Transitions of patients with traumatic brain injury and multiple trauma between specialized and municipal rehabilitation services-Professionals' perspectives

Rehabilitation is a complex field requiring broad interprofessional and interorganizational collaboration. System-induced setbacks, such as rehospitalization and decreased quality of care, can occur when patients transition between services. The focus of this study is the rehabilitation of patients experiencing traumatic brain injury (TBI) and multiple trauma. The aim of the study was to explore rehabilitation professionals' perspectives on interprofessional collaboration and coordination during transitions of patients with TBI and multiple trauma between specialized and municipal rehabilitation services. The study used a qualitative design based on a grounded theory approach. Data were collected at two specialized rehabilitation units through observation of interprofessional meetings and 16 semi-structured individual interviews with participating professionals. Eight focus group discussions were also conducted with professionals at the municipal rehabilitation services. Data were recorded, transcribed verbatim and analyzed using a constant comparative method. Core aspects of rehabilitation practice in specialized and municipal rehabilitation services were identified, together with possible barriers and facilitators of patient transitions between services. The core aspects of rehabilitation practice within the specialized rehabilitation units were interprofessional teamwork, a time-limited perspective on the rehabilitation process and an individualized approach based on specific needs, symptoms and signs. Within the municipal rehabilitation services, the core aspects of practice were multiprofessional teamwork, a long-term perspective on the rehabilitation process and a service-based approach to individual patients. Comprehensive and timely information transfers, joint meetings and videoconferences, and electronic patient records were considered transitional facilitators essential for seamless patient transitions between services.