Community Transition and Preventing Re-hospitalization After SCI: Support Systems and Success (855599)

A spinal cord or brain injury can have devastating effects on the individual, their family, and the community. It is estimated that up to 45% of individuals leaving rehabilitation will experience re-hospitalization in the first year, interfering with successful reintegration. Individuals discharging from acute rehabilitation were stratified into low, moderate or high risk for re-hospitalization at 30 days. The high-risk cohort were offered the transition support program. Those enrolled in TSP vs not enrolled experienced re-hospitalization at a rate of 5.7% vs 18% respectively.

Telephonic and/or face to face visits are designed to prevent re-hospitalization, improve health and safety outcomes, and promote self-advocacy. The clinical team guide participants to establish goals aligned with accessing medical follow up visits, reinforcing daily care regimens and medication adherence, and establishing community connections. The TSP framework will be shared. Opportunities to discuss outcomes with a recipient will guide the Q and A session.