Bridging the Gap: Neuro Transitional Success

What happens when need and vision align? 

A year-long study to assess the post-acute neurorehabilitation needs and support the transition to home for patients following a brain or spinal cord injury, stroke or other neurologic injury led to the creation of an important new neuro-transitional program at Baylor Scott & White Institute for Rehabilitation (BSWIR).

“For quite some time, we had envisioned a highly specialized program designed to facilitate support the safe transition from acute care or levels of care to home for thee patient populations. This study confirmed the need for such a program, noting a critical gap in the continuum. It was one of those ‘aha’ moments when we recognized our opportunity to change the trajectory of patient recovery,” said Jane Boutte, director of operations.

In August 2019, the Neuro Transitional Center opened in Dallas, adjacent to BSWIR’s rehabilitation hospital and Baylor University Medical Center, part of Baylor Scott & White Health. The location was chosen to allow access to the BSWIR campus’ extensive rehabilitation resources, as well as to emergency services and medical support, if needed.  

The 7,000 square-foot center offers a homelike setting, with nine private patient suites and three kitchens. A registered dietitian is onsite to help patients increase independence in performing daily living tasks, as well as a full complement of physical, occupational, speech and cognitive therapies, neuropsychology services, behavioral counseling and community reintegration activities.

According to Boutte, this residential environment, “feels like home and is designed to help patients get back to theirs.”


Turning vision into reality

The Neuro Transitional Center offers a more immersive experience and complements BSWIR’s inpatient rehabilitation and outpatient services, including the Day Neuro and Home Health programs. The center’s transdisciplinary teams draw on best practices in post-acute rehabilitation, providing the clinically-proven therapies, advanced treatment and robotic technologies to support individual physical and functional recovery. In addition, the center is the first of its kind in the Dallas-Fort Worth Metroplex to be equipped with a specialized ceiling lift that enhances patient safety and mobility, particularly for those with a spinal cord injury.

To qualify for the program, patients must:

  • Be 16 years or older
  • Require a 24-hour, seven days per week structured environment
  • Be medically stable
  • Have the ability to participate in therapy five days per week
  • Be able to be managed safely outside a hospital setting
  • No longer require round-the-clock physician or nursing care

The impact of COVID-19

Prior to the pandemic, the program conducted a range of weekly community outings to promote functional skill development and real-world practice. Family education and training sessions were held and with overnight stays accommodated. However, COVID-19 limited activities and visitation.

“Our team’s resilience and commitment to care excellence actually led to program improvement and growth,” said Boutte. Additional therapy equipment was moved into the center, virtual platforms were deployed for community skills-building, and family visits and conferences were facilitated using video meeting tools.  Essential caregiver visits were maintained in accordance with CDC and state guidelines.

“Despite its many challenges, COVID prompted a deeper bonding of our team, the individuals we serve and their families, which in turn resulted in even stronger outcomes,” she said.  

The results are in

Since the Neuro Transitional Center opened, 28 individuals – 16 men and 12 women – have successfully completed the program and returned home. Of these individuals, 17 were dealing with the complex challenges of stroke, seven with traumatic brain injury, three with spinal cord injury and one with other neurologic impairment. The average length of stay was 89 days and more than 81% of patients met their goals. Upon discharge, the majority (64%) chose to continue rehabilitation in a variety of BSWIR outpatient programs, 25% returned to full- or part-time work and 11% resumed some or all household responsibilities.

Given the severity of patient impairment upon admission to the Neuro Transitional Center, the number of those able to return to work is particularly significant. In addition, the burden of care on family members following discharge were reduced dramatically. “This is testament to the person-centered, evidence-based approach of our team, the personal determination of our patients and the support of their families and friends,” said Boutte.

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