People with newly acquired disabilities often face big challenges after returning home following a hospital stay and inpatient rehabilitation services. They and their care partners can benefit greatly from post-rehabilitation transition programs, but there’s an urgent need for these services in Alabama.
In response, UAB Medicine Outpatient Rehab Services partnered with other UAB departments and community groups to help people with disabilities enjoy better health and independence after leaving the hospital. This program, called Empowered Care, supports patients as they return home and learn to manage their well-being after a newly acquired disability.
The Empowered Care program connects patients and their caregivers with the resources, support, and support they need to achieve better overall wellness. UAB Medicine Outpatient Rehab Services is collaborating with UAB Spain Rehabilitation Center, UAB Physical Medicine and Rehabilitation, Lakeshore Foundation, the Alabama Head Injury Foundation (AHIF), UAB School of Health Professions, and UAB Innovation Institute.
With funding from the UAB Strategic Investment Fund, Empowered Care is part of UAB’s larger Forging Ahead plan, which supports large collaborative projects that are aligned with the plan.
Making connections
Jamie Wade, director of Outpatient Rehabilitation Services and Community Partnerships at UAB Medicine, says the program’s main goal is to connect people with disabilities to various rehab services and community partners, to help create a seamless continuum of care from point of injury to a life of wellness.
“This program is a means of making sure that patients are aware of and have access to multiple resources,” Wade said. “Excellent rehab work is already being done on the UAB medical and university campus, and great work is being done by community partners. There is no need reinvent the wheel or repeat any efforts. This initiative instead will coordinate, as much as possible, currently available post-rehab programs, support, and expertise. Collaboration among all these partners and ongoing communication with patients can make their transition back to home and community as seamless as possible. And in turn, it will ensure and maintain better outcomes.”
After leaving the hospital, patients work with a team of experts that may include therapists, mental health professionals, and rehab physicians. The program will also train “peer navigators” – people who can help patients solve problems, find resources, and feel supported. Peer navigators are persons with a lived experience of disability.
“We conducted interviews in 2018 that showed that many patients were going to online chat rooms to talk with other patients,” Wade said. “They were more comfortable problem-solving with them than they were with their health care providers. This prompted us to develop the role of a peer navigator. Peer navigators often have an understanding from their own experiences with disability. It’s a win, because they will have a role in our program that allows them to support others while being successfully employed. This is critical to this initiative.”
A key component will be new technology, such as apps and websites that help patients track their health and stay connected with their care teams. Patients will answer questions about their health using simple navigation tools tailored to individual needs and disabilities. This information will be shared with the peer navigators, who will use it to better coordinate community resources and communicate with the medical team.
As part of helping patients further integrate into their larger community, businesses will be invited to create friendly and welcoming spaces for people with disabilities. Events such as adaptive sports activities will help patients stay active and meet others. Students from the UAB School of Health Professions and staff from UAB Medicine and Lakeshore Foundation will help plan events and support participants.
Where the magic happens
Wade says Empowered Care involves addressing the basic needs of daily living for people whose lives are anything but basic. Knowing what those needs are, through coordinated communication, is crucial. For example, data show that patients with recent spinal cord injuries are more likely to return to an emergency room with a urinary tract infection. Coordinated communication will allow staff to connect them to more appropriate medical services instead.
Better communication also provides insight about why some patients may not be taking advantage of all available resources.
“One thing we discovered is that many patients knew about Lakeshore Foundation but didn’t go,” Wade said. “Imagine receiving excellent treatment and rehab at UAB and then going home using a wheelchair for the first time. You are still in the beginning of your rehab journey, not the end. There are new challenges, and it can be overwhelming. Working out at Lakeshore Foundation to maintain and build strength and coordination can help the person face new challenges, but they may be reluctant to go because they are overwhelmed. Individuals with good health can be a little intimidated and not always motivated to learn their way around a new gym. So, that can be a true struggle for those with newly acquired disabilities who are navigating a new normal.”
Wade says a successful rehabilitation program goes far beyond just medical care.
“It’s about how people function in the real world,” Wade said. “The magic of therapy is what happens when a patient goes outside the four walls of the therapy gym and tries new skills or their new wheelchair in the community. We want to give them all the support we possibly can. Building a network of experts, care partners, and community partners will empower people with disabilities to thrive in the community. I’m thrilled and grateful that the UAB Strategic Investment Fund has provided funding for this project.”
Learn more about UAB Outpatient Rehabilitation Services, which helps patients improve their quality of life following a hospital stay or a serious injury or illness.