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Telephone Follow-up: Supporting Community Transition Post ABI Rehab

Project Lead: Brianna Bourne, Edith Ng, Sandra Yue, Carmen Volpe

Project Purpose: The targeted outcome of the project was to refine and implement a sustainable telephone follow-up process in the ABI Inpatient Services at Toronto Rehab, UHN.

About the project

The purpose of the project was to refine and implement a sustainable telephone follow-up process in the Acquired Brain Injury (ABI) Inpatient Services at Toronto Rehab, UHN.The objectives of telephone follow-up were:

  • To ease transitions home and to independent community living.
  • To promote patient and caregiver self-management and self-efficacy.
  • To support optimal rehab outcomes and allow for future program development and personal learning.
  • To align with ABI Best Practice Guidelines.

Project leads created a working group comprised of interprofessional clinicians, patients, and caregivers to develop the telephone follow-up processes and tools. The process was piloted and PDSA (Plan-Do-Study-Act) Cycles continued to refine the process.

Resources

Download the complete case report

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