Community re-integration is a core rehabilitation goal following an acquired brain injury (ABI). A primary aim of the Acquired Brain Injury Transitional Rehabilitation Service (ABI-TRS) in Brisbane, Australia, is to facilitate early community re-integration outcomes for adults with ABI and their families during the transition from hospital to home. Results from a 5-year (2017–2021) evaluation of the ABI-TRS demonstrated improved community re-integration outcomes for clients with ABI over time and in comparison to a quasi-control group. This presentation will discuss these quantitative results with reference to key features of the service model, focusing on three community re-integration domains: home integration, social integration, and productive activity.

Method: Individuals with ABI completed the 12-week ABI-TRS community-based program, involving intensive, goal directed rehabilitation using an interdisciplinary, client-centered model. Self or clinician-rated questionnaires were completed at 0 (baseline), 3 and 12 months. Outcomes were compared to an historical quasi-control group (HIST). Specifically, this presentation reports MPAI-4 and SPRS outcomes. Data analysis involved linear mixed model analysis, random intercept models and post-hoc analysis. Data for the period January 2017 to March 2019 were included in the analysis (changes to service delivery commencing with the beginning of the COVID-19 pandemic meant that data post-March 2019 was excluded from analysis). Reported service model data was drawn from a process evaluation undertaken as part of the larger service evaluation.

Results: At baseline, ABI-TRS clients (n = 155) were more impaired across a range of items than HIST (n = 124) including functional abilities, independent living skills, home and community participation, adjustment to injury, interpersonal relationship status and occupational activity. A considerably shorter inpatient stay for ABI-TRS clients may have contributed to this. At 3 months post-hospital discharge, ABI-TRS clients had made significant clinical improvements, but HIST did not, in functional abilities, home and community participation, independent living skills, adjustment to injury and occupational activity. At 12 months post-hospital discharge (ABI-TRS data only), ABI-TRS clients continued to demonstrate statistically significant improvements in these areas. Service model features contributing to community re-integration included: intensive therapy services in the home and community; access to a range of individual and group-based interventions, as well as case management; a functional approach to therapy, with a focus on enabling participation in meaningful life roles, independence in the home and community, facilitating return to productive activities; and a family-centered approach which incorporates family and extended support network needs.

Conclusions: ABI-TRS clients made significant clinical improvements in relevant community re-integration domains which were maintained at 12-months post-hospital discharge. Key contributors from the service model were identified. It can be concluded that participation in ABI-TRS resulted in improved community re-integration outcomes for adults with ABI.