Our Services

Bedfordshire Acquired Brain Injury Service 
Bedfordshire Neuro Therapy Services 
Kempston Clinic 
Halsey Road
Kempston 
Bedfordshire   MK42 8AU

Email for general enquiries: ccs.beds.abi@nhs.net
Email for referrals only: ccs.bedsneuro.referrals@nhs.net

Referrer leaflet:

0708 - ABI Service

• are over 18 years old and are registered with a Bedfordshire GP
• have sustained a significant acquired brain injury, which is evidenced by scans and medical records
• are likely to have had a loss of consciousness for longer than 30 minutes, been disorientated and confused for more than a day, had a Glasgow Coma Score of less than 8, and/or a loss of concurrent (ongoing) memory.

*People with a mild / moderate brain injury will be considered on a case by case basis for provision of community rehabilitation based on need.

An acquired brain injury may have been caused by an event such as: 

• trauma e.g. assault, road traffic accident
• Cerebral Anoxia - lack of oxygen to the brain due to a medical emergency such as heart attack
• Complex Cerebral Vascular Accident, such as stroke or haemorrhage
• infection such as encephalitis, or meningitis
• non progressive tumour.

Referrals to the ABI Service are made by Health or Social Care professionals. Once a referral has been received with the required medical and social history, a member of the ABI Service will be allocated to offer an assessment.

The patient can be seen with their family at the hospital, in their home or any other clinical setting.

For patients whose needs are beyond the scope of local services, the ABI service provides clinical case management. This role is underpinned by specialist clinical skills and in-reaches to the acute hospitals once the patient is medically stable. Through assessment and identification of the patient’s clinical needs local solutions are considered where appropriate.

Where specialist in-patient rehabilitation is required the role of the ABI clinical co-ordinator is to guide placement to either Level 1 Specialist Rehabilitation under the NHS England contract or make onward referrals to a range of specialist providers in the independent sector.

Once a placement option has been identified the clinical co-ordinator facilitates funding and regularly monitors the placement on a 6 or 12 weekly basis in order to ensure quality and review the appropriateness of the placement.

Discharge planning is facilitated by the clinical co-ordinator and the wider Multi-Disciplinary Team (MDT). Patients are transferred home, linking in with the ABI community rehabilitation pathway and other community services or when the risks associated with living at home cannot be effectively mitigated then a longer term placement is facilitated with assessment and co-ordination of the appropriate funding stream i.e. continuing healthcare / social services funding.

Some patients who experience stroke may be unable to return home straight away due to the nature of their rehabilitation needs i.e. due to complexity or intensity.

The therapists in the acute hospital will consider if the patient’s rehabilitation can be supported at home through the Early Supported Discharge team, if not, a referral will be made to the ABI team, who will arrange for an interim placement in one of four local specialist rehabilitation units depending on the patient’s specific needs. Placement is funded by the NHS for an average of six weeks with some patients returning to the community earlier and some requiring a longer stay.

The ABI Service will monitor progress with a review at four weeks and facilitate discharge when patient’s needs can be met in the community and/or refer to local services as appropriate. If a longer term placement is required a referral will be made to social services.

The Acquired Brain Injury (ABI) Community Pathway provides a person-centred package of rehabilitation care, delivered in the home environment, for individuals who have experienced an acquired brain injury. Rehabilitation care is provided by a Multi-Disciplinary Team (MDT)  that may include neuropsychologists, occupational therapists and physiotherapists. The exact roles you will interact with will reflect the nature of the ongoing difficulties.

Following a referral to the ABI Community team, a typical rehabilitation journey will start with an initial period of assessment which is most usually conducted by a neuropsychologist and an occupational therapist. Assessment will include emotional wellbeing and cognitive abilities (e.g. memory, communication), with an emphasis on how these might impact your ability to engage in daily activities (e.g. personal care, access to the community, engaging in leisure activities or work).

The assessments will be reviewed by the MDT so that an individual rehabilitation package can be developed that reflects your long term rehabilitation goals. In some cases the assessment may indicate that other services are more appropriate to meet specific needs and the ABI service will make onward referrals and signpost at this stage.

Each ABI is unique and therefore each rehabilitation journey is unique, however as a guide you might expect to be supported through the community pathway for a 12 - 16 week episode. This is a guideline only and care is taken to ensure that a patient is only discharged from the service when there is agreement that their rehabilitation goals are met. Within the community pathway there is provision to support engagement with other groups (e.g. Headway, Stroke Association) that may be beneficial to support your ongoing recovery journey.

The scope of the service in the community includes:

• Support the transition from post-acute rehabilitation through provision of episodes of person centred, evidence based  rehabilitation solutions.
• Intervention at any point of the recovery pathway to support further transition e.g. community integration, return to work.
• Consultation to community rehabilitation services to provide clinical oversight and guidance to community teams that are providing rehabilitation to people with  complex presentation resulting from ABI.
• Liaison with a wide range of services including mental health services, local authority, voluntary services and employers to manage transitions and facilitate sustainable sources of support.
• Planned review in order to prevent breakdown of packages.
• Clinical input and training to support packages of care commissioned through continuing healthcare or the local authority which can result in a reduction of care costs.

 
For patients who have longer term needs due and require placement or a complex package of care, funding responsibilities are considered with Health and Social service colleagues to determine eligibility for different funding streams.

Decisions regarding funding for long term support can be complicated so the team works within the current National Framework for NHS Continuing Healthcare. 

The ABI Clinical Co-ordinators will liaise with social services colleagues during the assessment process to determine eligibility for funding through the NHS (CHC funding) or social services funding.

Once funding eligibility has been established the ABI team will either

• Liaise with social services to ensure thatthere is a thorough handover OR
• Liaise with Bedfordshire CHC team once a placement or care package has been established. The CHC team will be responsible for longer term case management and review and will link in with the ABI team is needs change or specialist input is required.