Background
Southeastern Ontario (SEO) is a large, predominantly rural area with an incidence of Traumatic Brain Injury (TBI) (excluding concussion) over the most recent 6 fiscal years of 920: 11.3% had a mental health diagnosis at the time of the TBI. An implementation survey relating to a Guideline for rehabilitation of adults with moderate-to-severe TBI released in 2016, indicated that two high priority best practice recommendations relating to collaboration and continuity of care in TBI and mental health and/or addiction issues, were not fully implemented in this region.

Intervention
A 20-member, multi-sector (rehabilitation, mental health, addictions, corrections and women’s shelter) and lived experience working group met over several months to develop a mechanism for addressing the complex, unmet needs of adults in this region with moderate-to-severe ABI complicated by mental health/addiction issues. The working group developed the referral process, inclusion and exclusion criteria, consent process and forms, discussion format, and performance indicators. 

It was decided to develop a Collaborative in each of 3 sub-areas and this Collaborative has been piloted in one of the sub-areas with data collection relating to process, outcome and sustainability. 

Outcomes
The Collaborative’s purpose is to develop capacity to address complex, unmet needs using a shared-care model incorporating discussion about sequential/concurrent care. The SEO ABI System Navigator coordinates monthly “rounds,” with 7 Collaborative members, including Physiatry, Psychiatry, Addictions Medicine, and community service providers, to address unmet needs of people meeting specified criteria including presence of a high-risk situation defined as “individuals or families facing a number of risk factors that affect multiple areas and in all likelihood will lead to something bad happening, and happening soon.” The discussion was to review only those clients who give consent and to monitor the number of clients who do not consent. Baseline data was gathered over an 8-week period. Providers identified 30 people meeting the inclusion criteria: 80% male; 53% urban, 17% rural, 17% incarcerated; 67% required supported accommodation, 37% required psychosocial intervention, 30% required addiction service; barriers to care through usual means were client refusal (50%), no psychiatrist (23%), and long waiting lists (23%).

The SEO ABI System Navigator is tracking performance indicators related to volume of referrals and unmet needs, referral timeframes, percentage of needs met, barriers to meeting needs, and use of healthcare system and patient flow in SEO. 

Benefits of the Collaborative include:
•	Enhanced provider understanding of services, mandates, roles, and admission criteria 
•	Enhanced collaboration amongst service providers
•	Enhanced understanding of how best to identify and work with people with ABI
•	Better communication amongst service providers about how best to meet the needs of people with ABI
•	Improved continuity and efficiency of care

ABI and Addiction/Mental Health Collaborative