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.