Transition Support

Team members help patients set goals to make this transition easy and manageable. These goals for patients and families often include:

• Assess clients for early prevention of medical complications.
• Reinforce knowledge and skills learned in hospital-based rehabilitation programs.
• Facilitate effective medication management.
• Provide recommendations for home safety.
• Assist in the identification of local community support services.

Clients entering the program will collaborate with a Transition Support case manager to achieve their goals. Clients and case managers work together to:

• Move toward optimal health, safety, and wellness management.
• Follow discharge plan and home care instructions to prevent rehospitalization.
• Develop a client-centered treatment plan in the home.
• Locate and utilize appropriate community resources (financial, healthcare, wellness, etc.).
• Develop self-advocacy for medical, health, and wellness needs

Individuals who have completed rehabilitation but need training to carry over skills and increase functioning in the home and community are appropriate for Shepherd Center’s Life Skills Training Program.

Shepherd Center staff members assess each person’s current functional level to determine the type of training needed to develop compensatory strategies for his/her injury, thus increasing independence and maximizing participation in home/family life. A collaborative approach is used to develop an individualized treatment plan after the assessment.

Life skills training services are offered through Shepherd Center’s Transition Support Program on a fee-for-service basis to include:

• Community support: Assists in locating and utilizing resources and services in his/her community.
• Daily living tasks: Develop a structure to increase independence with daily activities.
• Home management: Assists in organizing the home to develop a system for managing household tasks.
• Money management: Provides training in consumer transactions, budgeting, banking, and bill paying.
• Medication management: Assists in the development of a structured system for taking and filling medication prescriptions. Reinforces the purpose of each medication and potential side effects.
• Meal preparation: Reinforces healthy eating habits and provides training in menu planning, grocery shopping, and meal preparation.
• Safety awareness: Emphasizes personal safety in both home and community.
• Time management: Establishes a structured daily routine by utilizing time management and organizational skills to promote constructive use of time.
• Lawn care/gardening: Evaluates the ability to plan, organize, and perform lawn and garden maintenance tasks.
• Transportation access: Assists with identifying local transportation options. Provides training in the use of transportation systems, including MARTA and MARTA Mobility.
• Health and Wellness: Assists with implementing exercise plans and accessing community resources to sustain a healthy lifestyle post-injury.

Case managers will receive monthly reports. Regular meetings allow clients and their treatment team to discuss progress, ask questions, or make changes to the treatment plan.