Project improves access to community rehabilitation after traumatic brain injury

Consumers with traumatic brain injury are seeing improved wait times for rehabilitation in the community, thanks to a recently completed quality improvement project. 

Completed by ABI, a specialist neuro-rehabilitation provider, and Active+, a rehabilitation provider in Tāmaki Makaurau, the project aimed to improve access to community rehabilitation after traumatic brain injury when consumers leave hospital. 

Project lead Michelle Wilkinson says that people who receive treatment in hospital after experiencing major trauma generally experience delays in accessing the right rehabilitation in the community, in a timely manner.

Consumers need the right rehabilitation to meet their needs. The sooner rehabilitation starts, the better their outcomes, and they are able to return to their day-to-day lives sooner and return to work or study.

‘Our aim was to create a seamless transition between hospital and the community so that our clients could get back to living their lives as soon as possible,’ says Ms Wilkinson.

‘We wanted to have 90 percent of those who need rehabilitation in the community, to begin that rehab within two weeks of discharge.’

The project team worked alongside allied health and trauma teams at Te Whatu Ora Health New Zealand Counties Manukau, ACC and academics from the Auckland University of Technology.

When the project began it took an average of 12 working days for a referral to be processed, hospital referrers weren’t told when a referral had or hadn’t been accepted making follow-up difficult, and the process for making a referral was complex.

Through a series of workshops in May and June 2021, the project team identified reasons why the referral process wasn’t working well:

• ACC had to give approval before rehabilitation could begin, which often led to delays.
• Māori and Pacific peoples were under-represented in referrals to rehabilitation.
• Community rehabilitation teams felt they were not getting enough referrals, consistent with injury rates for concussion or traumatic brain injury.
• Hospital clinicians were unsure of the referral process, who to refer, and when and where to send the referral.
• Hospitals often didn’t receive acknowledgement that a referral had been accepted and actioned.
• Consumers were expecting follow-up but were unsure if they had been referred or who they had been referred to.
• Many people in the Counties Manukau area are not registered with a general practitioner which means that a referral back to primary care for follow-up on discharge from hospital wasn’t a reliable safety net.

‘Once we had identified the issues affecting the referral process we worked with the wider project team to brainstorm what sorts of changes we could make and how to go about it,’ says Ms Wilkinson.

‘Then we ran a series of PDSA (plan, do, study, act) cycles to test our ideas, make changes and tweak our approach, and see which ones got us closer to our aim.’

The project team trialled and implemented several changes including:

• review of the current traumatic brain injury pathway to include mild traumatic brain injury and clinical concerns that support a high-quality referral
• removing the need to get ACC approval for rehabilitation (in consultation with ACC)
• co-designing a referral form for community traumatic brain injury rehabilitation in consultation with ABI, Active+ and clinicians at Counties Manukau
• using a ‘close the loop’ process so that the hospital referrer is notified when the referral is received and the consumer had been allocated to a clinician for rehab.

The team found that having a multidisciplinary team to form, test and adapt ideas was invaluable.

The project initially began in Middlemore Hospital then expanded to include the Kidz First Children’s Hospital.

Ms Wilkinson says the project team was pleasantly surprised to see that the time between hospital discharge and starting rehabilitation reduced to a median of one working day, once the project was fully embedded.

‘The number of high quality referrals increased and low-quality referrals were eliminated.’ she said. 

‘There was also an increase in referrals received for Māori and Pacific peoples, which was  a positive outcome of the project.  

‘Although Māori continue to be under-represented compared with their major trauma burden, access to rehabilitation is more equitable when compared with our baseline data.’

The project was so successful that ACC trialled the pathway in four urban and regional hospitals, and implemented it nationally across all hospitals in August 2022. 

‘There was a real sense of pride and achievement when ACC took our project nationally,’ said Ms Wilkinson.

‘That’s when it hit us that we had made a real difference and created a faster, easier and more equitable referral process for those with a traumatic brain injury.’

In 2021 the trauma rehabilitation national collaborative brought together 11 teams of rehabilitation clinicians from across Aotearoa New Zealand to complete quality improvement projects that would improve outcomes for patients’ rehabilitation after major trauma. The collaborative is part of a broader programme of work by the National Trauma Network, Accident Compensation Corporation (ACC) and the Health Quality & Safety Commission to establish a contemporary system of trauma care in Aotearoa New Zealand. 

Find out more about the National Trauma Network on the Commission’s website and read the full case study from ABI and Active+ below.