Improving Traumatic Brain Injury Rehab Care With Comm Health Services: a Research Project Within the TBI Model System

The usual Transition Supports and Services (USS) that prepare care partners of persons with TBI for post-rehabilitation discharge, so the the delivery of traditional CHW outreach services such as finding health, community and social determinants referrals, problem-solving, and connecting care partners to long-term supports/services

"Novel aspects of the CHW experimental intervention for TBI care partners include:~1. CHW services begin prior to inpatient rehabilitation discharge;~2. care partners get timely, useful health management materials;~3. encounters focus on unlimited, brief, situation-focused calls to help care partners assess and resolve pressing concerns; and~4. long-term support capacity for care partners is built by establishing a reliable referral network of medical, community, and social services that become foundational resources beyond study completion."