“Where Do I Go from Here?”: Improving Transitions from Hospital to Community in Rehabilitation Care 1947

Monday, October 27, 2025

4:45 PM - 5:45 PM

Location: ROOM: Williford A >>> DIRECTIONS: Third Floor >>> From the Main Elevator Bank, proceed left. Williford A is the first room on your right.

Corresponding Presenter(s)

Carla Tierney-Hendricks, PhD, CCC-SLP (she/her/hers)

Research Fellow
Spaulding Rehabilitation Hospital
Stoneham, MA, United States

Slides Slides

Presenter(s)

RN

Renee C. Noordzij (she/her/hers)

Medical Student
Spaulding Rehabilitation Center
Boston, MA, United States
Tolu O. Oyesanya, PhD, RN (she/her/hers)

Associate Professor
Duke University School of Nursing
Durham, NC, United States
Mary D. Slavin, PT, PhD

Director of Knowledge Translation, Rehabilitation Outcomes Center at Spaulding
Spaulding Rehabilition Hospital
Charlestown, MA, United States

Non-Presenting Contributor(s)

JS

Jeffrey C. Schneider, MD

Associate Professor, Dept of PMR
Spaulding Rehabilitation, Harvard Medical School
Boston, MA, United States

Presenter(s)

Flora M. Hammond, MD

Professor & Chair
Indiana University School of Medicine
Carmel, IN, United States

Moderator(s)

Janet Prvu Bettger, ScD, MS

Professor and Vice Chair for Research
UNC Department of Physical Medicine and Rehabilitation
Chapel Hill, NC, United States

Transitional care–interventions recognized by CMS to bridge the gap between different levels of care or care settings–is known to ensure continuity of care and reduce the risk of medical complications and readmissions. However, the evidence of benefit for rehabilitation populations is only just emerging. The session will describe this critical gap and highlight key research focused on post-acute transitional care for populations of patients who experienced burns, traumatic brain injury, post-stroke aphasia and spinal cord injury. From these population specific studies, we will synthesize the commonalities in the post-acute needs and strategies across rehabilitation populations and highlight the unique considerations relevant to specific clinical conditions. Additionally, we will facilitate a discussion about how this work can inform clinical care processes and future intervention and implementation research.

Learning Objectives:

Define transitional care and its importance to long-term outcomes in rehabilitation.
Examine intervention components and strategies for post-acute transitional care across rehabilitation populations. (i.e., stroke, burn injury, brain injury, spinal cord injury).
Reflect upon the commonalities and unique considerations for transitional care across various rehabilitation populations.