​Going Home from Rehab: Now What? Reeve Summit 2021 Session Roadmaps Daunting Transition

Posted by Reeve Staff in Daily Dose on March 31, 2021 # Reeve Summit

Going Home from Rehab: Now What? Reeve Summit 2021 Session Roadmaps Daunting Transition

As anyone who is living with paralysis can attest, the post-hospital transition home is a critical phase. The end of inpatient rehabilitation signals the beginning of a different journey, to reintegrate into home, family and community. This can feel like a daunting task for all involved. Having a roadmap helps.

That’s the idea behind a workshop at the Reeve Summit 2021, “Going Home From Rehab: Now What?” explores what individuals should expect during the transition home and how a structured transition support program (TSP) can help. Laura O’Pry, RN, BSN, CCM, CRRN, Transition Support Program Manager at Shepherd Center, and Pete Anziano, Shepherd’s Peer Support Program Manager, will lead the virtual session.

Transition Support Plans Aim to Prevent Rehospitalization, Improve Health and Safety

TSPs are increasingly prevalent adjuncts to post-hospital rehabilitation. Their primary goal is to prevent rehospitalization, while improving health and safety and supporting autonomy for the individual and family. An estimated 36 and 45 percent of people leaving rehabilitation end up back in the hospital within the first year. This interrupts community reintegration, often just as someone is planning to return to work, school, or other activities. It may also lead to secondary complications.

Preventing rehospitalization has the potential to reduce healthcare costs and improve the probability of successfully reintegrating into one’s community.

Establishing Goals for Day-to-Day Living, Medical Care, and Community Reintegration

“A structured TSP that is individualized and designed based on identified needs provides resources to enhance community re-entry,” says O’Pry. “Shepherd Center’s TSP comprises a team of clinicians who place the family and the patient in the center of all decisions and plans.” The team includes specially trained case managers, recreation therapists, peer support liaisons, and vocational therapists. Guided by data on the most common reasons for rehospitalization, they work with families to establish goals around day-to-day activities. This might include follow-up medical care, daily hygiene and medications, identifying financial resources, and establishing community connections.

Anziano will review research validating the importance of peer mentorship and share how peer involvement augments clinical care. Drawing from their experience at Shepherd, he and O’Pry will provide suggestions on how to translate research findings into actionable items that make a difference now. The session will also include time for open dialogue among participants and Q&A.

Second Annual Reeve Summit April 27-29 Features 40+ Virtual Sessions on Paralysis Topics

The second annual Reeve Summit: Where Care, Cure and Community Connect takes place April 27-29, 2021. “Going Home from Rehab: Now What?” (April 29, 2-3 p.m. EDT) is one of more than 40 virtual sessions that will explore topics relevant to the paralysis community, including advocacy, caregiving, employment, research, and health and wellness. Participants around the globe will have a chance to hear from experts, ask questions, and share their own experiences of living with paralysis.


The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.