Settings and services pathways

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The brain injury specialist rehabilitation settings pathway goes from the point of injury to the client being back in the community. The pathway includes:

  • acute hospital care and rehabilitation
  • in-patient rehabilitation
  • transitioning to community living
  • living in the community.

This pathway is unique for each person and typically includes health and community services. The pathway is influenced by age at injury, age of client, life stage, e.g. younger – school return; older – work return.

The exact service pathway will vary from person to person and will vary from child to adult services.

This is a pathway through settings and services. The availability of services and settings also impacts on the particular pathway for the individual.

Figure 3: Settings and services pathway

Life before the injury

The injury

Getting immediate help


Ambulance, emergency department



Hospital intensive care unit

Re-learning skills

Hospital rehabilitation, transitional living

Brain injury or general rehabilitation unit


Discharge planning

Assessments, care planning, funding management, case management

Back into the community

Living in community

Support services, case management

Continuing to re-learn

In the community with rehabilitation

Supported accommodation, outpatient services, case management, work continuing

Discharged from the community team

Living in the community

In community for life

Community services, case management, schools, workplaces, therapy services


The person
Community services settings
Health services settings

For many people, case management is the process that weaves all the threads together through services and settings.

For children, a typical service pathway may also include transition from children’s to adult services. Children’s services also include rehabilitation for schooling and education.

In the community the person could be living independently in their own home, alternatively they could require supports to live in their home and access the community and community services.

A typical setting and services pathway for severe brain injury

  1. The injury event
  2. Emergency services, possibly including retrieval
  3. Hospital acute care, possibly including the intensive care unit and surgery
  4. Hospital rehabilitation
  5. Transitional care, possibly including the Transitional Living Programs
  6. Discharge planning and discharge to the community
  7. Living in the community, often with ongoing rehabilitation and out-patient services
  8. Vocational rehabilitation, where applicable.
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