Summary of fellowship:
The goal of the fellowship was to enhance assessment and management skills of patients presenting with protracted concussive symptoms across the lifespan with the implementation of a post emergency department concussion follow up and knowledge dissemination to primary care providers. Patients received follow up phone calls approximately 14 days most ED visit assessing for ongoing symptoms and predisposing factors for persistent concussive symptoms. Patients over the age of 6 were not included in the telephone triage.

The overall learning objectives where to enhance clinical management of patients after sustaining a concussion that have ongoing symptoms after 1 months time. Through literature, clinician mentoring and patient care, skills in the management of adult and pediatric clients with ongoing physiological, vestibular, ocular, affective, cognitive, sleep, and cervico-genic post-concussion disorders were developed. Expertise development focused on assessment, diagnosis, and rehabilitative case management.

Outcomes:
A telephone triage post ED follow up was developed with direct communication with the primary care provider to enhance the continuum of care for patients from acute to community services. Patient education was enhanced both with updated discharge information however also with ability to answer specific questions in phone call follow up. Although a delay in initiating telephone triage led to lower total numbers than expected, a total of 30 patients were eligible to received phone call follow up
in the month of January (Jan. 6-16 Emergency Department visits). A total of 16 patients were successfully contacted. The telephone follow up has been integrated and sustained through resources within the Trauma Program, with patient and provider satisfaction repeatedly emphasized. Primary care providers received basic information around concussion and aiding in return to learn/earn/play guidelines, along with resources in the community to assist in management of ongoing rehabilitation needs. The ED physicians received focused education on the assessment and diagnosis of concussion in the ED, in addition to updated resources for patient dissemination upon discharge from
the ED.

An additional pilot opportunity was identified with the Outpatient Brain Injury Rehabilitation (OBIRS) program to facilitate partnership between community providers and outpatient hospital services to enhance the continuum of care for concussion patients presenting with post- concussion syndrome in Northeastern Ontario. In addition, a community partner position was fostered with the ABI steering committee within HSN to support ongoing work on the wing to wing concussion care model. OBIRS will initiate rotating education sessions for individuals in care in both the community and outpatient clinic on a monthly basis to enhance the educational support provided. These will be initiated in March.

From a broader community level, a clear wing to wing care pathway has been created for concussion patients in the Greater Sudbury Area which focuses on providing the right care to the right patients at the right time, along with clearer data of the burden of concussion on the ED. With in-depth review of ED data, an average of 118 concussion related resentations are made to the Emergency Department on a monthly basis.

Overall Experience:
This fellowship allowed for targeted education in patient care, along with learning from leading provincial/national clinicians in the field that otherwise would not have been able to occur. This has fostered not only clinical expertise in Northeastern Ontario, but also collegial networking that will aid in future research and care advancement partnerships. The fellowship has enhanced the access to services specific to concussion management and treatment in an area of the province that has one of the highest rates of head injury but also the fewest services available. Being able to travel to other sites at CHEO and Concussion North in Barrie was truly a highlight of the fellowship.

Sustainability:
Personal sustainability and incorporation will be continued through integration in a community based interprofessional concussion management clinic. This will enhance access to services and enhance patient care in the local area. The community clinic will also continue to support primary care providers and provide ongoing education through various formats including but not limited to grand rounds, local conference gatherings and 1-to-1 consultation. The fellow has established a position on the Acquired Brain Injury Steering Committee as a community partner to continue to ensure acute to community continuity of care.

The post-ED telephone triage follow up with be assumed through the Regional Trauma Program. Alignment of knowledge base was established and handover complete to allow continuation of telephone follow up with patient approximately 14 days after their visit to the ED. Ongoing evaluation will continue as to the overall outcome metrics of reducing post-concussive presentations to the ED and feedback from primary care providers.