Table 1 Intervention Plan

Baseline assessment and usual care

In the hospital, after obtaining informed consent, prior to or shortly after discharge.

Obtain baseline functional and psychological assessments using the following:

 • Short Physical Performance Battery (SPPB),

 • Patient Health Questionnaire-9 (PHQ-9),

 • Generalized Anxiety Disorder Scale (GAD-7),

 • Medical Outcome Study Short Form (SF-36).

See description of Usual Care.

First home visit (TMH intervention starts)

After hospital discharge, 0–1 month post-injury.

Obtain physical, cognitive, and psychological assessments, social and community needs assessment for patient and caregiver, and a thorough medication reconciliation. Review of medical appointments. Use of Healthy Aging Brain Care Monitor (HABC-M) to document symptoms and trigger treatment protocols.

Plan of care development

From start of first home visit to end of second home visit.

Emphasis on coordination of care between primary and specialty services. Document and finalize individualized care plan.

Second home visit

Within 1–2 weeks of the first home visit.

Implementation of individualized care plans and treatment protocols, dissemination of educational materials, and connection to in-home and community services.

6-month interaction period

From first home visit to end of 6 months.

Bi-weekly contact with patient and caregiver at minimum, continue to address identified needs and reinforce treatment protocols, revising as needed. At end of 6 months, transition care to primary care provider.