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Quality requirement 5: Community rehabilitation and support.

*An asterisk in an example indicates that its approach could be adapted for other long-term conditions

Quality requirement 5

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.

Acquired Brain Injury Service, Stourbridge, West Midlands

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.

Action on Neurology programme

See pages 31-34 and 50 of the Action on Neurology report for information on:

Community Brain Injury Rehabilitation Team (CBIRT), Leeds

CBIRT is a small interdisciplinary multi-agency team which provides community-based rehabilitation to people who have had a traumatic brain injury in the previous five years and support to their families. Intervention is based on client’s rehabilitation goals and is delivered in the client’s home, in community locations or at the team’s base. 
The team uses a range of outcome measures and operating protocols that may be useful to other teams.

Community Head Injury Service (CHIS), Vale of Aylesbury

The Community Head Injury Service is a specialist community brain injury rehabilitation service providing a county-wide service to Buckinghamshire and Milton Keynes, serving adults with acquired brain injury.

Community Multiple Sclerosis Team (CMST), Regional Neurological Rehabilitation Centre, Newcastle

The Community Multiple Sclerosis Team was established in 1995 to serve the city's population of people with Multiple Sclerosis (MS). The team was set up as a joint venture between health, social services and the local branch of the MS Society.

Community Neuro-disability Unit at the Royal Hospital for Neuro-disability in London

The Community Neuro-disability Unit at the Royal Hospital for Neuro-disability in London provides a comprehensive range of services to meet the disability and nursing needs of people with profound neuro-disabilities in the community and to help them to remain at home. The service works in partnership with primary health, social care and other agencies.
Care provision is seamless so that people can move from one service to another depending on their needs.

Community Rehabilitation Team, Princess of Wales Community Hospital, Worcestershire

This primary care trust based service aims to help people with a physical disability to remain in the community, maintain their independence and achieve the best quality of life.

The Disabled Adults Resource Team (DART), Bristol, S.Gloucestershire and N. Somerset

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.

Down Lisburn Trust Community Brain Injury Team, County Antrim, Northern Ireland

Down Lisburn Trust Community Brain Injury 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. Services are delivered in people's homes, a day centre, hospital, leisure centres and other locations in the community to suit individual needs.

Headway, Dorset

Headway Dorset is a voluntary organisation and a limited company which serves individuals with a brain injury living in Dorset.

Huntington’s Disease Service, Milton Keynes

The service was developed to provide an easily accessible, equitable, appropriate and clearly defined route for people diagnosed with HD to follow, benefiting them, their carers and professionals involved in their treatment.
The service is accessed by a single point of contact, with an open referral system. Each clinician involved utilises part of their work hours to be part of the service so that it has been set up with no additional costs to the services that are involved.

*Independent Living Team, Nottingham

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.

*Integrated Occupational Therapy Service, Middlesbrough

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.

Leeds Young Adult Team, St Mary’s Hospital, Leeds

The Leeds Young Adult Team provides multidisciplinary input to young adults (16-25 years) with a physical impairment.
The team is part of transitions services in Leeds and works closely with a wide variety of agencies and services. 
Formal study of effectiveness compared different approaches to delivering care to this client group.  The study found that a coordinated approach (such as that delivered by YAT) produced better results at no extra cost that an ad-hoc approach.

Moor Green Regional Acquired Brain Injury Service, Birmingham

Moor Green is a regional rehabilitation service for adults with acquired brain injury which is delivered in a purpose-built centre in the community. The use of clients and ex-clients in the delivery of a variety of rehabilitation programmes is being trialled
The service is willing to share their skills and resources for client involvement.

Motor Neurone Disease Care Centre Programme

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.

Multiple Sclerosis (MS) Young Woman/Mother and Toddler Group, Stockport

The MS Young Woman/Mother and Toddler Group in Stockport was established as a collaborative project in 2003, with funding from the local branch of the MS Society. With a population of 300,000 in Stockport, there are about 350 people living with MS, and about 50 of these are women under the age of 40 years.

Neurology Pro Active Care Team (NeuroPACT), Surrey Primary Care Trust

The service began as a pilot for the national Action On Neurology Programme in 2004, concentrating on neurodegenerative conditions, especially Multiple Sclerosis (MS) and Parkinson’s Disease (PD). NeuroPACT has primarily been resourced with existing services which are now able to work in a more coordinated and effective way. 

The service includes nurse-led clinics, ward assessment of patients, regular joint clinics, home visits, drop in clinics and self-management teaching sessions to meet patients’ needs.

The team are willing to share their pathways and policies

Northumberland Head Injuries Service (NIHS), Northgate Hospital, Morpeth

NIHS provides accessible community-based rehabilitation for people with traumatic brain injury (TBI) throughout Northumberland. NHIS is an integrated health and social care service. Having a “joined up” service, helps with communication, inter-disciplinary goal setting, speed of referrals and enables clients to progress through the rehabilitation phase more quickly than if they were awaiting interdepartmental referrals.

The Oliver Zangwill Centre for Neuropsychological Rehabilitation, Princess of Wales Hospital, Ely

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.

*Osmondthorpe Resource Centre, Leeds

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.

Physical Disability Support Team, Northwick Park Hospital, Harrow, London

The Physical Disability Support Team at Northwick Park Hospital was established in 1999 to address a gap in services for younger physically disabled people with complex disabilities (mostly neurological).

Regional Specialist Community Rehabilitation (Outreach Team), Regional Rehabilitation Unit, Northwick Park Hospital, Middlesex

The service is part of the Regional Rehabilitation Unit based at Northwick Park Hospital and is part of the network of specialist rehabilitation services to the region.  The Outreach Team, offers a consultancy service on the management of patients with long-term neurological conditions in the community and in acute hospital settings.

The service has developed a number of resources, which it would be willing to share.

The Spasticity Service, The National Hospital for Neurology & Neurosurgery, London

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.

Further reading

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

Additional links

Overview of the examples

How the examples were chosen and evaluated, and how to submit an example.

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