Quality requirement 5: Community rehabilitation and support

People with long-term neurological conditions living at home are to have ongoing access to a comprehensive range of rehabilitation, advice and support, to meet their continuing and changing needs, to increase their independence and autonomy and help them to live as they wish.‘Home’ in this context means the place where the individual chooses to live, which may be their own accommodation or may be a residential or care home.

The ABI service uses a case management model to enable individuals with acquired brain injury (ABI) to maintain or improve their independence, social skills, confidence, self-esteem and quality of life, and supports them to access social and leisure opportunities in the community. Long-term open access is in place to enable clients to access the service as and when required. The service has developed a variety of resources which it would be willing to share including a staff training programme for support workers, and staff and volunteers in the voluntary sector, and protocols to support the case management approach.

Examples of good practice from the Action on Neurology pilots.

CHIS is a specialist community brain injury service. They have developed a multi-agency, county-wide rehabilitation referral protocol and operational policy.

The CMST was set up as a joint venture between health and social services and the local branch of the MS Society, with partnership working across organisational boundaries. Occupational therapy and social work staff are funded by health organisations but employed by social services in order to promote joint working. There are links with the local branch of the MS Society.

The unit meets disability and nursing needs of people with profound neuro-disabilities in the community and helps them remain at home. It provides rehabilitation and secondary health services, and helps people to maintain or develop their functional skills and to stabilise and improve their health. This helps prevent problems with community packages of care and avoids unnecessary admissions to acute hospital or long-term care.

The team provides a seamless, flexible service with one point of access. Their work is predominantly with people with multiple sclerosis. Based in a community hospital, the team endeavours to work collaboratively with other health, social and voluntary services.

DART works according to the social model of disability and aims “to support disabled people in the community in aspects of their lives which they consider most relevant in order to contribute to the enhancement of their overall quality of life”. The team has carried out and published results of pilot projects into short-term counselling interventions for disabled people, and speech and language therapy needs. They have developed a number of resources which they are willing to share including standards of practice for rehabilitation assistants and for therapists, protocols for specific interventions eg splinting, postural management, fatigue management, and case file documentation. This model can be applied to people with a range of conditions.

The team is an integrated health and social services team which promotes personal independence, psychological wellbeing and social reintegration for people with an acquired brain injury. It won the 2004 UK Public Servant of the Year Team Award in Health, and has developed a number of resources, which it is willing to share.

Headway, Dorset aims to improve community integration for people after brain injury, through access to leisure services and specific projects such as Riding for the Disabled.

The aim of the team is to enable people to continue living in their own homes. The team aims to be proactive and person-centred, providing a seamless service between disciplines. The team is funded jointly by health and social care organisations, and includes social workers, occupational therapists, physiotherapists and community care officers. The team runs an ‘independent living bungalow’ that helps people to develop independent living skills.

The service delivers occupational therapy across acute hospitals, community hospitals, community and intermediate care, and is willing to share its experience of developing an integrated service.

The Motor Neurone Disease (MND) Association funds a network of twelve MND Care Centres based in regional neuroscience centres. They deliver high quality coordinated assessment and management of care to all people with confirmed or suspected MND in line with the Association’s Standards of Care. The individual centres have developed a number of resources and different ways of working which they are willing to share including fast-track diagnostic clinics, nurse-led clinics, taped consultations, development of advance directives and preferred place of care for specific use in MND, MND care pathways and review processes, carers’ information days, links with local ambulance services, use of volunteers in clinics, and education for staff in primary and secondary care.

The local branch of the Multiple Sclerosis Society, multiple sclerosis specialist nurses and the Stockport Team for Adult Rehabilitation have won a Partnership Award for their fortnightly Multiple Sclerosis Young Woman/Mother and Toddler Group. The group offers advice and support to women living with multiple sclerosis who have or are planning to start a family.

The Centre provides rehabilitation for the individual cognitive, social, emotional, vocational and physical needs of people with non-progressive brain injury, and support for their families. The Centre seeks to innovate, apply the latest research findings, evaluate the service and investigate ways to improve neuropsychological rehabilitation. The Centre has researched and developed the NeuroPage service, a memory system or alerting device for people with amnesia or impaired attention which is available throughout the UK.

Approximately 50% of people attending the centre have some form of acquired brain injury. The centre is a Leeds Social Services Resource Centre and has many years of experience of working with this population. As a result, they have developed a wide range of strategies and areas of expertise to meet individuals’ particular needs. The centre creates opportunities for individuals with acquired brain injury and members of the local community to become involved in how services are provided. Developments include a ‘one-stop shop’ centre, a training course on skills for volunteers, outreach work, employment advice, ‘transitions project’ with a local school, and drop-in services.

The team has an open referral system, offering assessment, advice, rehabilitation and psychological support to people with physical disabilities in order to promote maximum independence at home and enable them to integrate into the community. The team were awarded the Multiple Sclerosis Society’s Measuring Success award in June 2003 and have produced the ‘Pathway of Care for Motor Neurone Disease’ and ‘Return to Work flowchart’. The approach is holistic, focusing on all aspects of an individual’s life.

The Spasticity Service offers comprehensive multidisciplinary assessment, treatment and follow-up to patients with spasticity. An Integrated Care Pathway is used which ensures that for the majority of patients a single clinic visit is sufficient for assessment and initial management of their spasticity. A variety of treatments for spasticity are available including Botox, functional electrical stimulation and intrathecal therapies. The team has developed a number of protocols and treatment algorithms and are compiling them into a manual which they are willing to share.

The United Kingdom Brain Injury Forum (UKABIF) has produced a Mapping Survey of Social Services provision for adults aged 16 years and over with acquired brain injury and their carers in England, which includes examples of good practice