i) Part of a team

Working with a person with an acquired brain injury often means being part of a team. It is important to understand everyone's role.

The nature of the team can change over time with the stage of the rehabilitation process:

Stage 1: Acute rehabilitation

This acute stage involves initial management to ensure the person is medically stable in the Intensive Care Unit and high dependency wards. Acute rehabilitation normally occurs within hospital with a strong focus on physical recovery and regaining independent living skills.

The Team: Acute care staff and family and friends

Stage 2: Post-acute rehabilitation/community re-settlement

This stage involves managing the transition from hospital back home, and the ongoing process of rehabilitation that occurs after discharge. The focus of rehabilitation at this stage may include return to work or study, finding alternatives where this is not possible and relearning skills for community living.

The Team: Rehabilitation team

Stage 3: Social rehabilitation

This is the long-term rehabilitation aimed at maintaining and enhancing the level of participation in community life that people with ABI can achieve over their life span (community integration).

The Team: Community living team

The Rehabilitation Team members

In addition to family and friends some of the common roles are:

Rehabilitation Specialists
Nurses
Case Managers
Physiotherapists
Social Workers
Occupational Therapists
Neuropsychologists
Clinical Psychologists
Recreation Officers
Speech pathologists
Residential Care Staff

The rehabilitation team's primary responsibility is to the individual who has the brain injury. They are working with this individual to achieve his or her goals. The extent the brain injury has limited that person's ability to make informed decisions is determined by the Team through the assessments and observations conducted.

If the Team feels the individual is not able to understand the complexities of the information being given in order for a decision to be made, they will approach another who is perceived to make decisions that are in the best interest of the person who has the brain injury. This may be a family member or a close friend. If it appears there is conflict or discrepancies in what different people feel is most appropriate for that person, the rehabilitation team may consider making an application for an independent decision-making body. An application may be made to the Guardianship Tribunal. A substitute decision-maker may be appointed in areas of accommodation, medical and dental management, finances and service utilisation. If no family person is identified as suitable then a Public Guardian or Estate Manager can be appointed.

Rules of thumb:

1. See yourself as part of a team - not just the team in your organisation but part of a team of all the people involved with the person with ABI.
2. Identify the people is this team. For example if the person has just come through acute hospital care the team will include the rehabilitation team. If the person has been living in the community for many years the team may primarily include local community service providers.
3. Understand the others roles.
4. Connect with the other members of the team when you need to.

 

A mother with a person with an ABI said:

You have to just pull together as a family unit. You need everything else out there working for you. You need the extended family helping and then you need the friends helping the extended family and you know this is like a sacred circle which even involves therapists and clinicians and it has to become a team to be successful.

A case manager said:

The biggest thing is to help maintain my stress levels and be more supportive to the other service coordination managers and the support workers is to work as a team. Because it is a big effort, so you have got to rely on each other.

 

(c) Copyright - See: Module 1: An Introduction to Traumatic Brain Injury www.TBIStaffTraining.info

 

 

ii) Members of the rehabilitation team

Rehabilitation Specialists

Rehabilitation Specialists monitor medical issues following the injury. They usually follow the individual through hospital and then follow them up through outpatient clinic appointments. They are able to provide legal reports.

Nurses

Nurses work closely with the individual in hospital. They get to know the individual very well and often express individual concerns to the rest of the Team. The nurses work to maintain the wellbeing of the individual in the hospital setting. Community nurses generally have specific tasks. For example, changing dressings and giving injections. They liaise with the local doctor.

Case Managers

Case Managers become involved with the individual when they have left hospital. They develop and oversee the rehabilitation plans and are frequently the primary contact person with whom the individual can raise issues, express concerns and ask questions for further information.

Physiotherapists

Physiotherapists work with the individual to maximise physical functioning and maintain joint integrity and muscle length. The individual usually spends time working with the physiotherapist in the gymnasium, at home and in the community. Physiotherapists may be involved in the rehabilitation process when the individual is in hospital and in the community.

Social Workers

Social Workers also work with the individual's family and help them to adjust to the individual's injury. They can be involved in legal and financial issues as well as injury claims and insurance. Social workers work with individuals and their families on a range of issues in the hospital and after discharge. They offer support and counselling to adjust to the many changes that can often arise from having had a brain injury. Social workers liaise with community services, government departments and other organisations such as insurance companies and solicitors to ensure the individual is informed of what is going on and their rights are protected.

Occupational Therapists

Occupational Therapists work with the individual to get them back to doing everyday activities. Occupational therapists look at what the individual was doing prior to their injury and what they will need to do when they leave hospital. The occupational therapist then works with the individual on regaining competence in these activities. It may be necessary for the individual to use adaptive equipment or make modifications to the home or work place to maximise the individual's independence. The occupational therapist will prescribe this equipment or environmental change. The occupational therapist will work with the individual in the hospital, home, community, workplace, school or educational institution and leisure environments.

Neuropsychologists

Neuropsychologists use a number of tests to identify where the individual is having difficulty with their brain function. Areas neuropsychologists examine include attention, memory, speed of information processing, flexibility in thinking, manipulation of information, abstract thinking and general knowledge. This information is fed back to the Team and provides information regarding the extent and severity of the injury and areas where these difficulties may affect daily functioning.

Clinical Psychologists

Clinical Psychologists work with the individual on specific areas that limit their ability to get on with everyday life. This may include counselling, developing behaviour management and support programs where the clinical psychologist works with the individual on specific areas of their behaviour. Different areas may be stress management, sleep disturbances, anxiety, depression and anger management.

Recreation Officers

Recreation Officers work with the individual to identify leisure and recreation options the individual can do in both their home and community. The recreation officer liaises with educational institutions and community facilities to find activities that are meaningful to the individual and meet their individual needs.

Speech pathologists

Speech pathologists initially work in hospitals to recommend advice on eating, including swallowing and appropriate food consistencies. As recovery occurs they work with the individual on areas of language, expressing themselves, understanding information they are receiving and social skills. Speech pathologists also work with the individual beyond the hospital in the community, in individual and group situations.

Residential Care Staff

Residential Care Staff work with individuals in the transitional living units. In the transitional living unit residential care staff are responsible for ensuring the safety of those in the house and the facilitation of the residential rehabilitation program or residential program with a leisure focus. Other carers or support workers may replace residential care staff when they return home or are in permanent independent housing.

The rehabilitation team's primary responsibility

The rehabilitation team's primary responsibility is to the individual who has the brain injury. They are working with this individual to achieve his or her goals. The extent the brain injury has limited that person's ability to make informed decisions is determined by the Team through the assessments and observations conducted.

If the Team feels the individual is not able to understand the complexities of the information being given in order for a decision to be made, they will approach another who is perceived to make decisions that are in the best interest of the person who has the brain injury. This may be a family member or a close friend. If it appears there is conflict or discrepancies in what different people feel is most appropriate for that person, the rehabilitation team may consider making an application for an independent decision-making body. An application may be made to the Guardianship Tribunal. A substitute decision-maker may be appointed in areas of accommodation, medical and dental management, finances and service utilisation. If no family person is identified as suitable then a Public Guardian or Estate Manager can be appointed.

(c) Copyright - See: Toolkit B. Working Together Promoting Independence - www.TBIStaffTraining.info

 

iii) Questions