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Martel L1, Thornton W1, Tefertiller C1
1Craig Hospital, Physical Therapy, Englewood, United States
Background: Rehabilitation doesn't end when a patient discharges from the hospital; he or she will likely have continued and often lifelong challenges to face transitioning back into their home and community. Education during inpatient rehabilitation focuses on many of the health conditions associated with re-hospitalizations, but patients and caregivers are often unable to transfer this education to their home environment beyond the supportive hospital environment.
Purpose: In hopes of addressing transitional challenges and decreasing hospital readmissions, Craig Hospital developed a pilot program titled “Soft Landing”. The primary goal of this program was to support patients through the unique challenges commonly faced by individuals discharging from inpatient rehabilitation to home after a catastrophic neurological injury. The purpose of this presentation is to present what was learned as a result of the pilot program, as well as how results of these experiences were used to develop a peer mentor program aimed at improving the transition back to home and community life.
Methods: The pilot program consisted of 10 supported discharges from both inpatient spinal cord injury and traumatic brain injury. Staff members from various disciplines accompanied each patient and their family members as they discharged home. Staff members documented education, safety and accessibility of the home, and safety and confidence of the patient and family when completing activities of daily living. Each supported discharge revealed unique gaps in education and competence with various aspects of the transition, while also exposing several common themes of challenges our patients face upon discharge.
Results: All patients and families who received supported discharges reported the experience was beneficial and recommended supported discharges for future patients. Using recommendations from staff, patients, and families, hospital work groups were formed to address the common challenges during the supported discharges. Work groups focused on topics including: medication management, equipment, discharge education, and day of discharge preparation. Each work group established goals and actions items to address system wide gaps in care and education.
Conclusion(s): The data gathered from the pilot project has been used to shape our system of care placing emphasis on empowering patients and families to be responsible for their successful home/community re-integration. In addition to changes the working groups have in place, future programming includes establishing a robust peer mentor program which will focus on continued support and empowerment during the first 6-12 months after discharge. Research from similar rehabilitation hospitals has shown that individuals working with peer mentors upon discharge had positive experiences, including fewer re-hospitalizations and higher growth rates for self-efficacy.A three year grant has been received to support the development and implementation of this program to include supported discharges when needed along with continued peer support after transition into the home community occurs. Efficacy of the program will be analyzed using multiple outcome measures including the Satisfaction with Life Scale, the Caregiver Burden Inventory, and the Moorong Self Efficacy Scale.
Implications: The Soft Landing program, lessons learned, and current and future program development can be used as an example for other rehabilitation hospitals throughout the nation and world.
Keywords: Rehabilitation, SCI, TBI
Funding acknowledgements: Craig Hospital and The Jay and Rose Phillips Family Foundation of Colorado.
Purpose: In hopes of addressing transitional challenges and decreasing hospital readmissions, Craig Hospital developed a pilot program titled “Soft Landing”. The primary goal of this program was to support patients through the unique challenges commonly faced by individuals discharging from inpatient rehabilitation to home after a catastrophic neurological injury. The purpose of this presentation is to present what was learned as a result of the pilot program, as well as how results of these experiences were used to develop a peer mentor program aimed at improving the transition back to home and community life.
Methods: The pilot program consisted of 10 supported discharges from both inpatient spinal cord injury and traumatic brain injury. Staff members from various disciplines accompanied each patient and their family members as they discharged home. Staff members documented education, safety and accessibility of the home, and safety and confidence of the patient and family when completing activities of daily living. Each supported discharge revealed unique gaps in education and competence with various aspects of the transition, while also exposing several common themes of challenges our patients face upon discharge.
Results: All patients and families who received supported discharges reported the experience was beneficial and recommended supported discharges for future patients. Using recommendations from staff, patients, and families, hospital work groups were formed to address the common challenges during the supported discharges. Work groups focused on topics including: medication management, equipment, discharge education, and day of discharge preparation. Each work group established goals and actions items to address system wide gaps in care and education.
Conclusion(s): The data gathered from the pilot project has been used to shape our system of care placing emphasis on empowering patients and families to be responsible for their successful home/community re-integration. In addition to changes the working groups have in place, future programming includes establishing a robust peer mentor program which will focus on continued support and empowerment during the first 6-12 months after discharge. Research from similar rehabilitation hospitals has shown that individuals working with peer mentors upon discharge had positive experiences, including fewer re-hospitalizations and higher growth rates for self-efficacy.A three year grant has been received to support the development and implementation of this program to include supported discharges when needed along with continued peer support after transition into the home community occurs. Efficacy of the program will be analyzed using multiple outcome measures including the Satisfaction with Life Scale, the Caregiver Burden Inventory, and the Moorong Self Efficacy Scale.
Implications: The Soft Landing program, lessons learned, and current and future program development can be used as an example for other rehabilitation hospitals throughout the nation and world.
Keywords: Rehabilitation, SCI, TBI
Funding acknowledgements: Craig Hospital and The Jay and Rose Phillips Family Foundation of Colorado.
Topic: Disability & rehabilitation; Education; Neurology
Ethics approval required: No
Institution: Craig Hospital
Ethics committee: Research Task Force
Reason not required: The project was considered a program evaluation/program improvement project.
All authors, affiliations and abstracts have been published as submitted.
