(a) Plan Required.—The Secretary shall, for each individual who is a veteran or member of the Armed Forces who receives inpatient or outpatient rehabilitative hospital care or medical services provided by the Department for a traumatic brain injury—

(1) develop an individualized plan for the rehabilitation and reintegration of the individual into the community with the goal of maximizing the individual’s independence; and

(2) provide such plan in writing to the individual—

(A) in the case of an individual receiving inpatient care, before the individual is discharged from inpatient care or after the individual’s transition from serving on active duty as a member of the Armed Forces to receiving outpatient care provided by the Department; or

(B) as soon as practicable following a diagnosis of traumatic brain injury by a Department health care provider.

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(b) Contents of Plan.—Each plan developed under subsection (a) shall include, for the individual covered by such plan, the following:

(1) Rehabilitation objectives for improving (and sustaining improvement in) the physical, cognitive, behavioral, and vocational functioning of the individual with the goal of maximizing the independence and reintegration of such individual into the community.

(2) Access, as warranted, to all appropriate rehabilitative services and rehabilitative components of the traumatic brain injury continuum of care, and where appropriate, to long-term care services.

(3) A description of specific rehabilitative services and other services to achieve the objectives described in paragraph (1), which shall set forth the type, frequency, duration, and location of such services.

(4) The name of the case manager designated in accordance with subsection (d) to be responsible for the implementation of such plan.

(5) Dates on which the effectiveness of such plan will be reviewed in accordance with subsection (f).

(c) Comprehensive Assessment.—(1) Each plan developed under subsection (a) shall be based on a comprehensive assessment, developed in accordance with paragraph (2), of—

(A) the physical, cognitive, vocational, and neuropsychological and social impairments of the individual; and

(B) the family education and family support needs of the individual after the individual is discharged from inpatient care or at the commencement of and during the receipt of outpatient care and services.

(2) The comprehensive assessment required under paragraph (1) with respect to an individual is a comprehensive assessment of the matters set forth in that paragraph by a team, composed by the Secretary for purposes of the assessment, of individuals with expertise in traumatic brain injury, including any of the following:

(A) A neurologist.

(B) A rehabilitation physician.

(C) A social worker.

(D) A neuropsychologist.

(E) A physical therapist.

(F) A vocational rehabilitation specialist.

(G) An occupational therapist.

(H) A speech language pathologist.

(I) A rehabilitation nurse.

(J) An educational therapist.

(K) An audiologist.

(L) A blind rehabilitation specialist.

(M) A recreational therapist.

(N) A low vision optometrist.

(O) An orthotist or prosthetist.

(P) An assistive technologist or rehabilitation engineer.

(Q) An otolaryngology physician.

(R) A dietician.

(S) An ophthalmologist.

(T) A psychiatrist.

(d) Case Manager.—(1) The Secretary shall designate a case manager for each individual described in subsection (a) to be responsible for the implementation of the plan developed for that individual under that subsection and the coordination of the individual’s medical care.

(2) The Secretary shall ensure that each case manager has specific expertise in the care required by the individual for whom the case manager is designated, regardless of whether the case manager obtains such expertise through experience, education, or training.

(e) Participation and Collaboration in Development of Plans.—(1) The Secretary shall involve each individual described in subsection (a), and the family or legal guardian of such individual, in the development of the plan for such individual under that subsection to the maximum extent practicable.

(2) The Secretary shall collaborate in the development of a plan for an individual under subsection (a) with a State protection and advocacy system if—

(A) the individual covered by the plan requests such collaboration; or

(B) in the case of such an individual who is incapacitated, the family or guardian of the individual requests such collaboration.

(3) In the case of a plan required by subsection (a) for a member of the Armed Forces who is serving on active duty, the Secretary shall collaborate with the Secretary of Defense in the development of such plan.

(4) In developing vocational rehabilitation objectives required under subsection (b)(1) and in conducting the assessment required under subsection (c), the Secretary shall act through the Under Secretary for Health in coordination with the Vocational Rehabilitation and Employment Service of the Department of Veterans Affairs.

(f) Evaluation.—

(1) Periodic review by secretary.—The Secretary shall periodically review the effectiveness of each plan developed under subsection (a). The Secretary shall refine each such plan as the Secretary considers appropriate in light of such review.

(2) Request for review by veterans.—In addition to the periodic review required by paragraph (1), the Secretary shall conduct a review of the plan for an individual under paragraph (1) at the request of the individual, or in the case of an individual who is incapacitated, at the request of the guardian or designee of the individual.

(g) State Designated Protection and Advocacy System Defined.—In this section, the term “State protection and advocacy system” means a system established in a State under subtitle C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15041 et seq.) to protect and advocate for the rights of persons with development disabilities.

(h) Rehabilitative Services Defined.—For purposes of this section, and sections 1710D and 1710E of this title, the term “rehabilitative services” includes—

(1) rehabilitative services, as defined in section 1701 of this title;

(2) treatment and services (which may be of ongoing duration) to sustain, and prevent loss of, functional gains that have been achieved; and

(3) any other rehabilitative services or supports that may contribute to maximizing an individual’s independence.