# ‘I imagine teams!’ – exploring the potential of team-based long-term brain injury rehabilitation in North Norway

## TL;DR

This study explores how team-based rehabilitation can improve long-term care for brain injury survivors in rural North Norway.

## Contribution

The study proposes a framework for team-based long-term ABI rehabilitation in rural areas, emphasizing collaboration and continuity.

## Key findings

- Establishing municipal core teams can strengthen local rehabilitation services.
- Ongoing collaboration between core and specialist teams enhances care continuity.
- Teams can serve as platforms for professional learning and knowledge sharing.

## Abstract

Acquired brain injury (ABI) is a leading cause of disability in adults worldwide, often resulting in long-term impairments that hinder community integration. While advancements in acute care have improved ABI survival rates, significant gaps remain in long-term follow-up. These gaps are exacerbated in rural areas, where dispersed populations, long distances, and limited access to rehabilitation professionals pose challenges. Although team-based approaches are crucial for effective ABI rehabilitation, these approaches have yet to be fully integrated into long-term care, thus highlighting the need for innovation. This study explores the potential of team-based organisation in improving long-term rehabilitation services for individuals with ABI in the rural context of North Norway.

This study employed a collaborative knowledge generation framework inspired by Experience-based Co-design, wherein researchers work with stakeholders to align research efforts and service development. Data were generated during a full-day workshop during which two focus groups comprising health and welfare professionals (n = 10) and individuals with ABI (n = 3) explored the potential of team-based organisation in improving long-term ABI rehabilitation services in a rural context. The data were analysed using a predominantly inductive approach to thematic analysis.

Four key themes were identified: (1) establishing municipal ‘core teams’ at the primary healthcare level to strengthen local rehabilitation services; (2) enhancing care continuity through ongoing collaboration between the core teams and existing specialist ambulatory rehabilitation teams; (3) sharing the management of long-term rehabilitation trajectories between teams; and (4) using teams as platforms for professional learning and knowledge sharing. These themes informed the construction of a framework designed to guide the development and application of team-based long-term ABI rehabilitation.

This study highlights the potential of team-based organisation in enhancing long-term rehabilitation services for individuals with ABI in rural contexts. Establishing core teams within municipalities and fostering ongoing collaboration between these teams and specialist healthcare teams can bridge service gaps to promote community integration and self-management. The proposed framework can guide the development and application of team-based long-term ABI rehabilitation in rural regions. Further research is needed to evaluate the framework’s real-world applicability and impact on rehabilitation outcomes, professional development, and overall service effectiveness.

The online version contains supplementary material available at 10.1186/s12913-025-13894-0.