Bridging the Gap; Transitional Rehabilitation from Hospital to Home for Adults with an Acquired Brain Injury

Background: It is estimated that approximately 19,000 people experience an acquired brain injury (ABI) in Ireland each year, which impacts significantly on quality of life for the person and their families. Unfortunately, the lack of community-based transitional rehabilitation services for people with an ABI leaving hospital, often results in many people being placed in inappropriate placements in nursing home facilities or being discharged home without supports.

 

Approach: Acquired Brain Injury Ireland is a leading provider of community-based neurorehabilitation for people with an ABI in Ireland. In 2007, ABI Ireland, in partnership with the Health Service Executive, established the first transitional rehabilitation service for adults with an ABI in the Northwest of Ireland. The service provides short-term high intensity neurorehabilitation to four individuals at any one time and provides a rehabilitation pathway from hospital to home. This model focuses on enhancing the independent living skills of participants, by supporting the individual and their families to understand the impact of the ABI, and through the development of individualised neuropsychological and cognitive rehabilitation programmes.

Support is provided in the service Monday to Friday, with individuals returning home to their families / community at weekends, to ensure transfer of their skills and strategies to their home environment. Rehabilitation is provided by Neuropsychology, Occupational Therapy and Rehabilitation Assistants on site and referrals can be made for Speech and Language Therapy and Physiotherapy. Upon discharge, a community-based rehabilitation team can continue to provide essential supports as the individual transitions home full-time. The model also allows for participants who previously accessed the transitional rehabilitation service to access a readmission to address new goals or prevent deterioration.

 

Findings: Since its establishment, the transitional rehabilitation service has supported over 250 people with an ABI and their families. With 85% of admissions to the service coming from the acute hospital, the service provides a timely and direct route for ongoing rehabilitation before the person returns home. The average length of time from injury to admission into the service is 17 weeks; therefore, optimising the potential for rehabilitation and recovery. Most people who have accessed the service have successfully been discharged home within 12 weeks. From 2022 – 2023, data analysis of aggregated Mayo-Portland Adaptability Inventory – 4 outcomes demonstrated that participants (n=10) who accessed the service achieved a reduction in their limitations across all subsets; abilities, adjustment and participation.

 

Implications: International research indicates that people with an ABI who access neurorehabilitation services earlier have better outcomes than those who access services later. Given the success of the transitional model, it is proposed that it be replicated to meet the needs of more adults with an ABI in Ireland.