# Enhancing the Transition from Hospital to Home for Patients with Traumatic Brain Injury and Families

> **NIH NIH R03** · DUKE UNIVERSITY · 2021 · $163,572

## Abstract

ABSTRACT
Despite high risks of readmission and complex medical needs, there are no transitional care standards in the
U.S. for patients with moderate-to-severe traumatic brain injury (TBI). Patients with moderate-to-severe TBI
(age < 65 years) discharged home from acute hospital care without inpatient rehabilitation have cognitive,
physical, behavioral, and emotional impairments that affect their abilities to independently self-manage their
health, wellness, and activities of daily living. Activity limitations often result in increased family involvement for
managing the person’s care. The complexity of needs combined with the fragmentation of healthcare services
creates the perfect storm for mismanaged symptoms, adverse health events, readmissions, and a lower
likelihood of return to work and school. Transitional care is defined as actions in the clinical encounter
designed to ensure the coordination and continuity of healthcare for patients transferring between different
locations or levels of care in close geographic proximity. In other patient groups who experience acute events
(e.g., stroke, myocardial infarction), transitional care management has led to improved patient and family
outcomes. Although preliminary research shows that patients with TBI and families desire and could benefit
from interventions to support the transition from acute hospital care to home, the strength of evidence on this
topic is low. TBI transitional care interventions developed to date are ineffective in improving functional
outcomes and do not incorporate family needs. Thus, the purpose of our study is to first develop and refine a
patient- and family-centered TBI transitional care intervention to support patients with moderate-to-severe TBI
and their family caregivers during the transition home from acute hospital care. The intervention will aim to
improve functional status for patients with TBI, reduce strain for their family caregivers, and direct patients and
families to appropriate resources and care that is concordant with their health-related goals. Second, we will
examine the feasibility and acceptability and assess the preliminary efficacy of the TBI transitional care
intervention. Our primary outcome will be patient functional status at 8 weeks post-discharge. We will also
examine secondary outcomes at 8 weeks post-discharge, including family caregiver strain and preparedness
for the caregiving role, and patient and family caregiver self-efficacy and healthcare utilization. The new
knowledge generated from the proposed research will guide our research team in designing and conducting an
NIH R01 implementation-effectiveness clinical trial of the TBI transitional care intervention and will ultimately
enhance the standard of care for patients with TBI discharged home from acute hospital care and families.

## Key facts

- **NIH application ID:** 10089463
- **Project number:** 5R03HD101055-02
- **Recipient organization:** DUKE UNIVERSITY
- **Principal Investigator:** Tolu O. Oyesanya
- **Activity code:** R03 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2021
- **Award amount:** $163,572
- **Award type:** 5
- **Project period:** 2020-02-01 → 2023-01-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10089463

## Citation

> US National Institutes of Health, RePORTER application 10089463, Enhancing the Transition from Hospital to Home for Patients with Traumatic Brain Injury and Families (5R03HD101055-02). Retrieved via AI Analytics 2026-05-22 from https://api.ai-analytics.org/grant/nih/10089463. Licensed CC0.

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