Rehabilitation for chronic neurological disorders including acquired brain injury

Based on the person's holistic rehabilitation needs assessment and their goals, agree a personalised rehabilitation plan (to include interventions covered by the sections on rehabilitation to maintain, improve or support function and to support education, work, social and leisure activities, relationships and sex, as appropriate) with:

• the person and

• those people important to the person's rehabilitation (see recommendation 1.8.5 in the section on initiating holistic rehabilitation needs assessment and who to involve) and

• the health, mental health and social care practitioners involved in the person's assessment or care.

When agreeing the interventions and approaches that will constitute the rehabilitation plan, think about and include in the plan:

• the timing, intensity and frequency of interventions

• how interventions relate to, and interact with, each other

• intervention modifications in line with factors such as developmental age and cognitive abilities

• the role of family, carers or others important to the person in delivering their rehabilitation

• the person's rehabilitation goals and how interventions will deliver these goals

• who will deliver the interventions

• how practitioners will liaise with one another and work together to enable interdisciplinary working

• the timing of review appointments for reassessing interventions, approaches, rehabilitation needs and goals.

Focus on interventions for optimising or maintaining the person's functioning and abilities, even when they have a time-limited prognosis or the potential for improvement appears to be limited.

Deliver rehabilitation interventions in settings that are appropriate to the person's rehabilitation goals and meet their preferences. This may be at home, school, work or in other community settings, and may include telehealth, where appropriate.

Practitioners involved in delivering the rehabilitation plan should work together to ensure timely and joined-up delivery of the interventions and approaches.

If the person is in work, education or training, collaborate with their employer or education provider (with the person's consent) to agree and deliver rehabilitation interventions that are relevant to the tasks and activities the person will be undertaking.

Review rehabilitation needs, goals and interventions when people are moving from acute to longer-term rehabilitation and update the plan accordingly.

Regularly review education support plans for adults if these cover rehabilitation provision, especially if the person's chronic neurological condition is progressive or fluctuating.

See also the sections on rehabilitation to support education for children and young people, and rehabilitation and the workplace.

Discuss and agree aspects of rehabilitation that may be delivered at a later date as well as what might inform decisions about stopping interventions.

Ensure people have access to the right equipment, technology and advice to help them prepare for changes that may happen in the future.

When rehabilitation ends or aspects of rehabilitation end, agree if follow-up appointments are needed, and whether they will be initiated by the practitioner or the person with the chronic neurological disorder, taking into account:

• any reasonably anticipated future rehabilitation needs (including those associated with either deterioration or improvement in the person's condition or around end-of-life care)

• the person's ability, or that of the family or carers, to get in contact if their needs change

• unpaid support for the person, including from their family, carers or social network

• ongoing support and care from healthcare and social care services including from voluntary, community and social enterprise (VCSE) organisations.

Decide which practitioners will be involved in follow-up, for example, care coordinator, nurse specialist, key therapist, healthcare assistant or support worker.

Plan follow-up for children at key neurodevelopmental stages, recognising that rehabilitation needs and goals may change over time and that new symptoms may emerge.

As part of the person's rehabilitation plan, assign them a single point of contact to:

• help them understand and navigate rehabilitation services

• coordinate their rehabilitation plan

• support them in accessing rehabilitation services, if needed

• refer them to other services, if needed.

Assess the person's ability, or that of their family or carers, if appropriate, to self-manage their rehabilitation and agree the most appropriate type of single point of contact for their rehabilitation. This may be a key contact, key worker or complex case manager.

Review the person's ability to self-manage their rehabilitation if significant difficulties are observed or reported, and change the type of single point of contact, if needed.

Think about the level of rehabilitation coordination, navigation and support the person needs before agreeing the single point of contact. Agree whether specialist clinical knowledge is necessary and the relative importance of a broad and detailed knowledge of local service availability.

Consider assigning a key worker if the person has:

• impaired cognitive function (including executive function) or communication difficulties that impacts their ability to self-manage their condition or navigate rehabilitation services or

• an unpredictable or rapidly changing neurological condition or

• multiple rehabilitation needs that require rehabilitation across multiple services and areas of care or

• the potential to develop new needs around accessing care and there are associated family support needs, such as when a child or young person moves between education settings.

Consider assigning a complex case manager if the person has severe, complex and long-term rehabilitation needs and:

• impaired cognitive function (including executive function) or communication difficulties that severely impact their ability to self-manage their condition or navigate rehabilitation services or

• is unable to advocate for themselves and has no-one to advocate for them (some people may have a legal right to advocacy) or

• has serious comorbidities (for example, poorly controlled diabetes or epilepsy), a learning disability, complex mental health needs, misuses drugs or alcohol or has neurobehavioural symptoms that place them at risk of harm to themself or others.

When rehabilitation significantly changes (for example, following a hospital admission) or ends, update the person about their single point of contact (if this is going to change) and make sure they know how to get in touch if and when new symptoms or impairment require assessment and rehabilitation.