Core activities wrapping around the person

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To work with individuals on their personal outcomes pathway the brain injury specialist rehabilitation services wrap core activities around the person through the whole process to enable outcomes to be achieved.

For example, core activities include the person being part of a person-centred team with family and carers and clinicians; therapeutic interventions promoting recovery, adaption, compensation and prevention; and managing challenging behaviours caused by cognitive impairments.

These core activities take place in a variety of settings including hospitals, home and other accommodation places, community locations, schools and workplaces.

Individually and collectively these core activities are key enablers of optimal brain injury specialist rehabilitation.

Figure 3: Core activities wrapping around the person

Core activities wrapping around the person, their family and their carers. Described in detail in the following sections.

  • Person-centred care, engagement with family and enabling self-management
  • Goal directed synergistic teamwork where the team includes the person, family and carers, rehabilitation specialists, clinicians and other services.

While person-centred care is a principle in all good practice healthcare and community services, it is especially important in brain injury specialist rehabilitation as it is carries the added significance that the injury, impairments and impacts are unique to the person and their rehabilitation pathway will also be unique.

Assessment incorporates the discovery of what is important to the person (their values – valued activities, people, places and beliefs) along with the biological, psychological and social aspects of the person. Brain injury specialist rehabilitation must be informed by the person’s values when addressing the biopsychosocial aspects of care. Brain injury specialist rehabilitation is optimised when all of these aspects are addressed within a teaching and learning framework. Services and information provided must be culturally appropriate (including for Aboriginal clients and their extended families).

Families and carers are recognised as important members of the rehabilitation team and can influence rehabilitation and community outcomes when providing emotional, practical and social support.

The rehabilitation team’s teamwork draws on the strengths, skills and expertise of all members of the rehabilitation team by engaging in respectful relationships to maximise the outcomes valued by the person. By working synergistically in this way the team produces something greater than the sum of its parts. The rehabilitation team includes but is not limited to the client, their family and carers and clinicians.

Self-management is enabled through a range of mechanisms which may include the provision of education and information, peer support, the development of problem-solving skills, cognitive approaches and coaching.

Intervention is not dependent on initial injury severity, but rather on the nature and degree of disablement and impact on the person.

Person-centred care requires staff to be able to bring their own person into person-centred work with the client.

Families are provided with education and support to maximise client outcomes and sustain positive family relationships.

The environment can facilitate the process and outcomes of brain injury specialist rehabilitation. The physical, social, and attitudinal aspects of the environment must be considered for this to occur.

The environment must be appropriate to meet the cognitive, behavioural and physical needs of people and their learning and rehabilitation needs. This will require adapted hospital wards, transitional environments and real life environments and situations.

Therapeutic interventions occur as early as possible in the recovery continuum. Rehabilitation provides a multidisciplinary team approach that is driven by the needs of the individual across different health and non-health disciplines.

  • Recovery refers to the process of returning towards a pre-morbid state or better.
  • Adaptation includes changing what or how we do things to complete a task or process successfully, as well as psychosocial adjustment.
  • Compensation refers to using an alternate strategy to achieve the same outcome.
  • Prevention has a key role in minimising the risk of adverse events or poor outcomes.

Specialised rehabilitation programs for people with severe and very severe TBI are provided in different health and non-health environments across the recovery pathway.

  • Managing disorders of consciousness, post coma minimally conscious person
  • Managing challenging behaviours caused by cognitive impairments
  • Managing cognitive impairments impacts in rehabilitation
  • Managing disturbances in mood and emotions
  • Managing PTA
  • Managing suicide risk, sexuality
  • Managing low levels of awareness and responsiveness.

Managing life and service transitions well often includes a period of time where services are provided concurrently to the client. This collaboration enhances handover for continuity of care and support for transition sustainability.

Managing service transitions

  • Acute to in-patient rehabilitation
  • Hospital to transitional living
  • Hospital to home
  • Child to adult services

Managing life transitions well

  • Specialised services tapering to generic services, for example health to disability, specialist medical to general practitioner.
  • Pre-school to school
  • Primary school to secondary school
  • Young person to adult
  • Single to married
  • New parenting roles
  • Education to employment.

Case management is an essential core activity because of the individual nature of each person’s rehabilitation process and the complexity of combining this with services and funding while engaging with family and carers and dealing with all the unique individual, family and social impacts. The timing, intensity and duration is flexible and responsive to individual circumstances.

When working with children services use family-centred care. Every family and child is unique and families know their child better than anyone else, therefore families must be part of the care.

Working with children also involves working with other services and in different settings, e.g. child health networks, schools, the justice system, foster care and guardianship, sibling counselling services and young adult transition services, relevant to the child.

Child protection issues are also considered and addressed as part of family-centred care.

  • Managing icare and other insurance funding
  • Collaboration with private clinicians
  • Collaboration with other health services, e.g. mental health, drug and alcohol.

Systems and processes are in place to ensure all relevant collaborations, partnerships and coordination of services are in place.

Systems and processes are in place to ensure all relevant stakeholders have up-to-date information about brain injury specialist rehabilitation services.

This requires a seamless service network with shared expertise across the network.

This involves staff:

  • participating in statewide brain injury specialist rehabilitation network activities
  • building effective ways of sharing expertise across the network
  • building agreed policies and processes to ensure client access and equity of services across NSW
  • working in collaboration across different networks and service delivery systems.
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