The Impact of a Care Transitions Intervention on People With Brain Injuries and Their Caregivers


  • Kristen Faye Linton Health Science, California State University, Channel Islands
  • Chrissy Stamegna Brain Injury Center of Ventura County
  • Veronica Zepeda Brain Injury Center of Ventura County
  • Charles Watson Brain Injury Center of Ventura County
  • Graal Diaz Ventura County Medical Center
  • Thomas Duncan Ventura County Medical Center
  • Lauren Van Sant Community Memorial Hospital



Care transitions, brain injury, hospital readmission, depression, caregiver burden


As our population ages, the prevalence of brain injuries increases due to strokes and falls. Brain injuries are a leading cause of rehospitalization for patients, and most brain injury survivors experience depression soon after hospital discharge. This study assessed the difference between: 1) survivors of brain injury’s baseline and 30-day depression, functional ability, and quality of life and caregivers’ depression and caregiver burden among those that received the Care Transitions intervention, and 2) 30-day hospital readmissions between survivors of brain injury that received Care Transitions and a control group. The study used a quasi-experimental pre-posttest design. Participants included people with brain injuries who received the Care Transitions intervention (n = 22) and their caregivers (n = 20) compared to a services-as-usual control group of brain injury survivors (n = 27). Care Transitions is a 90-day family-focused, home visitation, coaching hospital-to-home transition intervention. Outcomes were self-reported baseline and 30-day depression, functional independence, quality of life, and caregiver burden. Hospital record data was used to report readmissions. Study results showed that there were statistically significant differences between depression, functional ability, and caregiver burden between pre- and post-survey scores among Care Transitions participants. Care transitions’ participants experienced lower brain injury-related hospital readmissions than the services as usual control group. Social work hospital discharge planning needs to continue beyond the hospital and include home visitation to ensure patient and caregiver needs are met post-hospital discharge.

Author Biographies

Kristen Faye Linton, Health Science, California State University, Channel Islands

Assistant Professor, Health Science

Graal Diaz, Ventura County Medical Center

Trauma Coordinator

Thomas Duncan, Ventura County Medical Center

Trauma Director

Lauren Van Sant, Community Memorial Hospital

Medical Resident


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