The BIRP will do an initial assessment of needs and options once the referral is accepted. This will determine what the best service to meet the client's need is, and how best this can be delivered with available resources.
In assessing needs, and the best way to deliver what is needed, some of the considerations will include the following.
- Medical stability
- Intensity of interventions
- Geographic location of person
- Statewide service settings and locations
- Client, family and carer wishes
- What insurance resources are available?
- When is the right time to admit?
After an assessment has been made there are many typical setting and pathways available. There are also pathways for the person to re-enter brain injury specialist rehabilitation services as changes happen for the person, e.g. life and service transitions.
After an assessment has been made there are many typical settings and pathways. Some examples are described here.
- Patient is admitted to hospital. The stay may include intensive care, general ward and sometimes, general rehabilitation.
- If eligible (criteria met), the child, young person or adult may be referred for specialist brain injury rehabilitation.
- The person may be discharged home, or transferred to inpatient brain injury rehabilitation.
Inpatient brain injury rehabilitation units
- In the Sydney metropolitan area there are there are three centres where adult patients may be admitted, and two for children and young people though school age, for ongoing specialist inpatient rehabilitation.
- A feature of support provided for BIRP patients after discharge is the case management model.
Transitional living programs
- Some BIRP patients participate in a Transitional Living Program before their discharge home.
- Other BIRP patients may be admitted to a transitional living unit periodically for assessment or more intensive therapy.
BIRP Community settings
- After they are discharged home, some people may be referred to a community team which specialises in brain injury rehabilitation and community resettlement.
- There are fifteen BIRP services around NSW which provide various aspects of support once the person is living in their community.
Figure 6: Home and community settings
When the person is at home there are multiple settings where brain injury specialist rehabilitation takes place that is centred on where the person lives works and plays. Therapy interventions aim to integrate strategies learned into everyday living and assist the client to achieve their life goals.
Case management is an essential component in brain injury specialist rehabilitation across all of these settings. The client and family remains at the centre of planning and implementation of agreed goals.
Collaborative discharge planning is a key component of moving from hospital to home. Service coordination and concurrent care across different agencies assists in transition and community resettlement for people with TBI and complex needs.
At times additional support will be needed and the person can be referred back to the BIRPs. Triggers are key life transitions, key child development stages, changing schools, transition to adult services and managing a crisis.
Rehabilitation at home can include attendant carers working with the person on maintaining rehabilitation goals and developing everyday skills at home and in their local community. The definition of home is broad to encompass those who live alone, with family and/or friends, or sharing with others in open and supported accommodation (own property, rental, disability housing, aged care accommodation, etc.)
School, college, TAFE, university
Rehabilitation at school can include working with the classroom teachers to facilitate the child’s rehabilitation in the classroom, contributing to lesson plans and discussing strategies to aid learning.
This includes vocational rehabilitation for return to previous employment, upskilling and seeking new employment. BIRP clinicians may be working with vocational providers, employers and attendant care staff to achieve client goals.
Outpatient rehabilitation services such as circuit class, review clinics, day therapy.
Other community locations and services
This involves attendant carers working with the person on developing their skills in other settings, including using public transport, at the gym, shopping, facilitating social relationships and promoting participation in their community.
In the community for life
This setting highlights that circumstances and settings change. As changes occur, particularly at times of life transitions (returning to work, school to university) additional rehabilitation and support may be required.
From the NSW perspective the more common interstate referral pathways for people requiring brain injury specialist rehabilitation are:
- ACT – NSW
- Queensland – NSW
- South Australia – NSW
- Victoria – NSW.
The principles to apply to these referrals include the following.47
- Referrals are made to settings that have the level of care required by the client at the point of referral.
- The client should be admitted directly to an inpatient bed and relevant service and not via inappropriate pathways, for example the emergency department unless deterioration in the patient’s condition requires assessment in the emergency department.
- Good communication and clinical handover between referring and receiving senior clinicians that involves the patient flow units, resulting in the coordination of timely and safe patient transfer for ongoing care within medically agreed timeframes.
- Timely escalation involves immediate escalation with the appropriate service managers for decision making when an issue regarding patient transfer arises which will impact on the patient accessing safe and timely care within the medically agreed timeframe.
- Patient flow responsibility means that all facilities have personnel tasked with coordinating patient flow.
Memorandum of understanding
Ideally a memorandum of understanding and agreed policy documents on how these principles are to be implemented for each interstate referral pathway.
For paediatric rehabilitation services linked with one of the three tertiary children’s hospitals the referral process both ways is a medical referral to the respective paediatric rehabilitation service in the relevant state (Victoria = VPRS; Queensland = QPRS).