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CONNECT's Life Redesign Model™ - Client and Family Centred Care in Acquired Brain Injuries

Rationale / Objectives

Traumatic Brain Injury is the biggest disabler of Canadians under 45 years of age and an estimated 50,000 strokes occur in Canada each year with incidence rates on the rise in nearly every age group. To help those suffering from acquired brain injuries (ABI) and strokes, CONNECT and British Columbia's Interior Health (IH) partnered to develop the Life Redesign ModelTM (LRM) in 2007 in response to identified gaps in care for this population. In the model, specialized services are provided in a nurturing and innovative community environment to individuals with ABI and strokes. A  coaching-culture is used enabling residents to learn new skills through this teaching method. It also emphasizes the building of neurons after injury, and increasing the resident’s ability to manage their own lives. This community living model is based on the principles of partnership, participation, structured flexibility, accountability and smart risk. 

Project/Program Description & Major Achievements

The LRM program is based on the concept of service delivery driven by the goals of the residents. It involves coaching through multi-professional teams to work with residents and their families to achieve their own goals. The program addresses the need for transitional rehabilitation services for ABI, so individuals can be more effectively integrated into the community. This model also provides 24-hour care for brain injuries, cost effectively. In 5 years, 160 people with ABI substantially progressed to move on from CONNECT to home and greater independence. This translates into healthcare cost avoidance of $239 million over a 20-year period.

Lessons Learned

The approach of CONNECT’s LRM program is based on the culture of personal accountability and independence, which supports the resident’s wishes for their own lives. Additionally, it increases neuroplasticity by allowing the resident’s to pursue their goals in real-life, non-institutional settings. Part of the model's success is also the approach of the coaching as "doing-with" the residents in task, instead of doing for. CONNECT also choses to hire coaches based on how they fit with the organization, not just based on qualifications alone.

People / Organizations Involved

Further Description

CONNECT's LRM is the result of a 2007 request by Interior Health in British Columbia to build a better integrated system for the ABI population. This public private partnership (P3) model facilitated the development of two communities operating in BC (6 purpose-built condos with 7 bedrooms each in Kelowna), with more to be opened in Onatrio shortly (Hamilton in 2018). In the CONNECT LRM community, the residents function integratively with each other and with the organization in numerous ways that promote the brain changing and making new connections. The model exposes residents to real-life experiences and brings complexity and continuity to the rehabilitation setting. A major area of service is the CONNECT coaching staff. The coaches support and encourage residents to build a day based on their own preferences, giving them autonomy over their own lives. The coaches employed for the model include an independence coach (occupational therapy), a physical coach (physical therapy), a communication coach (speech and language therapy), a play coach (recreation therapy), a health and wellness coach (registered nurse), and a thinking coach (neuropsychologist). The LRM helps individuals to reinvent themselves, and give themselves confidence in their own ability to redesign their lives following life-altering brain injuries. CONNECT residents, on average, are 45 years of age and are expected to survive a further 25 years post injury.

Major Achievements

CONNECT’s LRM has increased the number of people who transition to a home environment and has reduced long-term healthcare costs. After 6 years of using this model, 77% of residents transitioned home or to a place of less dependence after a 9 month stay. Every year in operation, a 28 resident CONNECT could deliver future savings of $8.7 million to the system. This translates into healthcare cost avoidance of $239 million over a 20-year period. Accreditation Canada deemed CONNECT's LRM as a Leading Practice under the Client and Family Centered Care in ABI Services category. 

Metric

Result

Detail

% of residents transitioning to home (or lighter care) setting

77%

*following a 9 month stay

cost-avoidance

$8.7 million

*per year based on a 28 resident CONNECT