Improving TBI Rehabilitation Care Transitions with Community Health Services: A Randomized Clinical Trial (RCT)

Our RCT study, Improving TBI Rehabilitation Care Transitions with Community Health Services, evaluates the effects of supplemental community health services on TBI inpatient rehabilitation to home transitions. Based on broad stakeholder input, the intervention addresses five care partner needs: (1) managing TBI and other health conditions, (2) managing medication regimens, (3) differentiating symptoms and behaviors that require clinical attention, (4) finding resources and advocating for services, and (5) maintaining one’s own health and wellness. Community health transition services begin at IRF admission and are primarily delivered during the first 3-months following discharge. Services include: (a) implementing the discharge plan, reassessing concerns, and modifying plans, (b) facilitating SDOH-related resource identification, navigating systems, and establishing linkages, (c) supporting TBI day-to-day healthcare and safety needs, (d) offering unlimited, brief, situation-focused contacts to resolve pressing concerns, and (e) positively reinforcing care partner activation. Our proposed community health service delivery approach—emphasizing mHealth, brief encounters, just-in-time useful information delivery, and problem-solving—is highly responsive to care partners’ time availability and crisis resolution needs. It represents a marked evolution from offering weekly, one-hour caregiving education sessions. The primary outcome is care partner activation at 3-months post-discharge; secondary outcomes include care partner well-being and emotional distress.