Pre-hospital and trauma care: The Spaulding/Partners TBI Model System begins with rapid air medical transport provided by MedFlight. Helicopters transport patients from the field to one of the American College of Surgeons (ACS) certified Level I trauma centers in Boston on a rotating basis, including the two acute care hospitals in our system, Massachusetts General Hospital (MGH) and Brigham and Women's Hospital (BWH). The Department of Physical Medicine and Rehabilitation (PM&R) at Spaulding Rehabilitation Hospital (SRH) has the same membership as the Department of PM&R at MGH and the Division of PM&R at BWH. All three hospitals are part of Partners Health Care Network. Patients are seen in consultation by members of the Department of PM&R. Continuity from trauma service to inpatient rehabilitation admission is facilitated by the acute care consultation service provided by the Department of PM&R.

Comprehensive rehabilitation: Comprehensive brain injury rehabilitation in the Spaulding/Partners TBI Model System is provided by the 57-bed Brain Injury Rehabilitation Program at SRH. The program is housed in a 38-bed unit and another 19-bed unit. The program provides medical, nursing, physical therapy, occupational therapy, speech and language pathology, behavioral psychology, neuropsychology, recreational, and case management services. Team meetings are held weekly. The program is CARF-accredited for specialized brain injury rehabilitation. Occasional patients with special medical needs are housed on other floors while being treated by members of the brain injury therapy team. All local hospitals refer patients with severe TBI to the Brain Injury Rehabilitation Program. However, the largest sources are the two trauma centers in our Model System. Discharge from the program is usually defined as discharge from the unit. However there are occasional patients who cannot be discharged at the time their program ends. For these patients the end of program is defined as the time when they are designated as on administratively necessary days, skilled nursing facility level, or termination of benefits and the therapies drop to a maintenance level.

Post-Acute Services in Rehabilitation: Post-acute services are provided through the Brain Injury Outpatient Clinic and Rehabilitation Program at SRH, and postacute day and residential programs run by three other organizations: Community Rehab Care, Inc. (CRC), the Center for Comprehensive Services (CCS)-New England (operated by the Mentor ABI Group), and the Commonwealth of Massachusetts Statewide Head Injury Program's Head Injury Centers (SHIP HICS). Dr. Glenn is Medical Director for CRC, CCS, and for the Brain Injury Outpatient Program at SRH. All patients discharged from the Brain Injury Unit are followed through the Brain Injury Outpatient Clinic until there are no additional medical rehabilitation needs. Contact may be re-initiated at any time. TBI Model System research staff initiate re-contact with the clinic when needs are identified during follow-up activities. Linkages and referrals to community-based services may be arranged as well. PT, OT, Speech, and Psychological services can be provided by the Brain Injury Outpatient Rehabilitation Program, CRC, or at one of the CCS residential programs. CCS has several residential programs available. CRC and CCS both have home programs, as does Partners Home Health Care agency.

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