Referral to rehabilitation following traumatic brain injury (TBI) is a critical aspect of recovery and long-term outcome. The benefits extend not only to functional improvement but also to broader quality of life issues including return to work, social participation and overall community integration. Appropriate referral at the conclusion of acute care treatment is particularly important in determining the continuity and quality of care through different phases of recovery. Despite increasing evidence of its effectiveness however, differential access to rehabilitation is common. Patient characteristics are primarily cited as the reason for variations in referral to rehabilitation. Rehabilitation is a labour intensive and costly activity, and with growing demands to reduce overall health care expenditure there is increasing controversy about its provision. Health care practitioners are becoming increasingly important in determining the rationing of resources. The current context suggests the need to focus beyond studies of the effectiveness of rehabilitation, which focus only on the people receiving services, to examine the broader issue of equity of access.
This thesis investigates the patterns of referral from acute care following TBI, as a basis for improving knowledge about the factors influencing referral to rehabilitation for this population. It is argued that referral from acute care is a complex phenomenon that requires different perspectives to fully understand the factors influencing the type of post-acute care referral. The thesis focuses not only on what happens to patients with TBI at the end of acute care, but also the processes that operate to define this end result, and the contexts of care that frame the decision-making. Practitioners are viewed as central in the process of referral, interpreting patient characteristics and negotiating the contexts of care. The thesis draws on social problems theory to guide this complex investigation, and in particular to understand the process and context of referral.
A two-study multiple methods approach was conducted at two acute hospital sites. In the profile of referral study, a medical record analysis was conducted based on a prospective sample of patients with TBI. This provided the opportunity to describe the characteristics of post-acute care referral and to identify predictors of referral to rehabilitation. In the process of referral study, observations of team meetings, interviews with acute care and rehabilitation practitioners, and individual patient case studies were used to gain an in-depth understanding of the complexity of referral. The process of referral study sought primarily to understand referral as a function of patient characteristics and context of care factors, interpreted and mediated by practitioners. The process study was also important to confirm and extend the understanding developed from the profile study, and to explore other aspects of the contexts of care that were not investigated in the profile study. A model of the post-acute care referral process was developed from the analyses.
Place of treatment and review by a rehabilitation practitioner were significant predictors of referral to in-patient rehabilitation in the profile of referral study. Overall, referral to rehabilitation was more common for patients treated at the acute hospital site with an on-site brain injury rehabilitation unit. The process study revealed however that the interpretations and interactions of acute care practitioners were important in explaining the different orientations toward patients with TBI, and the complex process influencing referral to rehabilitation, particularly referral to non-inpatient rehabilitation. There was a strong orientation among practitioners toward clinical characteristics such as physical and cognitive function in referral decisions, although non-clinical factors such as age, family availability, and to a lesser extent, place of residence and Indigenous status, were also important. The interpretative processes of practitioners were further shaped by the involvement and advocacy of acute care practitioners, particularly allied health practitioners; the relationships between acute care and on-site rehabilitation practitioners, and between acute care practitioners and external referral options; the bias toward short-term acute rehabilitation services; the general lack of appropriate post-acute care options; and the value of efficiency of resource use. The interpretations and interactions of acute care and rehabilitation practitioners, and the context of care, were important in explaining patterns of referral rather than patient characteristics, indicating a need to consider improvements in practice and policy to ensure equitable access to rehabilitation following TBI.