The Repatriation Community Programs pilot project was funded by the Ontario Ministry of Health in 1990. Its mandate is to facilitate the return of brain-injured individuals from US rehabilitation facilities to their home communities in Ontario. Most Ontario residents receiving rehabilitation in the US fall into one of two‘hard to serve’groups: (1) those with severe behavioural difficulties; and (2) those at various levels of post-comatose unawareness whose families are unwilling to accept chronic care‘maintenance’. The pilot programme has been charged with demonstrating the feasibility of community-based care for severely brain-injured individuals and their families, as well as developing a model of service delivery and interagency collaboration which will expedite province-wide implementation of similar programmes. This paper describes the collaborative model developed over the first 2 years of the project. Issues leading to this model are identified and elements of the model are discussed.