Brain injury patients in Manitoba need more support when they're discharged from hospital, say members of the rehabilitation team working with a survivor of a fatal crash.

Megan Prince, 19, has spent the past month at the brain injury unit of the Riverview Health Centre. Prince was seriously injured in a fiery car crash on Opaskwayak Cree Nation in April, leaving her with brain hemorrhages, a spinal injury and multiple fractures throughout her body.

In the month she's been at Riverview, she's gone from requiring a wheelchair and not being able to stand to walking. Despite her progress, her health-care workers say there's still a long road ahead.

"We know that the real work starts when they leave here," said Emily Ewert, an occupational therapist working with Prince.

But help is limited at that point.

"There is no co-ordinated team to provide the therapies with physio [therapy] and speech [therapy] and occupational therapy and social work together as a team. It's a concern in general for going back to the community," said Laura Vandurme, Prince's speech and language pathologist.

Prince has daily sessions with a physiotherapist, occupational therapist, speech and language pathologist and nurses, and regular sessions with a social worker.

The team works collaboratively to meet Megan's goals, which include working on her strength, mobility and balance, so she can do things such as take a shower and cook for herself. Her long-term goal is to get back to school and work.

But Megan's discharge is mere weeks away, and when she goes, so does her collaborative therapy.

Riverview Health Centre only sees patients with a brain injury on an in-patient basis.

"[It's] frustrating, absolutely, very frustrating," said Vandurme.

"We know that they've worked so hard to make these gains, and we want them to be able to keep those gains and to continue forward."

While Prince has access to funding for therapy such as physiotherapy in her hometown of The Pas, members of her current health-care team say she might face a wait and definitely won't have the same level of co-ordination.

​They would like to one day see integrated, co-ordinated outpatient services for brain injuries, ideally at Riverview.

"All under one roof, everybody working together seeing same patient at the same time, and having that seamless transition so they leave here, the next week they go to the outpatient clinic," Vandurme said. "And to have that service for as long as they need it."

Prince is eager to return to The Pas, where her family, boyfriend, friends and dog are, but she values her therapy.

"I actually love this team. I think it's really helpful to be able to be in a good environment with good people when I'm working on my recovery," she said.

Ewert said more policy-makers need to understand what she and her co-workers know all too well:

"Brain injury is not a sprint, it's a marathon, and you have to be willing, able to put in services consistently throughout the whole process, not just in the beginning."

Vandurme pointed out the long-term effects aren't always immediately evident.

​"If you're having trouble with paying attention, concentrating, remembering information like paying bills, making sure you're making the right decisions in life and not acting impulsively … all of those things can be tough after a brain injury and not necessarily readily apparent, and that's why that extra support is so helpful," she said.

This story is part of a CBC Manitoba series called "Where Are They Now," about Manitobans whose stories have touched our hearts. Other stories in this series are: