Discharge Planning Following Acquired Brain Injury

Executive Summary:

Moderate to severe Acquired Brain Injury (ABI) is a major cause of long-term physical, cognitive and psychological disabilities in Australia. Management of such disabilities engages a broad range of stakeholders including patients, families and carers, health professionals, rehabilitation funders, healthcare and community service delivery organisations and policymakers. These stakeholders face myriad challenges, including understanding the individual, their family and social supports; determining prognosis, accommodation, ongoing healthcare and rehabilitation needs; and accessing and activating the required services, which involves facilitating co-ordination between multiple healthcare and administrative jurisdictions.

At each of the many points in the rehabilitation pathway – from the early inpatient phase through to eventual discharge to the community and the years that follow – healthcare, rehabilitation and other needs are evaluated against the changing progress and goals of the ABI patient, and the resources required to address these needs are mobilised. 

This NTRI Forum focused on a key decision point in this continuum – the transition of a person with ABI from an inpatient to a community setting. Discharge planning - the development and implementation of an individualised plan for a patient prior to them leaving hospital for home - can ensure that patients are discharged at an appropriate time in their care, and has been shown to reduce hospital length of stay and the frequency of unplanned hospital re-admissions.

Date: May 2013


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