k) Pathways for life after ABI  (including rehab, community... )Next l)

i) Unique individuals mean that service pathways are unique.

At the same time staff need to be aware of:

  • typical service pathways
  • local barriers to pathways
  • strategies for dealing with pathway barriers.

In 2008, an Interagency Agreement was signed between Ageing, Disability and Home Care (ADHC), NSW Health, Housing NSW and the Lifetime Care and Support Authority (LTCS). The purpose of the Interagency Agreement was to improve equity of access in the interface between health, housing and support services to meet the needs of people with ABI in the community.
A Pathways and Protocols Working Group comprising members from each of the inter-agency partners was convened to identify appropriate referral pathways and related issues for an adult with an ABI moving through health, disability and community services. This work has produced "Care and Support Pathways for People with an Acquired Brain Injury, Referral and Service Options in NSW" PDF (3.1Meg) May 2011.

This document includes 7 Example pathways and detailed information about all of the services mentioned in the example flow charts.

The seven pathway examples are:

1: Person with a recent ABI requiring housing and support
2: Person with a recent TBI requiring support up to 35 hours/week
3: Person with a previous TBI/ABI with drug/alcohol or mental health issues
4: Person with TBI/ABI with challenging behaviours
5: Person with previous TBI/ABI exiting prison system
6: Applicant or existing tenant of Housing NSW with a diagnosed or undiagnosed ABI/TBI
7: Person with TBI/ABI requiring formal support for more than 35 hours per week

People who sustain injuries in motor vehicle accidents (MVA) may have access to compensation (Workcover, LTSCA). This can increase service options and needs to be considered when planning service support.

Pathways Example 1:

Pathways Example 1

Rules of thumb

1. Be familiar with the pathway examples.
2. Identify referral contacts and access options.
3. Identify local barriers.
4. Identify strategies for dealing with pathway barriers.
5. Liaise with insurers when they are involved.


A case manager said:

I guess my role as a case manager is to coordinate the rehabilitation program for my clients that are referred to me and as well as to be once they are discharged into the community to be the contact person.

I think it can be a very confusing time for the client because they are going into the community where they were pre-injury but they've got the issue of disability to cope with. They have got a new lifestyle and they have got ongoing therapy and appointments so we become like a guide for the clients to assist them through that process.

Initially there will be a lot of appointments ... therapy over a period of time that will slow down... slowly they will reach a level of stability in the community where there will be less medical and therapy intervention and we will just stay with them until they get to a point where they feel they are able to cope independently, knowing that they can come back and receive services if needed.

What its like varies with level of the injury.

So for some people it can be six months to one year because they will quite often be returning to work and will be able to do some sort of pre-injury work or modified suitable duties and with family support be pretty independent.

Others of them will need longer term care just to do their basic activities of daily living.



ii) Pathways: Graphic

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Click on Individuals 1, 2, 3, 4 to see examples of different individuals.



iii) Clip 13 : Jonathan & Mother : The Story (7 min)

Jonathan's mother (& Jonathan) talking about what happened - the impact, rehabilitation, etc


iv) Clip 6 : Gabby's Mother : Service Pathway (3 min)

Gabby's mother describing Gabby's service pathway.


Answer the following question:

What are the stages in Gabby's pathway?
   Check your answers here

Accident while riding a bike


St Vincent's Hospital - Intensive care - coma - poor prognosis

St Vincent's Hospital - Acute Care

Liverpool Hospital Brain Injury Rehabilitation Unit ( 6-7 months)

Home with parents - 24 hour support (e.g. showering, cooking, getting in and out of bed)

Home with parents - less support


v) Services

In 2010 the Pathways and Protocols Working Group, a sub-group of the Steering Committee for the Interagency Agreement on the Care and Support Pathways for People with an ABI prepared:

Care and Support Pathways for People with an Acquired Brain Injury PDF
Referral and Service Options in NSW
(3.1 Meg) May 2011

This document includes both sample pathways and lists of services.

The lists of services include:

1 Information and service directory for people with an ABI
2: Rehabilitation in NSW health for adults
3: ADHC program options for adults with an ABI
4: Home and Community Care Program (HACC) options
5: ABI rehabilitation assessments and interventions
6: Housing NSW product options
7: Mental Health program options
8: Drug and Alcohol referral options
9: Lifetime Care and Support Scheme
10: Corrective Services NSW
11: Other services

vii) Questions

Answer the following questions:

A 28 year old single female has had a moderate traumatic brain injury from a car accident. She was living by herself before the injury. 12 months after the injury she is not able to live by herself.

What are some of the steps in her service pathway likely to have been.

   Check your answers here

Acute hospital bed
Brain Injury Rehabilitation Unit
Transition to Living Unit
Discharge planning & discharge
Insurance negotiations
Living with family or in Supported accommodation
Assessments and review (e.g. physio, speech, neuropsychological etc as needed)
Social rehabilitation services (e.g. recreation, vocational options etc as needed)
Support services (e.g. in home cleaning, etc as needed).