Recovery Insights Lab · Research direction

Needs after discharge

What needs emerge after formal rehabilitation ends—and how do they interact?

The research question

What challenges emerge after discharge, and which combinations make everyday recovery harder?

Fatigue, cognitive changes, emotional health, practical barriers, relationships, and access to care can affect one another long after formal rehabilitation ends.

This work will use survivor-reported experience and rehabilitation partnerships to identify recurring patterns, connect them with participation, and improve follow-up priorities.

Research model

Seeing post-discharge needs as a connected system

The visual keeps the person at the center while showing how needs can reinforce one another—and how we move from survivor feedback to useful follow-up and referral priorities.

Needs after discharge research model A visual model showing interconnected needs after discharge and how survivor feedback and rehabilitation partnership can identify patterns and translate them into better follow-up. Cognition memory · attention · planning Emotional health mood · adjustment Access to care follow-up · services Work, school & roles participation Practical barriers appointments · transport Relationships & caregiver support Fatigue & energy Physical symptoms pain · mobility · function WHAT HAPPENS AFTER DISCHARGE? Needs interact — they do not occur alone OUR APPROACH REACH Follow survivors after discharge LISTEN Surveys, interviews structured feedback MAP Find recurring need patterns LINK Connect needs to daily participation TRANSLATE Shape follow-up and referrals KEY DELIVERABLES Post-discharge needs taxonomy Needs-pattern map Follow-up question set Referral & coordination priorities
Needs do not occur in isolation. Understanding the pattern matters as much as identifying each need.

Contribute to this work

Recovery Insights Lab brings together lived experience, clinical knowledge, and community expertise. We welcome people and organizations who can help make this work more useful and grounded.

Survivors & families

Tell us what changed after discharge

Share needs that emerged, persisted, or became difficult to manage once formal rehabilitation ended.

Clinicians & rehabilitation programs

Help us understand follow-up in practice

Partner on outreach, follow-up questions, clinical interpretation, and where current referrals do or do not meet need.

Community partners

Help connect needs with available support

Share what services exist, where access breaks down, and where coordination could be stronger.

What this work will produce

A clearer map of what people need after discharge

A survivor-informed post-discharge needs map showing which challenges commonly occur together, how they affect participation, and where follow-up or support can be better coordinated.