Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2025
Summary
A network of Brain Injury Community Integration Services (BICS) that deliver specialist acquired brain injury (ABI) community rehabilitation and case management closer to home for people with moderate to severe brain injuries.
Dates: 1 July 2024 - 30 June 2025
Implementation sites: Sunshine Coast Hospital and Health Service
Partnerships: Metro North, Metro South, Townsville, Gold Coast, Cairns and Children's Health Hospital and Health Services
This project was presented as a Poster at CEQ Showcase 2025 (PDF 334KB).
Aim
To:
- provide timely and equitable access to specialist ABI community rehabilitation coordination and case management
- support individuals with moderate to severe ABI across Queensland
- achieve better outcomes, improved independence, and greater social participation.
Outcomes
BICS has provided:
- 785% increase in Sunshine Coast residents (From ABIOS 7 in 2022, to 85).
- 13 consumers have avoided readmission due to BICS involvement
- 95% of consumers are receiving case management
- 71% of consumers are receiving rehab specific intervention
- 27% of consumers and their supports are receiving ABI training and consultation
- 48% of consumers were not engaging in rehabilitation prior to BICS involvement
- 39% of consumers were not attending medical appointments prior to BICS involvement
- 34% are progressing return to work
- 23% are progressing or have returned to driving
- 8% consumers have discharged against medical advice
- BICS has provided a service to follow up and engage one consumer reduced inpatient length of stay.
Background
Prior to BICS, the Acquired Brain Injury Outreach Service (ABIOS) based in Metro South Hospital and Health Service (MSHHS) was the single designated provider of specialist ABI rehabilitation coordination and case management in Queensland. It has not seen growth in service capacity since its commencement as a Motor Accident Insurance Commission (MAIC) funded pilot in 1997. This results in significant demand pressures and inequitable access to specialist community rehabilitation services across the state. Timely access to specialist community rehabilitation supports community integration and improved patient outcomes when discharging from hospital with an ABI. In the months to years following injury, community rehabilitation has been shown to be an essential part of the rehabilitation continuum to assist people with psychosocial adjustment and increase the chance of safe and successful community integration. A lack of access to these services significantly increases the likelihood of poor outcomes, increased rates of depression, re-hospitalisation, institutionalisation, family and relationship breakdown, homelessness and being unable to successfully return to work and/or other important life roles.
The Statewide Brain and Spinal Cord Injury (BaSCI) Project, funded through the Commonwealth Community Health and Hospitals Program (CHHP), commenced in 2021, aiming to improve equity of access to specialist rehabilitation services and outcomes for people with ABI and/or spinal cord injuries in Queensland.
The Brain Injury Community Integration Service (BICS) pilot commenced in 2024 at four Hospital and Health Services (HHSs) – Sunshine Coast, Metro North, Townsville, and Gold Coast. Recognising their expertise and experience, BICS partnered with Metro South’s ABIOS for training and service development support to build the workforce capacity needed to deliver this important community integration service for Queenslanders with an ABI, closer to home.
Methods
In February 2023, the BaSCI Project Clinical Leads of Townsville, Sunshine Coast, Metro North, Metro South, and Gold Coast HHSs developed a self-assessed rehabilitation scorecard, identifying a lack of access to local specialist ABI community rehabilitation outside of MSHHS. Reflecting on the need for a networked model of specialist community rehabilitation services in Queensland, a proposal was written for the establishment of the Brain Injury Community Integration Service at four hub sites. Upon funding approval the four BICS sites, in partnership with ABIOS, undertook seven months of planning and consulting, consolidating information from ABIOS and other networked services such as the Specialist Palliative Rural Telehealth Service (SPaRTa), and interstate from the New South Wales Brain Injury Rehabilitation Program (BIRP). It was identified within SCHHS that a multidisciplinary team was required and the following positions recruited to: 0.8HP5 Occupational Therapist 1.0HP4 Social Worker 0.4HP4 Neuropsychologist (now Psychology) 0.2AO3 Administration Officer.
Sunshine Coast BICS clinical service commenced in February 2024. The BICS Rehabilitation Coordinators (RCs) are allied health professionals, highly experienced in rehabilitation. They are a key contact for ABI clients and their families, providing rehabilitation care coordination, service navigation support, referrals to appropriate services, rehabilitation interventions in the community and ABI education and consultancy. BICS RCs aim to improve quality of life and independence, support the achievement of community integration goals and establish sustainable networks of support for clients and their families. ABIOS developed and delivered a new 2-day training package to each of the four BICS.
Alongside ABIOS, a RC Community of Practice has been established, meeting monthly to build workforce capacity across Queensland, and foster a collaborative approach to skill and service development. Development of client resources is also occurring. The four BICS established standardised referral criteria, triage criteria and service outcome measures. Key outcome measures were collectively decided, including the Mayo-Portland Adaptability Inventory (MPAI-4), the Quality of Life after Brain Injury (QoLIBRI) and a Patient Reported Experience Measure (PREM), helping to inform improvements to services locally. Through predominately internal service promotion activities within each HHS, all four BICS have reached service capacity and now have waitlisted clients.
Discussion
Collaboration between the BICS sites and ABIOS has been crucial to BICS success. ABIOS has provided expert advice and support for BICS service development through the duration of the pilot. Each BICS has been able to understand local demand, adapt to local needs, and formulate service expansion strategies to meet growing demand. A key strength across the BICS sites are the passionate and highly experienced rehabilitation clinicians with expert knowledge of their local communities. For Sunshine Coast BICS broader stakeholder engagement, established policies and procedures, escalation pathways (e.g. NDIS) and clearer expectations of the service would be reviewed if developing the service again. Access to cars for community visiting, lack of leave cover and the geographical spread of the Sunshine Coast HHS has provided barriers to service delivery. Delays to clients accessing NDIS, the lack of appropriate providers in the community with ABI experience, and the lack of publicly funded psychology service has also presented challenges.
Furthermore, the nature of the BICS case management work does not align with an activity-based funding (ABF) model. Feedback on the service has been overwhelmingly positive, many clients and family members quoting “life changing”, and “I don’t think I would’ve made it without them”. BICS is currently project funded until June 30, 2025, with both local and Department of Health advocacy occurring in all sites to continue this specialist ABI community service.
References
Statewide adult brain injury rehabilitation health service plan 2016-2026. Brisbane: Queensland Health. System, Policy and Planning Division. (November 2016).
Statewide adult spinal cord injury health service plan 2016-2026. Brisbane: Queensland Health.
Key contact
Kate Harvey
Project Officer (Occupational Therapist) - Brain and Spinal Cord Injury Project
Sunshine Coast University Hospital