For many individuals living with the long-term effects of acquired brain injury and other neurological conditions, rehabilitation is not a finite event, but an ongoing journey. Needs change, goals evolve, and progress does not follow a linear trajectory.
To reflect this, NICE has recently published comprehensive guidance setting out what effective rehabilitation should look like for people living with chronic neurological disorders, including acquired brain injury. This marks a significant step forward in improving consistency, coordination, and access to long-term rehabilitation support across England and the UK as a whole.
Historically, rehabilitation has often been fragmented, difficult to navigate, and heavily dependent on local service availability. The new guideline aims to strengthen continuity and create a more coherent, person-centred approach across the health and social care pathway.
Key Recommendations
The recommendations will be familiar to case managers and rehabilitation professionals, as many already work to these principles. What is different now is that they have been given national endorsement.
NICE sets out that individuals with rehabilitation needs should:
- Receive a holistic rehabilitation needs assessment as early as possible.
- Have a personalised rehabilitation plan with clearly defined and collaboratively agreed goals.
- Be supported by a single point of contact responsible for coordination and continuity.
- Have access to support across emotional, psychological, cognitive, physical, social and communication domains.
- Receive support for family members and carers, recognising their critical role.
- Be provided with equipment and home adaptations to promote independence in daily life
These recommendations align closely with the values of case management, but they are now set as national expectations, not optional enhancements.
The Significance of Coordination
The emphasis on continuity and coordination is particularly important. Case managers have long acted as the “missing link” between services. NICE now defines this coordination as a core component of rehabilitation, shifting the burden away from families and into the system itself.
This supports a model in which rehabilitation adapts as needs change, rather than relying on fixed interventions or arbitrary discharge points. The introduction of a named coordinator or case manager offers stability across transitions such as:
Hospital to Community to Education or Employment to Everyday Life
Done well, this reduces duplication, prevents gaps in care, supports emotional security, and lowers the risk of individuals “falling out” of services.
Potential Benefits
If implemented effectively, the guidance has the potential to support:
- More coherent and joined-up care pathways
- Improved access to support when needs evolve
- Reduced stress and advocacy burden for families
- More equitable service provision across regions
- Greater recognition of the role of carers and supporters
By embedding flexibility, responsiveness, and person-centred planning into the expected structure of rehabilitation, the guidance reframes what “good” looks like across the system.
Looking Ahead: Implementation Considerations
NICE acknowledges that implementation will take time and will require service development. The challenge now lies not in the principles, but in practical delivery.
Workforce capacity will need development. Continuous, person-centred rehabilitation requires sufficient staffing, protected time for coordination, and professionals with skills in long-term case management. This may require expanding multidisciplinary team capacity, investing in training, and recognising coordination as core clinical work.
Roles will need clear definition across NHS, social care and independent providers. Without clarity on responsibility, there is a risk of duplication or gaps. Effective implementation depends on agreed accountability, shared communication pathways, and acknowledgement of the specialist contribution case managers provide.
Commissioners will need to embed case management pathways rather than short-term programmes
For the guidance to be effective, case management cannot be treated as an optional or time-limited add-on. Rehabilitation needs fluctuate over time, and people often move between hospital, community and vocational settings more than once. NICE advises commissioners to ensure that services provide access to a designated single point of contact who is responsible for supporting navigation, continuity and review as needs change. This may be a key contact, key worker or complex case manager, depending on the complexity of the individual’s situation. Embedding this function within commissioned pathways, rather than attaching it to short episodes of care, is essential for delivering consistent and person-centred rehabilitation.
Variation between regions is likely initially. Some areas may already be working in alignment with this model, while others will require time to build structures and capacity. The aim is not immediate uniformity, but gradual and sustainable improvement.
Conclusion
This guidance represents an important and welcome shift in how rehabilitation for neurological conditions is understood and delivered. It places continuity, coordination, and person-centred planning at the centre of best practice. These principles align closely with the core values of case management.
However, publication alone will not create change. Meaningful improvement will require sustained commitment: investment in capacity, clear commissioning strategies, and collaboration across health, social care, education, employment and independent providers.
The framework is now in place. The challenge is implementation.
Case managers are well-placed to lead this evolution. They support individuals and families day-to-day and also shape pathways, inform service design, and ensure that rehabilitation is not an isolated episode, but a consistent, responsive and lifelong support system.
If we get this right, rehabilitation becomes not just accessible, but effective. It provides people with the dignity, independence and continuity they deserve.