Understanding brain injury specialist rehabilitation in NSW

This information was written for health service planners, other professional bodies and clinicians.

Brain injury specialist rehabilitation

Brain injury specialist rehabilitation is a specialty discipline within rehabilitation that is most relevant to a subset of people who have experienced a brain injury. It is particularly relevant when the impacts of the brain injury produce acute, complex and functionally significant abnormality across multiple domains of cerebral function.

Most commonly brain injury specialist rehabilitation is for people with severe traumatic brain injury (TBI). Some non-traumatic brain injuries, often referred to as acquired brain injury (ABI), for example some hypoxic brain injuries and some strokes, have similar characteristics, effects and impacts to severe TBI. The nature of these brain injuries and subsequent impairments and impacts are described in Part A: Brain injury and specialist rehabilitation.

From injury to living in the community

The brain injury specialist rehabilitation pathway goes from the point of injury to the client being back in the community. Recovery and rehabilitation from severe brain injury is typically most rapid in the first three to six months but may continue for several years. The pathway includes acute hospital care and rehabilitation, in-patient rehabilitation, transitioning to community living and living in the community.

This pathway is unique for each person, it includes health and community services and has multiple sources of funding including health, community services, disability, motor vehicle and other insurance.

Brain injury specialist rehabilitation includes values, principles, pathways, wrap around services and special environments. Brain Injury Rehabilitation Programs (BIRPs) are located within NSW local health districts (LHDs) and the BIRPs are networked through the Agency for Clinical Innovation (ACI). The network is called the Brain Injury Rehabilitation Directorate (BIRD). The essence of brain injury specialist rehabilitation is described in Part B: Values, principles, pathways and core activities.

Integrated rehabilitation, care and support

The pathway of recovery following severe brain injury is often complex. A range of different health and non-health services are needed across the continuum of recovery, rehabilitation and community resettlement. A whole-of-person approach provides the framework for integrating person-centred health and non-health goals to achieve maximum recovery, adjustment to the impact on the hopes, dreams and aspirations of the individual.

There are a variety of health service settings and pathways that may be needed by the person before beginning the acute hospital setting phase, or being back in the community. Health services and pathways become integrated with other government and non-government services and pathways to meet the complex needs of people with a new brain injury causing disability. Services needed can include housing, income and decision-making supports and services that could be provided by the National Disability Insurance Scheme (NDIS), national government funded aged care services, NSW icare and Lifetime care, and private insurance.

Parts C, D, E and F describe the NSW services, settings, pathways and funding.

What is rehabilitation?

Rehabilitation is an important part of the recovery process after surgery or significant injury. Rehabilitation has a whole-of-person approach that aims to achieve the highest possible level of function, maximise quality of life and minimise the need for ongoing health and community support. Rehabilitation aims to restore function across physical, psychological, social and vocational domains.

Rehabilitation involves identification of a person’s problems and needs, relating the problems to relevant factors of the person and the environment, defining rehabilitation goals, planning and implementing the measures, and assessing the effects. The World Health Organization defines rehabilitation as ‘a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments’.⁶⁰ The concept of rehabilitation is broad, and rehabilitation:

• targets improvements in individual functioning
• includes making changes to an individual’s environment
• reduces the impact of a broad range of health conditions
• can occur for a specific period of time, involve single or multiple interventions delivered by an individual or team and typically addresses goals that are meaningful to the person
• can be needed from the acute or initial phase immediately following recognition of a health condition through to post-acute and maintenance phases.

Rehabilitation outcomes

Rehabilitation care contributes to the health and wellbeing of the community by improving health outcomes and reducing disease burden, reducing healthcare costs and costs of social services, reducing disability and improving community participation of people with a disability, and improving quality of life. Rehabilitation care aims to minimise or prevent disability, support people to improve their participation in life, and reduce the impact on families and the community.

Rehabilitation care helps people achieve and maintain optimal function in interaction with their environment through five outcomes.

• Prevention of the loss of function
• Slowing the rate of loss of function
• Improvement or restoration of function
• Compensation for lost function
• Maintenance of current function.

Rehabilitation principles

The Principles to Support Rehabilitation Care provide more details on these principles.⁴⁰

These principles are fundamental to all levels and types of rehabilitation care. Collectively, these principles inform the planning of rehabilitation services and how those services operate. Enacting these principles creates an environment and culture where person-centred rehabilitation flourishes.

Brain injury specialist rehabilitation is a specialty discipline most relevant to a subset of people who have experienced a significant brain injury. It is particularly relevant when the impacts of the brain injury produce acute, complex and functionally significant abnormality across multiple domains of cerebral function, including:

• cognitive impairment
• behavioural and personality change
• neurological impairment
• neurologically mediated medical issues
• multi-trauma
• lifestyle and participation restriction.

The majority of people entering brain injury specialist rehabilitation are likely to have experienced traumatic brain injury.

However, it is recognised that other causes of acquired brain injury can produce an equivalent symptom cluster, e.g. hypoxia, encephalitis or spontaneous intracerebral haemorrhage, and that such affected individuals may also be eligible for brain injury specialist rehabilitation.

Unique elements in brain injury specialist rehabilitation

Severe traumatic brain injury has unique characteristics, effects and impacts, which in turn require unique elements in brain injury specialist rehabilitation. Some of these elements include changes to the environment in which the rehabilitation is provided, how the rehabilitation is provided and what rehabilitation is made available to meet the unique demands of each individual.

For example, the physical mechanisms of a typical severe traumatic brain injury causes damage in multiple areas of the brain. This damage causes various affects, often including multiple cognitive impairments, which impact on the person’s life and their family and carers. This requires the rehabilitation process to be able to manage and work with multiple cognitive impairments and their subsequent impacts.

See Inclusion, exclusion and prioritisation criteria for details on criteria for brain injury specialist rehabilitation.

A brain injury can occur as a result of external trauma to the head of sufficient force to impact the brain, identified as traumatic brain injury. Other damage to the brain from stroke, tumour, hypoxia, infection, substance abuse or degenerative neurological diseases, e.g. multiple sclerosis, Huntington's disease, Parkinson's disease, motor neurone disease and Alzheimer's disease is identified as ABI.

Brain injury is often referred to as a ‘hidden disability’ because it is not always obvious, especially among people who have mild or moderate physical disability. It can, however, result in significant restrictions on an individual’s ability to participate fully in education, employment and other aspects of life. Relationships with families, friends and carers can also be affected by personality and behavioural changes.

Not all ABIs are appropriate for brain injury specialist rehabilitation.

Traumatic brain injury (TBI) is the most common type of brain injury appropriate for brain injury specialist rehabilitation and it has a set of unique characteristics, effects and impacts, which require the unique elements in brain injury specialist rehabilitation.

To understand the essentials of brain injury specialist rehabilitation, it is helpful to understand TBI and severe TBI in particular.

The key takeaway messages from understanding severe TBI are useful for understanding the requirements of brain injury specialist rehabilitation.

In addition to understanding the injury, impairments and impacts described above, brain injury specialist rehabilitation with children and young people also needs to consider:

• a child or young person’s developmental stages and challenges
• family-centred care
• life transitions for children and young people
• transition to decision-making for adolescents and young people and the practice implications of these perspectives.

Some key messages about specialist brain injury rehabilitation emerge from understanding the brain injury, impairments and impacts for each person.

These key messages have implications for brain injury specialist rehabilitation, in particular the principles on which it is based, the core activities that are undertaken and the pathways and settings that are relevant.

To achieve rehabilitation outcomes brain injury specialist rehabilitation:

• is underpinned by values and principles
• weaves together into a unified whole:
  • the person's injury and their personal journey of recovery and rehabilitation
  • the core activities and interventions that wrap around the person on their journey
  • service settings and pathways
  • funding pathways for rehabilitation and support services.⁴⁰

See Part F: Paying for and providing services for details of funding for services pathways.

Values are the beliefs that determine the attitudes and behaviours of the people who deliver rehabilitation services. Collectively these values inform the planning of rehabilitation services and how those services operate. Enacting these values creates an environment and culture where person-centred rehabilitation flourishes. These values are for everyone working in rehabilitation services.

• Respecting the individual and their context
• Working within respectful relationships
• Promoting hopefulness and resilience
• Fostering self-determination
• Partnering with families
• Openness
• Harnessing the lived experience of disability as a valuable resource
• Appreciating community needs and priorities for health and rehabilitation
• Recognising that biopsychosocial factors influence health and functioning.⁴⁰

Principles are fundamental truths or propositions that serve as the foundation for a system of belief or behaviour, or for a chain of reasoning.

Principles outlined here are the foundational propositions for effective brain injury specialist rehabilitation.

There are other principles that also create the necessary foundations on which brain injury specialist rehabilitation can sit, for example evidence-based practice and quality improvement. These are embedded in the organisational and state network foundations.

Some of the principles apply to other services as well, e.g. person-centred care, engaging with families and carers, goal directed, however they are listed here because they are particularly relevant to brain injury specialist rehabilitation and have a direct connection to the nature of brain injury and brain injury specialist rehabilitation.

The 17 principles listed below are the propositions that combine to build effective brain injury specialist rehabilitation.

1. Equitable, timely and culturally appropriate access

Equitable, timely and culturally appropriate access to care, services and equipment that people require, as close to where they live as possible.

This principle is important because in NSW, brain injury specialist rehabilitation is a statewide program and not every part of what is required for rehabilitation is in each location. There is therefore a need to balance local decision-making with statewide network needs to achieve this principle. It is also important that local services have relevant collaborative relationships with other parts of the network to ensure the quality of the local services.

2. Person-centred

The person is at the centre of planning and delivery of services.

The outcomes, service delivery and funding pathways are matched with this unique person and their needs.

Services are flexible and respond to changing rehabilitation needs.

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

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

3. Facilitative and supportive environments

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.

4. Enabling life in and with community

The person is seen as part of a social network which may include family, friends, the neighbourhood and community.

5. Enabling self-management

Enabling self-management maximises the health and wellbeing of the person. 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.

6. Engaging with and supporting families and carers

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

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

7. Family-centred care when working with children with a brain injury ¹⁵

Family-centred care is critically important in providing healthcare to children with serious medical conditions.

In the family-centred care of children, the client and their family members are fully involved with healthcare providers to make informed decisions about the healthcare and support services the child and family receive.

8. Engaging and coordinating with the community

The rehabilitation process engages and coordinates across health, disability, education, community and other services.

9. Collaboratively goal directed (to maximise independence)

The rehabilitation process is goal directed. The goals are identified collaboratively with the person at the centre. During rehabilitation improvement is focussed to achieve new goals.

The focus while living in the community is to maintain goals (and prevent deterioration) while achieving new goals as life changes and transitions happen and new needs and goals emerge.

10. Working constructively with challenging behaviours ^30,31

Many people with brain injury have challenging behaviours at some time during rehabilitation. The most common challenging behaviours are inappropriate social behaviour, verbal aggression and adynamia (lack of get up and go). Many people with severe brain injury display more than one type of challenging behaviour.

The team require positive behaviour support skills to work constructively with clients with behaviour changes following trauma.

There is access to specialised team members who manage challenging behaviours through social participation.

11. Manage life and service transitions well

It is important that hospital to community, hospital to school, inpatient to ambulatory and child to adult service transitions are well-planned and coordinated.

Life transitions including primary school to secondary school, not working to working, working to studying, single to married, parenting roles, etc. are managed well and allow the person to reconnect with rehabilitation services when necessary.

It is imperative that transitions from children's services to adult services are based on transition principles.

12. Case management ³⁴

Case management is a principle because of the individual nature of each person’s rehabilitation process and the complexity of combining this with services and funding while engaging with the family and carers and dealing with all of the unique individual, family and social impacts.

The intensity of case management changes in response to what is happening in rehabilitation and within the context of the life of the person and their significant others.

Case management is provided in a flexible manner and the duration of intervention is based on continuing need rather than having a pre-determined time-limited program.

13. Individualised multidisciplinary rehabilitation

People and their families and carers receive individualised multidisciplinary rehabilitation that develops their skills and participation.

14. Therapeutic interventions promoting recovery, adaptation, compensation and prevention

Rehabilitation care is optimised when the full range of treatment approaches are considered for every client. This includes therapeutic interventions promoting recovery, adaptation, compensation and prevention.

15. People with brain injury, families and carers are engaged in the improvement of brain injury specialist rehabilitation services

It is particularly important to note the additional effort and skill that is required to ensure that this happens in a brain injury specialist rehabilitation setting.

16. Leadership in brain injury specialist rehabilitation

Leadership is displayed at all levels providing a strategic and operational direction, a sense of team and a commitment to the principles of brain injury specialist rehabilitation.

17. Advocacy for improvement and reform

Brain injury specialist rehabilitation services work with people in health and community settings. The rehabilitation process often involves other services and settings. Services also work within wider policy contexts.

Getting the best outcomes in brain injury specialist rehabilitation involves advocating both in relation to particular services and settings and also within a wider policy and services context.

The personal experience of brain injury specialist rehabilitation is unique for each person. Brain injury specialist rehabilitation enables the person to work on achieving goals that are meaningful to them. The person works on the specific areas that are relevant and may include physical difficulty, thinking or cognitive processing, perception, social skills and relationships and goals meaningful to them that enable returning to work, getting about in the community, and adjusting to changes the person may experience following a brain injury.

This pathway is unique for every person with a brain injury.

The goal is for the person to be independent as they possibly can.

To understand the person's recovery and rehabilitation outcomes pathway, it is important to understand:

• their life before the injury
• the injury and the impairments it causes
• the wide impacts caused by the impairments
• the recovery and rehabilitation pathway for achieving outcomes to address the impairments and impacts, including surviving, relearning skills, returning to school and work and reconnecting with community.

Figure 1: Personal outcomes pathway

Legend

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.

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

Legend

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.

NSW Health

Parts C, D, E and F describe what is required in NSW health services to implement brain injury specialist rehabilitation as described in Part B.

NSW Health is responsible for managing and funding health services, including rehabilitation care at public hospitals. Funding should support timely access to quality health services, improve the value of the public investment in hospital care and ensure a sustainable and efficient network of public hospital services.

Brain injury specialist rehabilitation services are provided by LHDs and the Sydney Children’s Hospital Specialty Network.

Rehabilitation services across NSW are supported and enhanced by 13 specialised Brain Injury Rehabilitation Programs (BIRPs) located in 11 different LHDs. An additional two paediatric BIRPs are located in the Sydney Children’s Hospital Specialty Network. A number of other specialised rehabilitation programs also support rehabilitation services for a defined patient population, e.g. cerebral palsy, burn injury, spinal cord injury and stroke.

NSW Health has 15 LHDs and three specialty networks. Each has a governing board with overall responsibility for the strategic direction and operational efficiency of their LHD or specialty network. LHDs and specialty networks are established to operate public hospitals and institutions and provide health services to communities within geographical areas or a defined patient population for specialty networks. BIRPs existed before the current LHD boundaries were devised. The BIRP may provide services that overlap multiple LHDs.

The responsibilities of the LHDs and specialty networks are to:

• promote, protect and maintain the health of residents in the area
• conduct and manage public hospitals, health institutions, health services and health support services under its control
• achieve and maintain adequate standards of patient care and services and ensure the efficient and economic operation of its health services and health support services and use of its resources
• cooperate with other LHDs and the NSW Ministry of Health in relation to the provision of services
• make public information and advice concerning public health and health services available to the public within its area.

In NSW Health the LHDs and speciality networks strive to reflect the core values of collaboration, openness, respect and empowerment in our workplace.

Key questions for LHDs and the Sydney Children’s Hospital Specialty Network

• Are the foundational inputs in place?
• Are the foundational activities in place?
• How can local decision-making at the LHD (and speciality network) level and a statewide brain injury specialist rehabilitation network be best achieved?
• How can an equitable and transparent access to brain injury specialist rehabilitation services be achieved across the whole of NSW?
• What is in the best interests of the clients across the whole of NSW?

LHDs and the Sydney Children’s Hospital Specialty Network provide foundational inputs and activities essential for the operation of brain injury specialist rehabilitation programs.

Brain injury rehabilitation programs (BIRPs) are an essential ingredient in the provision of brain injury specialist rehabilitation. The BIRP is a population-based model with intensive intervention in metropolitan locations and affiliated with trauma hospitals for referrals. Metropolitan teams will refer to the specialised rural BIRP teams closer to where the person lives when ready for transition.

NSW has seven BIRPs located in Sydney and Newcastle metropolitan areas with eight BIRPs in key regional centres. See BIRPs in NSW for details.

Services provided by BIRPs

• Adult inpatient
• Adult transitional living program (TLP)
• Adult community team (and including outpatient services)
• Adult case management
• Paediatric sub-acute inpatient
• Paediatric in-reach to acute
• Paediatric community team including day hospital
• Paediatric case management

These services form the NSW Brain Injury Rehabilitation Program. ACI manages the clinical network and engages clinicians and consumers for better health outcomes.

Adult BIRPs provide services for clients fulfilling the following primary criteria.

• The client has suffered a brain injury appropriate for brain injury specialist rehabilitation.
• The client is aged 16-65 years.
• The client, or significant others, lives in the area covered by the BIRP or, particularly for adult inpatient services, the area of the state covered by each metropolitan BIRP.

Adult inpatient BIRPs provide consultation and support services when clients are in the acute care setting waiting for transfer, not yet ready for rehabilitation and not in need of specialist inpatient rehabilitation.

The core components in the continuum of services for the adult BIRP network of services are:

• acute admission
• inpatient rehabilitation
• transitional rehabilitation
• community-based rehabilitation including outpatient rehabilitation
• discharge.

There are many pathways through these core components. See Part E: Settings and pathways: the continuum of care.

Inpatient rehabilitation

Inpatient rehabilitation in a specialised brain injury rehabilitation unit involves dedicated inpatient wards for specialist rehabilitation for adults who are medically stable and require a high level of care, have had a severe or very severe brain injury and may still be in a state of confusion (post-traumatic amnesia). The units operate 24/7 with doctors, nurses, allied health and support staff in the team. The majority of admissions are received from trauma hospitals, however some trauma hospitals may refer to a non-BIRP rehabilitation service or to the local BIRP service. Each metropolitan BIRP unit may accept people living in other LHDs in need of this level of inpatient hospital-based specialist rehabilitation.

Transitional living programs

Transitional living programs (TLPs) provide contextually based rehabilitation with a community reintegration and social participation focus. TLPs emphasise a client-centred goal planning approach to rehabilitation within a supported therapeutic environment. Intervention is provided in individual and group sessions that incorporates functional skills, as well as more complex training in understanding the impact of brain injury, social communication, memory and even managing behaviour changes that affect performance in different situations. Involved staff provide formal and informal support and feedback about performance. The person is able to learn useful strategies to manage impairments arising from brain injury and apply these skills in home, education, employment and community settings. Family members and carers are engaged in the rehabilitation process to maximise opportunities to support clients to translate skills into daily living.

Most clients are admitted as a continuum of care (in the same BIRP or as a transfer of care from metropolitan to rural BIRP services) in response to changing needs for assessment and rehabilitation to support community participation goals. There are dedicated staff and most TLPs operate on a Monday to Friday basis thereby enabling the person to reconnect with their social network, practice and improve skills in everyday situations, identify barriers to participation and develop new and personally relevant goals.

Community-based rehabilitation

Community-based rehabilitation provides contextually based therapy and case management services. Outpatient medical and multi-disciplinary clinics are provided in metropolitan and some rural areas.

Case management

Case management is integral to the specialist rehabilitation team.

Where a rural BIRP has case management services only. They rely on consultation services to access medical and therapy services for outpatient clinics and the ability to refer clients to a range of other public and private medical and allied health staff, health and community services.

The core components of the BIRP paediatric network of services are:

• inpatient rehabilitation (dedicated bed)
• in-reach to acute and sub-acute services
• community-based rehabilitation
• transition to adult services
• discharge.

There are many pathways through these core components. See Part E: Settings and pathways: the continuum of care.

Inpatient rehabilitation (dedicated bed)

In major children's hospitals there are inpatient wards for specialist rehabilitation for children who are medically stable and require a high level of care, or who have had a severe or very severe brain injury.

The units operate 24/7 with doctors, nurses, allied health and support staff.

In-reach for sub-acute rehabilitation

The core components of the network of BIRP paediatric services consist of In-reach specialised brain injury rehabilitation services. Early notification facilitates the provision of specialised rehabilitation to children with an acquired brain injury (traumatic and non-traumatic) admitted to acute care beds in the three metropolitan paediatric trauma hospitals in NSW. The majority of children are discharged from acute care and receive subacute rehabilitation as an outpatient.

Community-based rehabilitation

Community-based rehabilitation is where therapy is delivered and practiced in everyday environments within the child’s home, school and community. Only one rural LHD has a multidisciplinary paediatric team to provide community-based rehabilitation. Community rehabilitation includes outpatient therapy services.

Outpatient medical and multidisciplinary clinics are provided in metropolitan and some rural areas.

Case management

Case management is integral to the specialist paediatric brain injury rehabilitation team. Rural paediatric BIRP case managers are co-located with adult, rural BIRPs for specialist rehabilitation case management services.

BIRP services essential functions

The essential functions for comprehensive brain injury specialist rehabilitation services include:

• case management
• brain injury rehabilitation specialist clinics (rehabilitation medicine)
• neuropsychology
• occupational therapy
• physiotherapy or exercise physiology
• psychology or clinical psychology (with expertise in behaviour therapy)
• social work
• speech-language pathology.

Each brain injury rehabilitation service or team must be able to provide or support others to carry out these three essential functions. For example, the adult inpatient rehabilitation service will offer all core activities, whereas a case management only service will work with clients to coordinate providers of the other functions.

These essential functions can be made accessible through a variety of mechanisms including:

• employment of staff
• access to staff in other parts of the local health district
• access to staff in the statewide BIRP network
• partnerships with private providers
• purchasing services.

Other staff roles

In addition to staff that provide the essential functions mentioned above, other staff roles may include:

• brain injury rehabilitation specialist physician or neuropsychiatrist
• dietitian
• diversional or play therapist
• recreational therapist
• rehabilitation support personnel, including educators, life coaches
• drug and alcohol clinicians
• vocational providers
• mental health clinicians.

The roles actually required in each situation are dependent on the needs of the clients in the brain injury rehabilitation program. Between all the members of the team there must be sufficient skills to carry out all of the core activities. See the full list in Rehabilitation core activities wrapping around the person.

The section Scope and staffing of brain injury specialist rehabilitation services describes the staffing required, but does not define full-time equivalents for each staff role. This is because of both the diversity of roles and the essential functions being accessible through a variety of mechanisms.

Establishing fixed staff client ratios is not the most appropriate guide to staffing levels. Rather it is more useful to consider:

• if there is a sufficient skillset to carry out the core activities between all members of the team
• and the relevant guides to rehabilitation staff client ratios.

The following are two examples of guides that may be useful when considering co-location, work flows, and staffing requirements.

• The Australasian Faculty of Rehabilitation Medicine Standards:
  • Standards for the Provision of Inpatient Adult Rehabilitation Medicine Services in Public and Private Hospitals 2011⁵
  • Standards for the Provision of Paediatric Rehabilitation Medicine Inpatient Services in Public and Private Hospitals 2015⁷
  • Standards for the Provision of Rehabilitation Medicine Services in the Ambulatory Setting 2014⁶
• The NSW Health Guide to the Role Delineation of Clinical Services provides a framework that describes the minimum support services, workforce and other requirements for clinical services to be delivered safely.⁴⁶ Rehabilitation services are described in section B18: Rehabilitation Medicine of that guide.

BIRPs provide a NSW population based decentralised service model that operates within and across LHDs.

Each BIRP, as well as being a local service is also a part of the Brain Injury rehabilitation Directorate (BIRD).

The BIRD is primarily focused on improving the health and social participation outcomes for children, young people and adults of working age (and their families and carers) with severe brain injury. This is done by working collaboratively with clinicians and others engaged in providing specialist rehabilitation services; encouraging consumers and the broader community to use evidence-based research to reduce unwarranted clinical variation and developing and supporting the implementation of system-wide opportunities.

The BIRD is led by an executive committee which includes consumers and representatives from metropolitan and rural adult and paediatric brain injury services of the NSW BIRP.

The network members include representatives from NSW and national consumer organisations, doctors, nurses, allied health clinicians, managers, researchers and other staff working in the NSW BIRP, clinicians in non-BIRP services and private practice and consumers and family members.

The network includes the paediatric reference group.

A key ingredient to the success of all of the brain injury rehabilitation services in the network is the sharing of expertise across the network. There are hub and spoke connections between the settings across NSW including clinical management support, professional development and telehealth.

The Brain Injury Rehabilitation Network provides foundational inputs and activities essential for the operation of brain injury rehabilitation programs.

People with a brain injury move through a series of settings as part of their recovery and rehabilitation pathways. The following diagrams provide a summary of the typical settings and pathways in the continuum from injury to living in the community.

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Note: Pathways are included for mild, moderate and severe brain injury; brain injury specialist rehabilitation is for those with severe brain injury; some people with mild and moderate injuries will be referred for specialist assessment clinics.

Pathways

Mild and moderate brain injury

• Mild and moderate brain injuries are most likely to be referred to a general practitioner (GP) or the emergency department.
• People may recover from mild and moderate brain injuries over time.
• Some people with mild-complicated and moderate brain injuries will have ongoing impairments and impacts significantly affecting their life where consultations, assessments, clinics and rehabilitation are likely to be of benefit. These people are referred for consultation, assessments and advice.
• Some people with a similar profile of impairments may be referred to the BIRP when the diagnosis of traumatic brain injury is unclear. They may then access services for a limited time to assist with care planning.

Severe brain injury

The typical initial settings and pathways for severe brain injury is:

• emergency department or retrieval and trauma services
• acute hospital care, including possibly intensive care unit
• hospital ward.

Typically the person is considered for rehabilitation either during acute care or when on a ward. For those who meets BIRP admission criteria a referral is initiated.

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.

Stages of care

After an assessment has been made there are many typical settings and pathways. Some examples are described here.

Acute care

• 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.

Settings: home and in the 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.

Home

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.

Workplace

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 services

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.

Pathways: interstate

Introduction

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.

Principles

The principles to apply to these referrals include the following.⁴⁷

1. Referrals are made to settings that have the level of care required by the client at the point of referral.
2. 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.
3. 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.
4. 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.
5. 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.

Paediatric ⁴⁴

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).

People with an acquired brain injury have the right to access rehabilitation services to promote recovery and minimise the impact of disability on their everyday lives. There are challenges, however, that health services are typically faced with in making decisions that balance client need, service capacity, access and geographic location.

These guidelines provide a clinical consensus structure for considering referrals and admissions to the NSW BIRP. They additionally provide a rationale for the allocation of scarce clinical and support resources for the specific target group for the NSW BIRP. Clear communication to referrers, engaging with other health services, government and non-government organisations and sharing care at key points in the continuum of recovery, rehabilitation and community care enhances individual outcomes.

Multiple sources of funds

The settings pathways range from acute hospital care to living in the community.

Brain injury specialist rehabilitation may also be episodic, as new situations and opportunities arise.

In addition to the funds provided for health services there are multiple sources of funds that the person may potentially be able to access to pay for the services and supports they require for rehabilitation and living independently in the community including disability, motor vehicle and other insurance funds.

One person can have multiple funding pathways, a person can be eligible for the National Disability Insurance Scheme, be receiving a workers compensation payment and have private disability insurance. Table 5 provides some of the more common funding pathways in NSW.

Key question

For each person with a serious brain injury the key question is

What is the insurance status of the injury event and the person's age at the time of the injury and the implications of this?

Funding sources

If the injury event is covered by insurance the person may be entitled to insurance payouts from the relevant insurance.

Irrespective of these insurance payouts people may be eligible to apply to the NDIS and commonwealth governments aged care programs including the Commonwealth Home Support Program.

If the age at injury is less than 65 the NDIS applies. If the age at injury is 65 or more the aged care programs apply.

The payments and services provided through the NDIS and aged care programs may be adjusted where the injury event is specifically insured and there are insurance payouts to the person with the ABI.

^* Serious brain injury is brain injury that may be appropriate for brain injury specialist rehabilitation

People under the age of 65, or over the age of 50 for Aboriginal and Torres Strait Islander people, at the time of a serious TBI are likely to be eligible to apply to the National Disability Insurance Scheme (NDIS).

The NDIS provides support for Australians with disability, their families and carers.

As an insurance scheme, the NDIS takes a lifetime approach, investing in people with disability early to improve their outcomes later in life.

The NDIS ensures that if someone is born with or acquires a permanent and significant disability they will get the support they need.

The NDIS supports people with disability to build skills and capability so they can participate in the community and employment.

To be eligible to access the NDIS one must:

• live in Australia and be an Australian citizen or a permanent resident or hold a Protected Special Category Visa
• be aged under 65 years, or under 50 for Aboriginal and Torres Strait Islander people, at the time of acquiring the disability
• usually need support from a person or equipment to do everyday things for themselves because of an impairment or condition that is likely to be permanent
• need some supports now to reduce their support needs in the future.

People over the age of 65 at the time of a serious TBI are likely to be eligible for Australian Government funded aged care services (and may also be required to make a contribution to their cost).

There are Australian Government aged care programs to support people living independently in their homes and to provide alternatives where they are unable to continue living independently in their own homes, e.g. aged care home.

Eligibility criteria includes:

• older person is usually 65+ or 50+ for Aboriginal and Torres Strait Islander people
• finding it harder to do the things they used to do.

Everyone who has an assessment through My Aged Care and is found to need services is eligible to access services that may be partly or fully funded by the Australian Government; and are regulated by the Australian Government.

Workers care

Some people with a serious TBI are covered by workers compensation insurance. In NSW icare is responsible for workers compensation insurance.

Lifetime care

The lifetime care pays for treatment, rehabilitation and care for people who have been severely injured in a motor accident in NSW. This includes people with serious TBI.

Lifetime care is a no-fault scheme. This means support is provided regardless of who was at fault in the accident, as long as the person meets the eligibility criteria for both their motor accident and their injury.

Eligibility criteria

• The person was injured in a motor accident in NSW on or after 1 October 2006 (for children under 16) or on or after 1 October 2007 (for adults).
• The injury was caused by the motor accident.
• The type and severity of the motor accident injury meet the injury criteria. Each application is assessed against specific criteria outlined in the Lifetime Care and Support guidelines.⁶¹

Severe injuries that may be eligible for the scheme include spinal cord injury, brain injury, amputations, burns and permanent blindness.

Many injury events are covered by private insurers under a range of different kinds of policies including public liability, income protection and disability insurance.

Brain injury specialist rehabilitation services have to work with private insurers and their lawyers when people with brain injuries are making insurance claims.

Additional question

The following is an additional question for brain injury specialist rehabilitation services and private insurers.

How can the client’s two interests be successfully met, i.e. gaining the maximum appropriate compensation through an insurance payout and maximising their rehabilitation?

There is sometimes an apparent conflict with maximising rehabilitation progress and reducing compensation payments and reducing rehabilitation outcomes and increasing compensation payments.

Activities

The processes or actions that use inputs to produce the desired outputs, and ultimately outcomes, that is ‘what we do’.

Brain injury specialist rehabilitation

Brain injury specialist rehabilitation implies rehabilitation for people who have:

• an injury to the brain
• damage to multiple areas of the brain
• multiple cognitive impairments
• significant impacts in their life
• a non-progressive brain injury, e.g. not a degenerative disease
• ability to actively engage in the rehabilitation process
• the likelihood that rehabilitation can make a positive difference to their future life.

Brain injury specialist rehabilitation implies rehabilitation for this specific group of clients who are a subset of people who have experienced an acquired brain injury ABI, of which those with TBI are the core group.

Client

The term client is used throughout this document to describe the person receiving the rehabilitation intervention, however resident, client, individual or participant may be substituted in different contexts.

Family-centred care

Family-centred care is ‘grounded in collaboration among patients, families, physicians, nurses, and other professionals for the planning, delivery, and evaluation of health care as well as in the education of health care professionals’.¹⁵

Foundational activities⁴⁰

Combined with the foundational inputs, foundational activities make rehabilitation service delivery possible.

Foundational inputs⁴⁰

Foundational inputs are the building blocks of the rehabilitation program. These are the preliminary requirements, which need to be in place before implementing a rehabilitation program.

Glasgow Coma Scale

The impact of the injury on the brain determines severity and ranges from concussion to persistent vegetative states and is typically classified from mild to very severe, according to the duration of unconsciousness (coma) as measured by the Glasgow Coma Scale.

Table 6: Glasgow Coma Scale

Injury severity category	Initial Glasgow Coma Scale
Mild	12-15
Moderate	9-11
Severe	3-8
Very severe	less than 3

Impacts

Impacts are the results of achieving specific outcomes, usually longer term and may take years to achieve. These are the consequences once the person achieves their outcomes and may be desirable or undesirable, anticipated or unanticipated. They are the changes that occur beyond the specific program targets.

Inputs

Inputs describe the ‘what’ and ‘who’ is used to do the work. It includes all the resources that contribute to the production and delivery of outputs or what we use to do the work.

Key stakeholders

A stakeholder is anyone who can affect or is affected by the program. They may be recipients, providers and internal or external. Key stakeholders are those who can influence the direction or priorities of the program, including participants and program sponsors.

Outcomes

Outcomes are the changes that come about through inputs and activities. They may be quantifiable. They are the medium-term results for specific beneficiaries that are the consequence of achieving specific outputs or what we wish to achieve.

Outputs

The final products, goods and services produced for delivery. Outputs are usually quantifiable and measurable or what we produce or deliver.

Post-traumatic amnesia

Not everyone with a brain injury, however, experiences a loss of consciousness or confusion as the immediate result of a TBI. Some people with a penetrating injury may initially be conscious following the injury. Some people have a hit on the head and get confused without ever losing consciousness. A football player after a heavy tackle may be confused or unsteady on their feet over a few minutes (this would be classified as a mild TBI and often in sport referred to as a concussion).⁵²

A critical indicator of severity for TBI is the length of post-traumatic amnesia (evidenced by a period during which the person is disorientated, unable to learn, unaware of time, place and person (self). They may display behaviours quite different than usual, being disinhibited, irritable or agitated.

Table 7: Post-traumatic amnesia categories

Injury severity category	Duration of post-traumatic amnesia
Mild	Less than 24 hours
Moderate	1-7 days
Severe	1-4 weeks
Very severe	More than 4 weeks

The primary group admitted to BIRP have severe or very severe PTA duration. Additional categories had been introduced into the BIRD state data collection for reporting and research purposes. By consensus of the 15 BIRP directors and managers in 2019, it was agreed to retain these categories for clinical purposes.

Table 8: Additional post-traumatic amnesia categories for BIRD data collection

Injury severity category	Duration of post-traumatic amnesia
Very severe	28 days to 3 months
Extremely severe	3-6 months
Chronic amnestic	More than 6 months

Principles

Principles are fundamental truths or propositions that serve as the foundation for a system of belief or behaviour or for a chain of reasoning. Principles here are the foundational propositions for effective brain injury rehabilitation.

Rehabilitation settings

These are the care settings or environments in which rehabilitation programs are delivered. The setting in which rehabilitation occurs is principally defined by the person’s changing needs over time and service availability.

Resources

Resources refer to both material and human resources.

Self-efficacy

An individual’s belief in their capability to succeed in a certain situation or accomplish a task. Self-efficacy influences how people set their health goals.

Sense of self

How an individual regards themselves, including an understanding of their qualities, strengths and personal attributes, all of which can be impacted by disability.

Traumatic brain injury

Mild

Mild TBI is also referred to as concussion. Recovery times vary greatly.

• Some people's symptoms subside within 48 hours. Others have symptoms persisting greater than a couple of weeks and these require careful assessment and reassessment.
• Some people's symptoms last months (post-concussion syndrome).
• The majority of people with post-concussion syndrome recover completely in three to six months.
• Some people do not fully recover and have lifetime impairments.

Mild traumatic brain injury (complicated)

Refers to people whose symptoms and impairments from a mild TBI have not resolved within three to six months.

Severe traumatic brain injury

Includes severe TBI and very severe TBI unless otherwise noted.

Values

Values are the beliefs that determine the attitudes and behaviours of the people who deliver rehabilitation services. Collectively these values inform the planning of rehabilitation services and how those services operate.

Acronyms

This Appendix outlines the process, conceptual frameworks and evidence used to develop this document.

Project committee

A project committee was established in June 2018 and continued to June 2019.

The committee oversighted the process for developing and drafting Understanding Brain Injury Specialist Rehabilitation in NSW and the associated Practice Checklist.

The committee worked on:

• reviewing the work to date within the ACI more widely and the Brain Injury Rehabilitation Directorate in particular that was relevant to brain injury rehabilitation
• developing conceptual frameworks for understanding brain injury specialist rehabilitation in NSW
• identifying stakeholders for consultation
• reviewing draft documents.

Committee members

• Anita J. Barbara, Manager, New England Brain Injury Rehabilitation Service
  and Rural Spinal Cord Injury Service (Northern Region)
• Marion Fisher, Outcomes Manager, ACI, Brain Injury Rehabilitation Directorate
• Karen A. Height, Service Manager HNE Kids Rehab
• Adeline Hodgkinson, Director Brain Injury Rehabilitation Unit, Liverpool Hospital
• Nick Rushworth, Executive Officer, Brain Injury Australia
• Barbara Strettles, ACI Network Manager, Brain Injury Rehabilitation Directorate.

Conceptual frameworks and evidence

The process for developing the conceptual frameworks and supporting evidence included:

• reviewing existing NSW Health and ACI publications
• developing initial conceptual frameworks
• consultations with practitioners and iterative redevelopment of conceptual frameworks
• an agreed conceptual framework
• a literature search on aspects of the frameworks including specific issues such as values, principles, workforce, case management, challenging behaviours, paediatrics, family-centred care and TBI rehabilitation standards.

Sources and types of literature and evidence

The types of literature that were used in developing the conceptual frameworks and identifying relevant evidence.

• Australian Professional bodies including The Australasian Faculty of Rehabilitation Medicine
• Australian bodies that set some relevant guidelines or standards such as National Health and Medical Research Council
• International professional bodies working on setting standards for brain injury rehabilitation, for settings similar to Australia e.g. Ontario Neurotrauma Foundation and the Institut national d’excellence en santé et en services sociaux (INESSS)
• ACI studies undertaken to address specific issues such as the challenging behaviours projects ^30,31
• Other existing policy documents within NSW Health and health services, e.g. NSW Health (2017) NSW Health guide to the Role Delineation of Clinical Services ⁵⁰
• Other literature references including family centred care¹⁵
• Information unique to NSW including the BIRD Network and adult and paediatric eligibility criteria.

Developing possible frameworks for documentation using core concepts

The initial conceptual framework for consultations was based on service planning and evaluation concepts including values, principles, service processes, pathways, standards and indicators and was additionally informed by conceptual frameworks being used in the ACI. The initial conceptual framework included the following.

Part A. Traumatic brain injury (TBI) and rehabilitation

Part B. Client pathways and brain injury rehabilitation

Part C. Brain injury rehabilitation: inputs to impacts consistent with values and principles

Part D. BIRP in NSW pathways, settings, processes and networking

Part E. Standards and indicators.

Consultations with practitioners and iterative redevelopment of conceptual frameworks

Drafts based on this initial framework were discussed face-to-face and in phone consultations with practitioners including:

• project committee members
• Royal Rehab
• Northern Brain Injury Rehabilitation Service and Northern NSW Rural Spinal Cord Injury Service
• Hunter Brain Injury Service
• Brain Injury Rehabilitation Service, Westmead Hospital
• South West Brain Injury Rehabilitation Service
• BIRD directors and managers meeting.

Arriving at refined conceptual frameworks

Following these consultations an overarching conceptual framework was agreed for Understanding Brain Injury Specialist Rehabilitation in NSW and included the structure of the current document.

Part A: Brain injury and specialist rehabilitation

Part B: Brain injury specialist rehabilitation values, principles, pathways and core activities

Part C: NSW local health districts and speciality networks

Part D: Brain injury rehabilitation programs (BIRPs)

Part E: Settings and pathways: the continuum of care

Part F: Paying for and providing services in the community.

Disability and rehabilitation - World Health Organization

The World Health Organization provides useful frameworks:

• Disability and rehabilitation ⁶⁰
• Classification of functioning. ⁵⁹

Rehabilitation model of care and principles - NSW

From 2013 to 2019 NSW Health and the Agency for Clinical innovation undertook a process to describe a rehabilitation model of care and associated principles. Key documents include:

• Rehabilitation Redesign Project ³⁹
• Rehabilitation Implementation Toolkit ³²
• Principles to Support Rehabilitation Care. ⁴⁰

Paediatric rehabilitation model of care - NSW

From 2016 to 2019 work was done to describe how child and family centred rehabilitation is meant to work in NSW. The key documents are:

• Paediatric Rehabilitation: Model of Care Diagnostic Project ²⁸
• NSW Paediatric Rehabilitation Model of Care. ⁵⁰

Brain injury rehabilitation model of care - NSW

From 2016 to 2020 the Agency for Clinical Innovation, in particular the Brain Injury Rehabilitation Directorate undertook a process to describe the brain injury rehabilitation model of care. A key document is:

• Diagnostic Report, Model of Care NSW Brain Injury Rehabilitation Program.³⁶

Brain injury rehabilitation - International standards and evidence

Organisations in the United Kingdom, Canada, Scotland, United States and New Zealand have undertaken extensive literature and other evidence reviews and established standards, including:

• American Occupational Therapy Association (AOTA) ⁴
• INCOG (International team of researchers and clinicians) ¹⁹
• Institut National d’Excellence en Santé et en Services Sociaux (INESSS-ONF) ²⁰
• New Zealand Guidelines Group (NZGG) ²⁷
• Ontario Neurotrauma Foundation (ONF) ⁵⁷
• Royal College of Physicians (RCP) ⁵¹
• Scottish Intercollegiate Guidelines Network (SIGN).⁵³

Brain injury rehabilitation specific issues – NSW

From 2010 to 2020 the Agency for Clinical Innovation, in particular the Brain Injury Rehabilitation Directorate, have undertaken work to better understand specific issues as they relate to brain injury rehabilitation, including:

• Challenging behaviours project ^{30, 31}
• Case management ³⁴
• Consumer engagement ³³
• Rural and remote ²⁹
• Transitional living ³⁷
• Outcomes ¹⁷
• Community rehabilitation team.^{18, 55}

Family centred care

There is an extensive literature on family centred care. A key documents is:

• Policy statement on family centred care.²³

Economic impact of brain injury

There are studies reviewing the economic impact of brain injury.¹

NSW Health policy

NSW Health has a policies that directly relate to brain injury rehabilitation including:

• Principles for Transition of Young People from Paediatric to Adult Health Care ⁴¹
• Interstate transfer guidelines ⁴⁷
• Guide to the Role delineation of Clinical Services ⁴⁶
• Rehabilitation services ^{5, 6, 7}
• Adult trauma management of closed head injury ^{42, 49}
• Infants and children: acute management of head injury.⁴⁸

Australian professional and standard setting bodies

Australian professional and standard setting bodies have done work that has let to relevant standards for use in brain injury rehabilitation, including:

• Australian Commission on Safety and Quality in Health Care ^{8, 9, 10}
• Australian Council on Healthcare Standards ¹¹
• Australian Institute of Sport and Australian Medical Association ¹²
• Australasian Faculty of Rehabilitation Medicine ^{5, 6, 7}
• National Health and Medical Research Council.^{24, 25}

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