Health and disability service models in rural and remote areas

Tuesday, 23 July 2013

People from more remote areas who have a serious injury are likely to be evacuated to a metropolitan facility where they will usually receive first class acute care and specialist rehabilitation. It is when they are discharged back home, with follow-up rehab still essential to their chances of optimal recovery, that they are likely to experience service deficits. The professionals required for the patient's ongoing care are likely not to be present - which is where a properly trained and supported local clinical agent might come in - perhaps styled a Community Rehabilitation Worker.

In many parts of rural and remote Australia there is a lack of trained professionals ‘on the ground’ to deliver a regular, consistent and high quality service to the patient or client. This is due to the shortage of positions in public health services (because of insufficient funds), the inability to attract and retain people for such positions where they do exist, and insufficient numbers of patients (or sometimes it's more accurate to say insufficient patients with the financial means) to make private practice profitable.

In south western NSW, for example, there is a shortage of allied health staff to provide brain injury rehabilitation therapy to clients who live in small and isolated communities, or on large farm properties, in the west of the state.

A person from those areas who is seriously injured is likely to be airlifted to Sydney or Adelaide for trauma management. There they will receive world-class care and treatment. When they are discharged from hospital and return to their local community, they will require significant follow up care and specialist rehabilitation management in order to maximise their recovery and capacity.

Depending on the severity of the injury, this rehabilitation ‘window’ could extend over a number of years. Here the clinical focus should be on cognitive, psychosocial, behavioural and physical domains, which will enhance the person’s capacity to work towards goals, to form and sustain relationships, and to assume a role in the community. If that opportunity is taken, and specialist clinical resources are applied, the person will return to the highest possible level of independence and quality of life, given the nature and extent of their injury. But if the opportunity is not taken or is not available, or its aspects are not applied consistently and well, for the rest of their life that person will exist at a lower level of capacity and engagement than what was possible.

For such a person whose home is in a more remote area, the best results will come from the early stages of post-hospital rehabilitation being provided by an interdisciplinary clinical rehabilitation team. Such teams are based only in the capital cities and some large regional centres. After the initial period of such specialist intervention at a regional centre, the person’s recovery may be optimised if they move back home, where the rehab is provided by the clinical team but through a ‘local agent’ - someone who actually lives in the small town where the patient has the social and community benefits of 'home'.

This local agent, who might be termed a Community Rehabilitation Worker, will work with the person who has the injury and their family. It could be a community nurse or an allied health assistant. Whatever their formal title, they will need to be trained and supported to continue to deliver the rehabilitation and case management strategies which have been put in place by the specialist brain injury rehabilitation service.

Their work will be designed to improve the patient's cognitive, physical, behavioural, social and psychological capacity - to help them to develop as far as is possible given the injury they sustained. This will enhance the likelihood of the person’s return to maximised participation in the community through employment, relationships and family, and through education, physical activity and engagement with hobbies and other interests.

The relationship between the Community Rehabilitation Worker and the specialist team in the city is an important one. There must be regular communication and mentoring to ensure that the strategies which have been agreed with the person who has the injury are implemented in a timely and professional manner. Adequate training and resources must be made available to enable the local worker to have an effective engagement with client and to focus on the goals within the context and activity of the patient's life.

The framework for this service model has great relevance for the development of services provided through DisabilityCare Australia. Models such as this will extend the reach of DisabilityCare Australia into rural and remote communities.
Such a model of care is at the interface of the health system (which encompasses rehabilitation) and disability (living with a disability in the community). And when it works well, those serviced by such a model of care can move seamlessly through the health system and on to disability care.

This is an aspiration well worth the battle and the advocacy.

Denis Ginnivan
South West Brain Injury Rehabilitation Service


The model proposed by Dennis Ginnivan in his ‘Opinion Piece’ is supported by our past research (2006 – 09), where a similar model was developed and trialled with 2 remote Aboriginal communities in Cape York, Qld. This research resulted in the development of a service model, based on principles of Community Based Rehabilitation, as defined by the World Health Organisation, and has been supported by key stakeholders in Aboriginal health in a number of communities across Queensland. The model identifies a local worker/s with brain injury knowledge as being the key link between smaller rural and remote communities and the mainstream brain injury health services located in a larger town or city. This worker/s becomes a key support within communities for people with brain injury and their families, whilst being themselves supported by a brain injury team located elsewhere. We believe this model has relevance to any rural or remote community where people with brain injury are currently receiving no service/support or intermittent service from visiting practitioners.

The concept of Community Based Rehabilitation, in its true definition, implies that a community will take responsibility for all its members’ needs, using its breadth of experience, talent, resources and knowledge, requesting assistance from others as required. The proposed model of having a ‘Community Rehabilitation Worker’ who has local knowledge and connections is a strength, and also offers stability to families within that community. It recognises that the role of community based rehabilitation is not only about understanding brain injury, but about understanding that community and how to utilise its strengths and assets to assist in the rehabilitation process for its members.

In addition to the above research and in collaboration with a South West Queensland Aboriginal Community, our service, Acquired Brain Injury Outreach Service (ABIOS), has developed a training programme specifically for Aboriginal and Torres Strait Islander Health Workers. This programme could be used with the proposed model of ‘Community Rehabilitation Workers’ to provide essential brain injury training and skill development in community based rehabilitation.

Further reading about this model and research is available in:

Kuipers, P, Gauld, S, Kendall, M, Smith, S, and Bowen, R (2013) ‘The International Community-based Rehabilitation model: A way of assisting people with brain injuries, their families, and communities’. In Muenchberger, H, Kendall, E, and Wright, J (eds) Health and Healing after Traumatic Brain Injury, Praeger, California, pp 203 -213.

Gauld, S, Smith, S and Kendall, MB (2011) ‘Using participatory action research in community-based rehabilitation for people with acquired brain injury: from service provision to partnership’. Disability and Rehabilitation, 33 (19 – 20), pp 1901 - 1911.

Sharon Smith and Susan Gauld,
Rehabilitation Coordinators,
Acquired Brain Injury Outreach Service
07 3406 2311 [email protected]
[email protected]

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