Building Bridges: Facilitating transition from inpatient rehabilitation to the community

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Building Bridges Facilitating transition from
in-patient rehabilitation to the community

• Jamie Feather - Social Worker
• Lynsay Duke - Deputy Team Lead, Occupational
  Therapist
• Regional Neurological Rehabilitation Centre
• Newcastle upon Tyne

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Regional Neurological Rehabilitation Centre

• Covers North-East and Cumbria
• 18 -65 age range
• 21 neuro-rehab beds
• 8 continuing care beds
• Multi-Disciplinary Team
• Day and out-patient Services

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TBI - acute transitions

• Traumatic event
• Physical cognitive impairments
• Financial issues
• Unable to work
• Impact on family friends
• Loss of independence
• Hope and expectation

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NSF Quality Requirement 1A Person Centred Service

• Integrated assessment
• Point of contact
• Care planning
• Information provision
• Education self-management

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Regional Neuro-Rehab CentrePerspective

• All in-patients receive full MDT assessment
• Keyworker and named therapists identified prior
  to admission to form therapy team
• Care planning integrated with goal-setting within
  Centre
• Information leaflets, Team Reviews
• Discharge Packs

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NSF Quality Requirement 4Early and Specialist
Rehabilitation

• Compliant with NICE Guidelines
• Improved access
• Seamless transition of care
• Meets the needs for severe and complex
  disabilities

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Regional Neuro-Rehab Centre Perspective

• NICE Guidelines
• Admission meeting and MDT Clinic
• Rehab between hospital, home and community
  settings throughout
• Early involvement of external agencies
• Provision for continuing care, low awareness
  patients

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• NSF Quality Requirement 5
• Community rehabilitation and support
• NSF Quality Requirement 8
• Providing personal care and support

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In-patients at Regional Neuro-Rehab Centre

• 2003 2004 26 discharges
• 2004 2005 43 discharges

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TBI discharge stage transitions

• Physical cognitive impairments
• Anticipation and apprehension
• Change in financial circumstances
• Loss or change of role of family friends
• Adjustment accommodation
• Loss or change of structure support
• New home
• New life

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Regional Neuro-Rehab Centre Perspective
Discharge

• Allocation to Social Worker in Centre who works
  as part of MDT retains care management
  responsibility for Newcastle residents
• Referral to host Social Services/PCT at 3 week
  point
• Involvement of host Social Services/PCT in team
  reviews and in-patient treatment
• Assessment provided to host Social Services/PCT
  by Social Worker/Occupational Therapist

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Regional Neuro-Rehab Centre PerspectiveDischarge

• Recommendations for care plan made by Social
  Worker to host LA/PCT informed by MDT assessment
• Liaison and support throughout care-planning
  process
• Training, education, information and advices
  provided to host LA/PCT
• Follow-up in the community

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Bridging the Gap

• Good understanding of the needs of people with
  acquired brain injuries, particularly resulting
  from cognitive deficits
• Timely involvement from Social Services/PCTs
• Willingness to work jointly to secure safe and
  effective discharge
• Willingness to share expertise and consider
  recommendations
• Ongoing involvement and review from LA/PCT
  post-discharge

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Gaps in the bridge

• Variable commitment from Local Authorities/PCTs
  to early involvement
• Inconsistency in joint-working arrangements
• Limited post-discharge input from Neuro-Rehab
  Centre
• Limited appropriate resources
• Variable review systems
• Variable commitment from social workers to
  maintain long-term rehab focus

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