Health CommitteeWritten evidence from The Nottingham Traumatic Brain Injury Service (LTC 21)
Summary
We wish to share with you our experiences of supporting people with the complex issues that result from a Traumatic Brain Injury as we believe that this model can successfully be implemented with other long term conditions.
The Nottingham Traumatic Brain Injury Service is an example of multi-professional expertise treating and promoting self-management of patients with this complex long term condition.
It is a specialist case management lead service for people with moderate and severe brain injury with additional input from a specialist Cognitive Behavioural Therapist, a specialist Occupational Therapist and an experienced Assistant Practitioner.
The team provide support and treatment to the patient and their families from their post injury in-patient stay through into the community.
The aims of treatment are to help patients maximise their level of function, adapt to and self-manage any residual problems and where possible return to previous roles including work and education.
This highly personalised service requires the team to work with agencies across the all sectors including primary and secondary healthcare including mental health services, social care, education providers, DWP, justice system, third sector, employers and recently the armed forces for veterans transitioning to civilian life.
Patient and family/carer feedback consistently demonstrates a very high level of satisfaction with the service, clinical outcomes demonstrate effectiveness and recent research has indicated a higher quality of life and return to work rate for patients receiving this specialist care as opposed to usual care.
Information
1. The Nottingham Traumatic Brain Injury Service began life as a research project hosted by Warwick University to evaluate the effectiveness of different models of delivery of brain injury rehabilitation. It was jointly funded by health and social care and moved away from the medical model by being a case manager lead service. The case managers have come from a variety of professional backgrounds including nursing, social work and occupational therapy. They provide therapeutic interventions, education and support and guide the patient and their family through the rehabilitation process, accessing other services as required. The team also has an Occupational Therapist, a Cognitive Behavioural Therapist (CBT) and an Assistant Practitioner. Funding for the CBT post came to support the team with those patients who were developing difficult to manage behavioural issues that were requiring high cost, specialist residential placement. It was argued and we have now shown that early intervention can prevent behavioural problems developing, the team has not needed to recommend or use such a placement for the last 4 years.
2. Our model utilises the specialist skills of the team and also supports the patient in accessing a wide variety of health, social, education, employment and voluntary services. Liaison and joint working are the norm, recent examples include working with social care, including child protection services, community based neurological therapy services, the police and probation service, housing associations, higher and further education providers, DEA and DWP, the Armed Forces Personnel Recovery Units, mental health services including drug and alcohol teams and third sector providers of voluntary work placements.
This model is an efficient use of the specialists’ time and ensures that patients access the other services they require at the most appropriate point in their rehabilitation pathway. This reduces waste and duplication, improves effectiveness and aligns with the right care, right place, right time ethos.
3. The case manager model provides continuity and personalised care for the patient and their family. Early intervention is often targeted at the family to support them in the early phase of recovery after the patient is discharged from hospital. Good education and appropriate support of family members can decrease the length of hospital stay and reduce the amount of support services required.
Interventions are delivered at a time and place to suit the patient and their families. This is often at home but can be a variety of community settings, including libraries, education settings, leisure facilities and the work place as required. Treatment programmes are individualised based on a comprehensive assessment and goals are agreed with the patient. Interventions continue as long as there are agreed, achievable rehabilitation goals and the focus is always self-management.
Feedback is sought via questionnaire from patients and their families after six months with the service and after discharge. The information is used to guide service developments.
4. The services vocational rehabilitation outcomes have been formally assessed. A recent College of Occupational Therapists funded Phd study demonstrated that compared to those receiving usual care, those being treated by the specialist service had a higher return to work rate, they reported a higher quality of life and had a reduced length of hospital stay. Those people who had returned to work also reported statistically significantly less depression and reduced anxiety levels compared to those people not in work. The economic evaluation showed similar costs across the pathways with the specialist service costing a mere £75 more than usual care. (Reference—Return to Work after Traumatic Brain Injury—Cohort comparison and economic evaluation. Brain Injury, May 2013;27(5): 507–520. On line link—http://informahealthcare.com/doi/abs/10.3109/02699052.2013.766929)
5. As more people survive Traumatic Brain Injury due to improved medical interventions, the prevalence of TBI is increasing in the population. Once the person has survived the initial injury, TBI does not limit life expectancy. Given that the average age of the 94 patients in the study quoted above was 34 years, people are living for many years with the effects of their brain injury. Evidence shows that early intervention can maximise recovery, promote return to work and minimise the dependency on health and social care services with the associated societal costs.
Conclusion
The experience of the Nottingham Traumatic Brain Injury Service over 21 years demonstrates that a specialist multi professional team working to the case management model is an cost efficient and clinically effective method of providing support and rehabilitation to patients with complex physical, cognitive, psychological and social needs.
We believe that this model is applicable to other groups of patients with complex long term conditions and we would be happy to share our more of our skills, knowledge and experience with the select committee or other interested parties.
8 May 2013