Strengthen effort for young people with an acquired brain injury - coherent continuity of care across secondary and primary health sectors

Agenda Target group and notification Outpatient clinic ”Strengthen Effort for Young People with an Acquired Brain Injury” Co-operation with local authorities

The project Allocation of 10 million DKK to North Denmark Region for a period of 3 years ( ) to ”Strengthen Effort for Young People with an Acquired Brain Injury”. Inaugurate an outpatient clinic which up until 31 December 2016 is responsible for an interdisciplinary examination and neurological assessment of a required plan for rehabilitation. Ensure a smooth transfer from secondary health sector to primary health sector. The predominantly part of the municipalities is responsible for rehabilitation of young people with an acquired brain injury. Enhance the qualifications of internal and external neurologic specialists.

The aim North Denmark Region aims at ensuring a focused and flexible rehabilitation for young people with an acquired brain injury. Ensure that patients between 15 – 30 years are offered a specialised and interdisciplinary ambulant follow-up and neurologic assessment in the secondary health sector, such as preparing a (renewed) plan for rehabilitation. In accordance with the MTV report, these efforts shall meet requirements of ambulant follow-ups in the secondary health sector for young people between years.

The target group Young people between years who either - are discharged from hospital after fracture of the cranium or a disease which can cause severe brain damage. or - are previously diagnosed with an acquired brain injury and thus require a new plan for rehabilitation. Criteria of inclusion: - Apoplexy - Traumatic brain injury (concussion is excluded) - Infections (e.g. meningitis and encephalitis) - Tumors - Encephalopathy (e.g. survivors from heart failure) - Subarachnoid hemorrhage Criteria of exclusion: - Congenital disease, transient ischaemia attack, concussion

Notification From hospital in North Denmark Region: Internal notification is sent to neurological outpatient clinic (code ) Wanted examination: Young People’s Project. Type of notification: Examination. From general medical practioners or medical specialists: Notification is made to Neurological Department (code ) Wanted treatment: Young People’s Project. Further information: Specification of diagnosis, time for the injury, department of hospitalisation, specification of functional ability and possible plan for rehabilitation.

Outpatient clinic: “Strengthen effort for young people with an acquired brain injury” Two main functions: 1. The aim of the project is to register young people being discharged from cerebral impact and to offer ambulant treatment og follow-up. 2. Hospitals/medical specialists/general medical practioners notify young people with an acquired brain injury to ambulant interdisciplinary diagnosis.

Interdisciplinary team, ambulant diagnosis Group of neurologic specialists: Young doctors with neurologic experience Neuropsychologist Occupational therapist Physiotherapist Medical social worker Medical secretary

Procedure of coherent continuity of care Notification Authorisation attached with a notice Brief the municipal contact person Procedure in the clinic days Participate in meetings with local authorities, if required. Telephone contact after ½ year. Contact local authorities as required. 1 year follow-up Feedback from the clinic. Municipal contact person participates. Municipal procedure

Interdisciplinary ambulant examination Patient review Interdisciplinary anamnesis Neurophychologist Occupational therapist Physiotherapist Medical social worker Interdisciplinary conclusion Feedback to: - patient - relatives - local authorities Diagnosing Database Extended examination

Feedback and information of the course of disease to the local authorities The visitation results in an interdisciplinary conclusion and a possible renewed plan for rehabilitation. The young patient and relatives will be invited to a meeting. Municipal collaborators will be invited to a meeting in agreement with the patient. Further initiatives can be arranged, e.g. contact institution of higher education, notify the outpatient clinic of Liaison Psychiatry.

Interdisciplinary co-operation across health sectors The aims: Ensure continuity of care from secondary health sector to primary health sector. Ensure continuation of the work-in-progress. Ensure that the patient establishes contact with a professional coordinator from the local authorities. Ensure that the local authorities acquire knowledge of the patient and the consequences of having a brain injury.

Method: Municipal involvement in giving feedback to the patient Individual continuity of care is handed over to the municipal collaborators. Sketch further development of the course of disease for the patient. Potential advice for rehabilitation will be considered on request by the local authorities. Avoid misconceptions. Possibility of arranging follow-ups with the local authorities in order to ensure a smooth handing over of the plan for rehabilitation.