67 fatalities. There was no age identified for 12 submersions (26).In 2018-28 Jul 20, there were 230 fatal drownings in Texas (15).According to the Texas Drowning Prevention Alliance, more than 50% of drowning victims treated in emergency departments or require further care and for every fatal drowning, there are five non-fatal submersion injuries. Consequently, there is an estimated 1150 non-fatal submersions over the past three years, many of whom will have severe brain damage that may result in long-term disabilities.Texas county statistics for 2017-2020 are in appendix 2 (15). Carbon monoxide poisoning:Carbon monoxide (CO) poisoning results in delayed neurologic problems in 2.75% of the total victims. Symptoms include hypertension, history of psychological disorder, and initial symptoms of headache, nausea or vomiting, weakness, malaise, lethargy, and dizziness, (32) as well as concentration problems, cognitive disturbances, emotional liability, personality changes, amnesia, dementia, psychosis, gait disturbances, movement disorders (19) and other impairments mentioned above. The Texas Poison Center Network documents hundreds of carbon monoxide poisonings each year. (6). One of the long term conditions is delayed neurological sequelae in which cognitive and neurological compromise can develop about six months after the CO event if not properly treated (32)Traumatic brain injury (TBI):The CDC reports, falls are the leading cause of non-fatal injuries for all children ages 0 to 19 adding up to almost 2.8 million children each year and above 65 have the highest number of ABIs from falls (23). Falls are the most common cause of traumatic brain injuries (47%) (9) followed by intentional self-harm (33% of TBI related deaths) and motor vehicle accidents (14%). From January 2000 to Sep 2019, the US Military has had 413,858 TBIs (Numbers for TBI): 82.8% were mild, 9.8% moderate, 1.0% severe, 1.3% penetrating, and 5.2% not classified (20).In July 2015, the Texas Legislature’s Sunset Advisory Commission adopted a management action (non-statutory) directing collaboration between the University Interscholastic League (UIL) and UT Southwestern (UTSW) forming TEX-CON. UIL and UTSW athletic concussion data collection in 2017 to June 2018 showed 3058 concussions reported to the registry, but only 27.4% of UIL districts were enrolled. This consisted of the first aim to establish a dataset relating to concussion. The second aim is to create a centralized database to upload concussion events and a third to analyze and report data results. All 6A UIL schools are required to report concussions in all sports starting in the 2019-2020 school year (1). Although COVID-19 prevented data collection for spring sports, there was an 87% of division 6A schools reporting to ConTex with a total of 3032 concussion incidents with 2966 from 6A schools. Concussed athletes were evaluated within 24 hours in 50% of the cases (10).Impact of ABIThe cognitive, emotional, physical, behavioral, and perceptual changes after an ABI may impact an individual's ability to work, drive, read, write, manage their finances, take care of their children, live independently, or participate in community and social activities. Improvements may come as a result of hard work and rehabilitation. Recovery is dependent upon the nature of the injury or disease, the individual, family support, the availability of resources, and, access to appropriate rehabilitation at the appropriate time(s) and for the appropriate amount of time. Texans with ABI are fortunate to have access to a large number of acute and post-acute rehabilitation providers throughout the state. Texas is the only state to require insurance companies to provide coverage for the spectrum of rehabilitation services needed after a brain injury, including cognitive rehabilitation and post-acute brain injury rehabilitation. Because of the acquired brain injury law, Texans have greater access to acute and post-acute rehabilitation than any other state. In addition, Texas partially fills a rehabilitation gap by providing Comprehensive Rehabilitation Services (CRS) to individuals with TBI or traumatic spinal cord injury (SCI) without adequate insurance. While Texas leads the way in these two key areas, Texas does not currently offer programs and funding to help meet the long term needs of individuals living with brain injury. Other states have long term brain injury residential programs, structured brain injury day activity programs and more robust brain injury vocational rehabilitation programs. Access to all of these programs help individuals increase their ability to return to work and reduce disability and medical complications.The United States, the direct and indirect costs of traumatic brain injury is estimated to be $48.3 billion annually with the lifetime costs for one person surviving a severe TBI can p to $4 million. Average acute rehabilitation costs for survivors of a severe TBI $55,000 (13). The estimated national economic cost of TBI in 2010, including direct and indirect medical costs, is estimated to be approximately?$76.5 billion. Additionally, approximately 90% of the total TBI medical costs are from fatal TBI’s and TBIs requiring hospitalization, many of which are severe.Falls in individuals over 65 years of age are the most common cause of TBIs. In 2015, the total medical costs for falls totaled more than $50 billion. Medicare and Medicaid shouldered 75% of these costs (12).BackgroundWHAT IS THE TEXAS BRAIN INJURY ADVISORY COUNCIL (TBIAC)?The TBIAC was established as the Texas Traumatic Brain Injury Advisory Board in 1997 by former Governor George Bush to give brain injury survivors, their families and caregivers, service providers and state agencies a voice in identifying and meeting the needs of people with brain injury. In 2003, the Texas Traumatic Brain Injury Advisory Council was established in statute by the 78th Texas Legislature. In 2015, the 84th Texas Legislature removed most health and human services advisory councils from statute and authorized the Health and Human Services Commission (HHSC) to reestablish the TBIAC in rule. With advocacy from the TBIAC, the scope of the Council was expanded to include all acquired brain injuries and the name was changed to the Texas Brain Injury Advisory Council. The Texas Brain Injury Advisory Council advises HHSC and state leaders on the prevention of brain injury and improving the quality of life of individuals who have survived brain injuries and their families and caregivers. The TBIAC:Informs state leadership (the Governor and Legislature) of the needs of people with brain injuries and their families;Recommends policies and practices to meet those needs;Encourages research into the causes, prevention, treatment of brain injuries;Promotes long-term services and supports for people with a brain injuries;Promotes brain injury prevention and awareness throughout the state; Facilitates the development and implementation of sustainable supports and services to meet the complex needs of persons who have survived a brain injury. Historically, the TBIAC has advocated for or supported:Full funding for the Comprehensive Rehabilitation Service (CRS) program, a Texas state program which funds rehabilitation for individuals with traumatic brain injury or spinal cord injury;The creation of and funding for the Office of Acquired Brain Injury;Implementation and improvement of the TBI Registry by the Department of State Health Services;Providing training of 2-1-1 staff in acquired brain injury needs and resources;Requiring insurers to provide acute and post-acute rehabilitation services to individuals with acquired brain injury including cognitive rehabilitation therapy;Adding cognitive rehabilitation therapy to the services available under Texas’ Medicaid home and community based services waiver programs;Requiring children to wear helmets when bicycling or participating in bull riding and other rodeo events;Educating school personnel regarding sports concussions;Educating law enforcement personnel in effectively interacting with individuals with brain injuries;Identifying youth in the Juvenile Justice System with brain injuries and implementing testing approaches to improve management of, and outcomes for, juvenile offenders with brain injuries; andEducating the public through brochures, public service announcements, appearing on media broadcasts, and speaking at community events.The TBIAC will continue to advocate for persons with brain injury and their families and to depend on input from all persons involved with brain injury and brain injury care and treatment.TBIAC Accomplishments:85th Texas Legislation creation and initial funding of the Office of Acquired Brain Injury2016 TBIAC recommendationProvided feedback to the Office of Acquired Brain Injury on the Texas Brain Injury Resource Guide scheduled for publication in 2018Acquired Brain Injury Family Navigator pilot study established (TBIAC 2016 recommendation)Active coordination with the Family Navigator pilot studyCoordination with Texas Cerebral Palsy on navigating state systems Conducting qualitative and quantitative researchVolunteer TBIAC members attended the 4th Federal Interagency Conference on Traumatic Brain Injury and the Annual Congressional Brain Fair in Washington, DC Up-to-date brain injury knowledge provided to the Office of Acquired Brain Injury and other Health and Human Services Commission officesRequest from the Texas Workers Compensation Department of Insurance regarding workers compensation for individuals with brain injury Plan initiated to gather information from physicians and case managers regarding brain injury compensation claimsRoutine stakeholder meetings with Texas Workforce Commission Vocational Rehabilitation Services for outreach efforts Interfaced with HHS Medicaid Managed Care ServicesConsider adding neurologists, neuropsychologists, psychotherapists, developmental pediatricians, and physical medicine and rehabilitation to the physician specialties monitoredProvided member panel experts for the Texas Brain Injuries Conference on August 3, 2018. The conference was sponsored by the Office of Acquired Brain Injury for individuals with brain injuries and their caregiversLegislative RecommendationsAccess to CareAdd Cognitive Rehabilitation Therapy to the State Medicaid Plan.Problem Legislation Addresses:Currently the Texas Medicaid state plan does not cover Cognitive Rehabilitation Therapy (CRT). It is common for individuals with brain injury to have cognitive deficits which impact their ability to make choices, understand, remember and use information. Cognition includes attention and concentration, processing and understanding information, memory, communication, planning and organizing, reasoning, problem solving, decision making, judgment, and impulse control. Cognitive rehabilitation has been proven to be an effective treatment to address cognitive deficits resulting from an acquired brain injury (ABI). The Cognitive Rehabilitation Task Force of the American Congress of Rehabilitation Medicine reviewed 370 studies and concluded there is sufficient evidence that support cognitive rehabilitation clinical protocols as effective for cognitive deficits as a result of an ABI. Early intervention yields improved vocational/productivity outcomes, social integration, and independence.Legislative HistoryTexas added CRT to the STAR+PLUS, Home and Community-based Services (HCS), and Community Living Assistance and Support Services (CLASS) Medicaid waiver programs in 2014 through Rider 66. This is an improvement for waiver participants with brain injuries; however, a significant number of individuals with acquired brain injuries do not have timely access to these waivers. Additionally, many individuals with an ABI cannot access services because they do not meet the disability-onset age requirements or medical condition requirements. Texas passed legislation requiring insurance companies to cover cognitive rehabilitation under Texas Insurance Code Chapter 1352 which was established in 2001 when the 77th Legislature passed House Bill (HB) 1676, effective September 1, 2002. Rules to implement the statute were adopted August 26, 2002 (28 Texas Administrative Code §§ 21.3101-21.3107).Require Texas Workforce Commission, in collaboration with the Office of Acquired Brain Injury and Texas Brain Injury Advisory Council, to develop a Vocational Rehabilitation plan for individuals with Acquired Brain Injury across all levels of functioning. Problem Legislation Addresses:Currently, individuals with an Acquired Brain Injury (ABI) are inadequately served through Texas Workforce Commission, Vocational Rehabilitation Program. While it is often difficult to predict Vocational outcomes for some individuals with an Acquired Brain Injury, many individuals have the capability of returning to gainful employment. In some instances, ongoing supports may be required to assure vocational success. However, there are individuals who may be able to work without supports. Other states across in the US are successful in providing Vocational Rehabilitation services to individuals with ABI. By addressing this issue, individuals with an ABI will have the opportunity to become gainfully employed and contribute to our state economy. They will also have the opportunity to become more engaged and active, increasing their opportunity to live a healthier life style and potentially reducing health care costs to the state. Support for ServicesAdequately fund the Office of Acquired Brain Injury including travel reimbursement costs for Texas Brain Injury Advisory Council survivor and caregiver members. The Office of Acquired Brain Injury provides guidance, referrals and service coordination for survivors of brain injuries and their families, including returning combat veterans, by arranging a comprehensive system of care through federal, state and local resources. Full funding will enable the OABI to carry out its mission including support of the Texas Brain Injury Advisory Council (TBIAC). Funding will support:3 full time employees (FTEs)Travel reimbursement funds for TBIAC consumer members for council meetings, outreach and education activities, and other activities to prevent brain injuries and improve lives. (HHSC Legislative Appropriations Request, Rider Revisions and Additions Request, 3C Page 15)Provide permanent and sufficient funding for the Comprehensive Rehabilitation Program.The Comprehensive Rehabilitation Services (CRS) Program provides services needed to help Texans with a traumatic brain injury and/or traumatic spinal cord injury live independently in their home and community. The program focuses on three primary areas that affect both function and quality of life: mobility, self-care, and communication skills. Services are provided in the person’s home, a hospital, a residential facility, or an outpatient clinic or in a combination of settings to encourage the maximum flexibility in service and gain toward independence. CRS services include inpatient comprehensive medical rehabilitation services, post-acute brain injury rehabilitation services, and outpatient therapies. The services are time-limited and designed to assist the consumer with daily living skills and to prevent secondary medical conditions, thereby increasing the consumer’s ability to function independently and reduce the need for ongoing state services (HHSC LAR 3.A. Page 229 of 491).The CRS program was first funded in 1991 with the establishment of dedicated funding to aid the recovery process of Texans who have experienced TBIs and/or traumatic SCIs. Part of the funding for the CRS program came from surcharges on convictions of felonies and misdemeanors. Other money has come from General Revenue Funds appropriated by the Texas Legislature.Address Unmet NeedsRequire The Texas Health and Human Services Commission, in collaboration with TBIAC and the HHSC Office of Acquired Brain Injury, to submit to the legislature by November 2020 a comprehensive plan to improve long term outcomes, reduce disability, and decrease long term healthcare costs for Texans with acquired brain injuries. People with acquired brain injury may experience a host of disabling conditions, from physical to cognitive to mental illness. Coordination of services, appropriate long term community living supports, mental health counseling, and behavioral modification services are all available to some populations with disabilities in Texas, but, for the most part, not for individuals with acquired brain injury. Recommendation: Under the leadership of the Texas Health and Human Services Commission, in collaboration with TBIAC and the HHSC Office of Acquired Brain Injury, will submit a comprehensive plan to the legislature by November 30, 2020 that will: Address long-term residential services and community services including day habilitation, supported living and supported work Assess current services with regard to what is availableIdentify gaps and barriers to access services Ensure that providers have the knowledge and skills to meet the needs of this population Develop the tools, protocols, and reporting procedures for use by hospitals, emergency systems, school districts, state agencies and others for identifying individuals with an acquired brain injury Develop a uniform screening and assessment tool to identify the services and supports needed by individuals who have an acquired brain injury In collaboration with the OABI, the TBIAC will evaluate recommendations for legislature regarding motorcycle helmet laws through analysis of current available data in Texas, as well as other states with more/less restrictive laws.Given the potential long term implications of brain injury, including, but not limited to the possibility of: loss of employment, caregiver requirements, associated health care costs, the data will better inform the state of Texas on how to offer optimal safety to motor cyclists.Data InfoAdd non-traumatic brain injuries to the Brain Injury Registry maintained by the Department of State Health Services.The Department of State Health Services has maintained a traumatic brain injury registry since 1998. Texas needs a registry of all acquired brain injuries to better inform policy making. Evaluate other states’ brain injury programs for best practices, including public education for Texans with Acquired Brain Injury. Texas must evaluate and review other state’s brain injury programs, taking into consideration the programs and best practices for Texas. Additionally, concussion treatment especially within the public education system needs to be evaluated for consistency and efficacy. Require Health and Human Services to evaluate and develop a system to ensure Acquired Brain Injury data is collected even when ABI is not listed as a primary diagnosis. Currently data is collected solely on the primary diagnosis. Brain injury survivors have many diagnoses such as heart attack, collapsed lung, seizures, cerebral palsy, and mental disorders. Therefore, the Acquired Brain Injury diagnosis may not be noted during data collection. Health and Human Services must create a system to collect all diagnoses. Non-Legislative RecommendationsThe Office of Acquired Brain Injury pursue a federal Traumatic Brain Injury Act grant to fund the Family Navigator Program. The Family Navigator Program (FNP) will connect the family of a Texan with an acquired brain injury with a trained volunteer, who is either an experienced caregiver or survivor of a brain-injury.?As much as possible, the FNP will be present to listen and help families gain access to needed services and resources, from the onset of the diagnosis throughout the recovery process and the return of functional living. Likely, a successful FNP will create a lasting dependable relationship with the survivor and family.? Fliers will be made available online and in waiting rooms and emergency departments of hospital and rehabilitation facilities throughout Texas, beginning with 3 primary areas: Dallas, Houston, and rural areas of San Angelo. Determine contacts in each area and process system of how the Family Navigator Program will be integrated and adjusted for each area in the state.Collaborate with the Office of Acquired Brain Injury on current and future projects, including fact sheets, brain injury conferences, promoting Brain Injury Awareness Month and brain injury training for first responders and law enforcement personnel. Committee members and volunteers will help plan, create, research, organize, serve, emcee, and participate in the Texas Brain Injury Awareness Month Celebration (which is in March of each year), Texas Brain Injury Conference each year (which was in August of 2018); annual update for OABI’s “Texas Brain Injury Resource Guide” to help individuals with brain injuries and families; develop brain injury fact sheets to clarify and improve brain injury awareness; and develop and promote training of first responders and law enforcement to better treat and recognize the brain injury population.Collaborate with Health and Human Services to create guidelines and best practices for the Veterans Recovery Pilot Program per H.B. 271, 85th Legislature, Regular Session, 2017, regarding Hyperbaric Oxygen Chamber Treatments.Request for proposal deadline Mar 19, selection made Nov 19, pending funding. Closed.Build a network of brain injury focused social media sites, resources, and contacts to promote education and prevention through the Office of Acquired Brain Injury website. We acknowledge that social media in today’s mobile-ready world is one of the primary means of communication between individuals and generations. Thus, we are recommending Texas brain injury services to create user-friendly, easily-accessible web-paths to find the services they need. Instead of “reinventing the wheel,” we want to choose and establish a non-expensive “center-cog” website on the internet where people can find links that can answer the 2 most prominent questions: 1) What services are available? 2) How do I get them? Include contacts and information available on a 24/7 basis.Strengthen partnerships and communication with state agencies as well as other state and national brain injury organizations. We hold to this bottom-line truth: We can help each other. Now, it is time to start building relationships with, not only, other agencies within the State of Texas, but also the hundreds of non-profit organizations whose aim is to assist the brain injury community. Strengthening our service to other Texans who experience life after brain injury is one of our fundamental goals.References1. 6A concussion injury reporting instructions – all sports. . 2013 Final submersion report. Accessed 31 Jul 20. . 2018 Texas Stroke System of Care Report, Texas HHS. Accessed 5 Sep 20. . Acute ischemic stroke infographic. Accessed 5 Sep 20. . Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association.?Circulation. 2017;135:e229-e445. Accessed 5 Sep 20. monoxide –the silent killer. Accessed 26 Aug 20. for Disease Control and Prevention. (2016) Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. 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Role of calpains in the injury-induced dysfunction and degeneration of the mammalian axon. Neurobiol Dis. 2013 December; 60:1-42. Accessed 5 Sep 20. , Brent E., De Witt, Douglas S., (2010). Traumatic Brain Injury: A Disease Process, Not an Event, Journal of Neurotrauma, 27(8): 1529-1540.Neurologic Sequelae Symptoms. Accessed 30 Sep 18. Bedriye Müge Sonmez, Murat Dogan Iscanl?, Sel?uk Parlak, et al. Delayed neurologic sequelae of carbon monoxide intoxication. Turkish Journal of Emergency Medicine April (2018) 1-3Numbers for TBI. Accessed 31 Jul 20. , Rhonda D., (2007). “Self-administering, Insuring, and Funding Benefit Plan”, Human Resources: Chapter 21. Accessed on October 28, 2016. the ones you love – child injuries are preventable. Accessed 6 Sep 20. of the state of Texas. Accessed 5 Sep 20. , Loretta J.; Malloy, Rachel. Risk factors of pediatric stroke. Journal of Neuroscience Nursing:?April 2020 - Volume 52 - Issue 2 - p 58-60)Submersion 2014 final report. Accessed 30 Aug. Department of Insurance vs American National Insurance Company.” May 18, 2012. Accessed on 7 Sep 20. Drownings. Accessed 1 Jul 20. . Accessed 30 Sep 18. Office of Acquired Brain Injury Feasibility Study for Providing Community Supports and Residential Services for Individuals with Acquired Brain Injury, 2009, Report to the 81st Legislature, Regular Session. Virani SS, Alonso A et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association.?Circulation. 2020 Mar 3;141(9): 354-359. Accessed 6 Sep 20. , KJ Valentine, et al. Carbon monoxide poisoning: risk factors for?cognitive sequelae?and the?role?of?hyperbaric oxygen. Accessed 25 Aug 20. .)AcronymsAcronymFull NameHHSCHealth and Human Services CommissionTBIACTexas Brain Injury Advisory CouncilABIAcquired Brain InjuryTBITraumatic Brain InjuryDSHSDepartment of State Health ServicesmTBIMild Traumatic Brain InjuryCRSComprehensive Rehabilitation ServicesHBOTHyperbaric Oxygen TreatmentLPALicensed Psychological AssociatesCRTCognitive Rehabilitation TherapyOABIOffice of Acquired Brain InjuryBIAABrain Injury Association of AmericaASAAmerican Stroke AssociationEMSEmergency Medical Services (Texas)COCarbon MonoxideSCISpinal Cord InjuryAPPENDICS 1: COUNTY CHILD DROWNING 2018-JUL 2020Texas children drownings2018 StatisticsCountyDrowningsAgeGenderLocationAnderson12MLakeAngelina23FPool (Hotel/Motel)1MPondBell11MPool (Backyard)Bexar53MPool (Community)3MPool (Backyard)2MPool (Backyard)4MPool (Backyard)0 (7M)MBathtubBrazos21MPond3FPool (Backyard)Burleson115FLakeCameron29FPool (Backyard)9FPool (Backyard)Chambers15MPool (Backyard)Coleman12MPool (Backyard)Dallas41FBathtub0 (10M)MBathtub4FPool (Apartment)10FPool (Apartment)Denton21FPool (Backyard)3FLakeEctor12MPool (Backyard)Fort Bend28MPool (Community)2MPondGalveston62MPond17MBathtub2MPool (Backyard)11MBeach16MBeach1MPool (Backyard)Gray11MPondGrayson116FLakeGuadalupe15MPool (Backyard)Hale111MBathtubHarris106MPool (Apartment)2MPool (Apartment)4MPool (Apartment)12FRiver15MPool (Backyard)1MJacuzzi2MPool (Backyard)0 (11M)MBathtub1MPond1MLakeHarrison10 (8M)FBathtubHays116MPondHidalgo111FStorage ContainerHood217MLake8FStock TankHunt12MPool (Backyard)Jasper11FPool (Backyard)Jefferson22MPool (Backyard)Kaufman16MPondKerr13FPondLiberty22FPond4MPondLive Oak13MLakeMcLennan31FPool (Backyard)3MPool (Backyard)3FPool (Apartment)McMullen12MPool (Backyard)Montague12MPondMontgomery22MPool (Backyard)1MPondNueces414FBeach2MPool (Backyard)0 (8M)MBathtub2MPool (Backyard)Parker14FPool (Backyard)Rockwall11MPool (Backyard)Rusk117MLakeTarrant130 (11m)FBathtub1FPool (Backyard)2MPool (Backyard)4MPool (Backyard)6MPool (Apartment)8MPool (Backyard)5MPool (Apartment)7MPool (Apartment)13MLake12FPool (Backyard)2FPool (Apartment)1FBathtub3MPool (Backyard)Taylor10 (10M)FBathtubTravis12MPool (Backyard)Waller13MPool (Backyard)Web11FPool (Backyard)Wise12MPool (Backyard)Young11MLakeTotal91?2019 StatisticsCountyDrowningsAgeGenderLocationBandera12MJacuzziBastrop12MPool (Backyard)Bell26MPool (Apartment)1FPool (Backyard)Bexar113MPool (Hotel)Brazoria217MBeach1MPondBrazos22FPool (Backyard)2FPool (Community)Cameron24MPool (Apartment)3FPool (Backyard)Collin51FPool (Backyard)7MLake16MPond3MPool (Backyard)1FPool (Backyard)Dallas33FPool (Backyard)4MPool (Community)7FPool (Apartment)Denton116MHot TubEl Paso21MBathtub3FHot tubErath116MPool (Apartment)Fort Bend43MPool (Apartment)2MPool (Backyard)2MPool (Backyard)5MPool (Community)Galveston37MPond1MPool (Backyard)5MPool (Apartment)Gregg14MBathtubHamilton110MStock TankHarris182MPool Backyard)2FBeach6MPool (Community)1FBathtub2FPool (Backyard)6MPool (Apartment)2FHot Tub16MMarina8 monthsMBathtub6MPool (Apartment)7MBeach10MBeach13FBeach9 monthsFBathtub3FBathtub4FPond5MPool (Backyard)3FPool (Apartment)Hays115MRiverHill113FLakeHidalgo38 monthsMBucket9MLake10MPool (Backyard)Hunt13MBathtubHutchinson117MLakeJasper18MPool (Backyard)Matagorda216MBeach10FRiverMontague11MPondMontgomery23MPond4MPondNueces25MPool (Apartment)3MBeachParker29 monthsFBathtub3MPool (Backyard)Smith217MLake3FPondSan Patricio17MLakeTarrant66 weeksMBathtub17MLake2MPool (Backyard)5FPool (Apartment)7FPool (Apartment)10FPool (Apartment)Travis53FPool (Backyard)4MPool (Hotel)1FBathtub5MPool (Apartment)2MPool (Community)Waller12FPool (Backyard)Williamson36FPool (Community)3MPool (Backyard)4MPool (Backyard)Wise23FBathtub13MLakeTotal87?2020 Statistics- updated 7/28/2020CountyDrowningsAgeGenderLocationAransas12FSeptic tankBell11MBathtubBrazoria13MPool (Backyard)Brazos17FBathtubBexar317MLake4FPool (Backyard)5MPool (Backyard)Chambers22MPond2MPondCooke11FPool (Backyard)Collin11MPool (Backyard)Dallas210 monthsMBathtub2MPool (Backyard)Denton216MLake13FLakeEctor12FPool (Backyard)Ellis13MPool (Backyard)Fort Bend31FPond3MPool (Backyard)5MPool (Apartment)Galveston41MPool (Backyard)2MPond10MBeach17MBeachHarris81MBathtub2MPool (Backyard)4MPool (Apartment)4MPool (Apartment)4FPool (Backyard)4MBathtub5FPool (Backyard)14MBathtubHidalgo12MPool (Backyard)Hood21MPool (Backyard)3MPool (Backyard)Jasper23MPond2MPool (Backyard)Jefferson13MPondKaufman17FPondKendall13MPool (Backyard)Kerr11FRiverLiberty111?monthsFBathtubLlano11MPool (Backyard)Nueces21FBathtub1MBathtubRockwall12MPool (Backyard)Sabine12FLakeTarrant15FPool (Backyard)Washington12FPool (Backyard)Wichita11FPool (Backyard)Webb11MBucketWilliamson13MPool (Backyard)Total52?Appendix #2Texas Summary Statistics Stroke Hospitalization, Medicare Beneficiaries, Percentage Discharged Home, All Races/Ethnicities, Both Genders, 2015-2017Race or EthnicityStroke Hospitalization, Medicare Beneficiaries, Percentage Discharged HomeStateNationalAll Races/Ethnicities47.147.5Black40.340.3White48.148.6Hispanic45.746.6Texas County StatisticsStroke Hospitalization, Medicare Beneficiaries, Percentage Discharged Home, All Races/Ethnicities, Both Genders, 2015-2017Counties with insufficient data are displayed at bottom of the report.CountyStateValueCategory RangeLa SalleTX38.0??38.0 - 44.3 (52)DimmitTX39.0??38.0 - 44.3 (52)WebbTX40.1??38.0 - 44.3 (52)ZavalaTX40.5??38.0 - 44.3 (52)VictoriaTX40.6??38.0 - 44.3 (52)KnoxTX40.6??38.0 - 44.3 (52)DuvalTX40.7??38.0 - 44.3 (52)UptonTX40.9??38.0 - 44.3 (52)BaylorTX41.0??38.0 - 44.3 (52)HansfordTX41.0??38.0 - 44.3 (52)GoliadTX41.7??38.0 - 44.3 (52)RefugioTX41.7??38.0 - 44.3 (52)WilsonTX41.9??38.0 - 44.3 (52)MedinaTX42.0??38.0 - 44.3 (52)ArcherTX42.2??38.0 - 44.3 (52)BeeTX42.5??38.0 - 44.3 (52)MaverickTX42.5??38.0 - 44.3 (52)WilbargerTX42.5??38.0 - 44.3 (52)CameronTX42.6??38.0 - 44.3 (52)McMullenTX42.7??38.0 - 44.3 (52)BrownTX42.8??38.0 - 44.3 (52)CollingsworthTX42.8??38.0 - 44.3 (52)BrewsterTX43.0??38.0 - 44.3 (52)AtascosaTX43.1??38.0 - 44.3 (52)PresidioTX43.1??38.0 - 44.3 (52)GreggTX43.2??38.0 - 44.3 (52)KlebergTX43.2??38.0 - 44.3 (52)Jim WellsTX43.3??38.0 - 44.3 (52)Val VerdeTX43.3??38.0 - 44.3 (52)StonewallTX43.4??38.0 - 44.3 (52)DallasTX43.4??38.0 - 44.3 (52)EllisTX43.4??38.0 - 44.3 (52)BexarTX43.5??38.0 - 44.3 (52)San SabaTX43.5??38.0 - 44.3 (52)PanolaTX43.6??38.0 - 44.3 (52)San PatricioTX43.7??38.0 - 44.3 (52)BanderaTX43.7??38.0 - 44.3 (52)HemphillTX43.8??38.0 - 44.3 (52)YoungTX43.8??38.0 - 44.3 (52)Live OakTX43.9??38.0 - 44.3 (52)NuecesTX43.9??38.0 - 44.3 (52)JacksonTX43.9??38.0 - 44.3 (52)KinneyTX43.9??38.0 - 44.3 (52)UpshurTX44.0??38.0 - 44.3 (52)WichitaTX44.1??38.0 - 44.3 (52)FrioTX44.1??38.0 - 44.3 (52)DickensTX44.1??38.0 - 44.3 (52)DeWittTX44.2??38.0 - 44.3 (52)CaldwellTX44.2??38.0 - 44.3 (52)Jeff DavisTX44.2??38.0 - 44.3 (52)KarnesTX44.3??38.0 - 44.3 (52)RockwallTX44.3??38.0 - 44.3 (52)MilamTX44.6??44.4 - 46.8 (50)TarrantTX44.6??44.4 - 46.8 (50)LeeTX44.6??44.4 - 46.8 (50)CollinTX44.7??44.4 - 46.8 (50)ClayTX44.8??44.4 - 46.8 (50)WillacyTX44.8??44.4 - 46.8 (50)NavarroTX44.8??44.4 - 46.8 (50)ComalTX44.9??44.4 - 46.8 (50)GuadalupeTX44.9??44.4 - 46.8 (50)HarrisonTX45.0??44.4 - 46.8 (50)CampTX45.0??44.4 - 46.8 (50)CalhounTX45.0??44.4 - 46.8 (50)MorrisTX45.0??44.4 - 46.8 (50)SomervellTX45.0??44.4 - 46.8 (50)El PasoTX45.2??44.4 - 46.8 (50)HaskellTX45.2??44.4 - 46.8 (50)KendallTX45.3??44.4 - 46.8 (50)BrooksTX45.3??44.4 - 46.8 (50)FayetteTX45.4??44.4 - 46.8 (50)HudspethTX45.4??44.4 - 46.8 (50)FallsTX45.5??44.4 - 46.8 (50)BowieTX45.5??44.4 - 46.8 (50)McLennanTX45.5??44.4 - 46.8 (50)BastropTX45.7??44.4 - 46.8 (50)EastlandTX45.7??44.4 - 46.8 (50)CassTX45.8??44.4 - 46.8 (50)KerrTX45.8??44.4 - 46.8 (50)NacogdochesTX45.8??44.4 - 46.8 (50)Palo PintoTX45.8??44.4 - 46.8 (50)ThrockmortonTX45.8??44.4 - 46.8 (50)RuskTX45.9??44.4 - 46.8 (50)FanninTX45.9??44.4 - 46.8 (50)EdwardsTX46.0??44.4 - 46.8 (50)LavacaTX46.0??44.4 - 46.8 (50)RealTX46.0??44.4 - 46.8 (50)AustinTX46.1??44.4 - 46.8 (50)BlancoTX46.2??44.4 - 46.8 (50)FoardTX46.2??44.4 - 46.8 (50)Fort BendTX46.3??44.4 - 46.8 (50)CookeTX46.4??44.4 - 46.8 (50)MidlandTX46.4??44.4 - 46.8 (50)WhartonTX46.5??44.4 - 46.8 (50)Red RiverTX46.6??44.4 - 46.8 (50)GlasscockTX46.6??44.4 - 46.8 (50)HowardTX46.6??44.4 - 46.8 (50)JohnsonTX46.7??44.4 - 46.8 (50)ZapataTX46.7??44.4 - 46.8 (50)TerrellTX46.7??44.4 - 46.8 (50)TravisTX46.8??44.4 - 46.8 (50)ColoradoTX46.8??44.4 - 46.8 (50)FreestoneTX46.9??46.9 - 49.1 (53)HopkinsTX46.9??46.9 - 49.1 (53)UvaldeTX46.9??46.9 - 49.1 (53)ShelbyTX47.0??46.9 - 49.1 (53)StarrTX47.1??46.9 - 49.1 (53)ParmerTX47.1??46.9 - 49.1 (53)HaysTX47.1??46.9 - 49.1 (53)LimestoneTX47.1??46.9 - 49.1 (53)JackTX47.2??46.9 - 49.1 (53)ChambersTX47.2??46.9 - 49.1 (53)CherokeeTX47.2??46.9 - 49.1 (53)PecosTX47.2??46.9 - 49.1 (53)RainsTX47.4??46.9 - 49.1 (53)LlanoTX47.4??46.9 - 49.1 (53)HillTX47.4??46.9 - 49.1 (53)HoodTX47.5??46.9 - 49.1 (53)AndersonTX47.5??46.9 - 49.1 (53)MontagueTX47.5??46.9 - 49.1 (53)McCullochTX47.6??46.9 - 49.1 (53)DentonTX47.7??46.9 - 49.1 (53)HoustonTX47.7??46.9 - 49.1 (53)GonzalesTX47.7??46.9 - 49.1 (53)ErathTX47.8??46.9 - 49.1 (53)BaileyTX47.8??46.9 - 49.1 (53)HardemanTX47.9??46.9 - 49.1 (53)KentTX47.9??46.9 - 49.1 (53)SuttonTX47.9??46.9 - 49.1 (53)WilliamsonTX47.9??46.9 - 49.1 (53)ParkerTX48.0??46.9 - 49.1 (53)HarrisTX48.0??46.9 - 49.1 (53)JonesTX48.1??46.9 - 49.1 (53)Van ZandtTX48.1??46.9 - 49.1 (53)WallerTX48.2??46.9 - 49.1 (53)ReaganTX48.2??46.9 - 49.1 (53)MartinTX48.2??46.9 - 49.1 (53)WiseTX48.4??46.9 - 49.1 (53)KenedyTX48.4??46.9 - 49.1 (53)KaufmanTX48.4??46.9 - 49.1 (53)HendersonTX48.6??46.9 - 49.1 (53)MatagordaTX48.6??46.9 - 49.1 (53)BellTX48.7??46.9 - 49.1 (53)GillespieTX48.8??46.9 - 49.1 (53)GrimesTX48.9??46.9 - 49.1 (53)LamarTX48.9??46.9 - 49.1 (53)WashingtonTX48.9??46.9 - 49.1 (53)BrazoriaTX49.0??46.9 - 49.1 (53)DeltaTX49.0??46.9 - 49.1 (53)DawsonTX49.0??46.9 - 49.1 (53)Deaf SmithTX49.1??46.9 - 49.1 (53)Jim HoggTX49.1??46.9 - 49.1 (53)KimbleTX49.1??46.9 - 49.1 (53)HutchinsonTX49.1??46.9 - 49.1 (53)FranklinTX49.1??46.9 - 49.1 (53)AngelinaTX49.2??49.2 - 52.2 (48)MasonTX49.2??49.2 - 52.2 (48)WalkerTX49.3??49.2 - 52.2 (48)TrinityTX49.3??49.2 - 52.2 (48)HidalgoTX49.3??49.2 - 52.2 (48)GraysonTX49.3??49.2 - 52.2 (48)CrosbyTX49.4??49.2 - 52.2 (48)AransasTX49.5??49.2 - 52.2 (48)BosqueTX49.5??49.2 - 52.2 (48)NolanTX49.5??49.2 - 52.2 (48)MooreTX49.6??49.2 - 52.2 (48)BurnetTX49.6??49.2 - 52.2 (48)GalvestonTX49.6??49.2 - 52.2 (48)CallahanTX50.0??49.2 - 52.2 (48)HuntTX50.1??49.2 - 52.2 (48)MontgomeryTX50.1??49.2 - 52.2 (48)WardTX50.2??49.2 - 52.2 (48)MillsTX50.3??49.2 - 52.2 (48)StephensTX50.3??49.2 - 52.2 (48)MenardTX50.6??49.2 - 52.2 (48)MarionTX50.9??49.2 - 52.2 (48)CulbersonTX50.9??49.2 - 52.2 (48)IrionTX51.0??49.2 - 52.2 (48)OrangeTX51.0??49.2 - 52.2 (48)LynnTX51.1??49.2 - 52.2 (48)MadisonTX51.2??49.2 - 52.2 (48)WoodTX51.2??49.2 - 52.2 (48)CokeTX51.2??49.2 - 52.2 (48)MotleyTX51.3??49.2 - 52.2 (48)SmithTX51.3??49.2 - 52.2 (48)PotterTX51.3??49.2 - 52.2 (48)JeffersonTX51.4??49.2 - 52.2 (48)GainesTX51.5??49.2 - 52.2 (48)HartleyTX51.6??49.2 - 52.2 (48)TitusTX51.6??49.2 - 52.2 (48)LampasasTX51.7??49.2 - 52.2 (48)Tom GreenTX51.8??49.2 - 52.2 (48)TaylorTX51.8??49.2 - 52.2 (48)RunnelsTX51.8??49.2 - 52.2 (48)OldhamTX51.8??49.2 - 52.2 (48)SabineTX51.9??49.2 - 52.2 (48)San JacintoTX51.9??49.2 - 52.2 (48)SterlingTX52.0??49.2 - 52.2 (48)ConchoTX52.0??49.2 - 52.2 (48)HockleyTX52.2??49.2 - 52.2 (48)HaleTX52.2??49.2 - 52.2 (48)RobertsonTX52.2??49.2 - 52.2 (48)NewtonTX52.2??49.2 - 52.2 (48)ColemanTX52.3??52.3 - 65.6 (49)BordenTX52.3??52.3 - 65.6 (49)CoryellTX52.4??52.3 - 65.6 (49)HamiltonTX52.4??52.3 - 65.6 (49)GarzaTX52.6??52.3 - 65.6 (49)San AugustineTX52.6??52.3 - 65.6 (49)SchleicherTX52.6??52.3 - 65.6 (49)CochranTX52.7??52.3 - 65.6 (49)BrazosTX52.8??52.3 - 65.6 (49)ArmstrongTX52.8??52.3 - 65.6 (49)LubbockTX52.9??52.3 - 65.6 (49)RandallTX53.0??52.3 - 65.6 (49)FloydTX53.0??52.3 - 65.6 (49)LambTX53.0??52.3 - 65.6 (49)CraneTX53.2??52.3 - 65.6 (49)ComancheTX53.2??52.3 - 65.6 (49)TerryTX53.2??52.3 - 65.6 (49)ShermanTX53.4??52.3 - 65.6 (49)ShackelfordTX53.4??52.3 - 65.6 (49)FisherTX53.4??52.3 - 65.6 (49)LeonTX53.7??52.3 - 65.6 (49)OchiltreeTX53.8??52.3 - 65.6 (49)AndrewsTX53.9??52.3 - 65.6 (49)BurlesonTX53.9??52.3 - 65.6 (49)MitchellTX54.2??52.3 - 65.6 (49)ReevesTX54.2??52.3 - 65.6 (49)PolkTX54.5??52.3 - 65.6 (49)CrockettTX54.7??52.3 - 65.6 (49)HardinTX54.8??52.3 - 65.6 (49)CottleTX54.9??52.3 - 65.6 (49)CarsonTX54.9??52.3 - 65.6 (49)WheelerTX55.0??52.3 - 65.6 (49)EctorTX55.4??52.3 - 65.6 (49)DallamTX55.6??52.3 - 65.6 (49)ScurryTX55.7??52.3 - 65.6 (49)TylerTX55.8??52.3 - 65.6 (49)DonleyTX55.9??52.3 - 65.6 (49)LibertyTX55.9??52.3 - 65.6 (49)JasperTX55.9??52.3 - 65.6 (49)LipscombTX56.8??52.3 - 65.6 (49)SwisherTX57.1??52.3 - 65.6 (49)WinklerTX58.5??52.3 - 65.6 (49)YoakumTX58.5??52.3 - 65.6 (49)BriscoeTX58.9??52.3 - 65.6 (49)HallTX59.3??52.3 - 65.6 (49)GrayTX59.3??52.3 - 65.6 (49)CastroTX60.7??52.3 - 65.6 (49)ChildressTX62.6??52.3 - 65.6 (49)RobertsTX65.6??52.3 - 65.6 (49)CountyStateValueCategory RangeKingTXInsufficient Data??Insufficient Data (2)LovingTXInsufficient Data??Insufficient Data (2) Retrieved 6 Jul 20 ................
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