Who this is for
Adults post-trauma or post-surgery, medically discharged to home. Acute post-op members with complications routed back to surgical team. Members with severe PTSD features routed to Trauma-Informed Care Pathway in parallel.
What brings people here
Post-trauma or post-surgical referral within 12 months of event; PCP referral for delayed recovery; member self-referral after major surgery.
Clinical framework
OneVillage-developed.
How the 8 weeks run
Baseline assessments, your first SMART goal, and the 1:1 that sets up everything after it.
Specialists and clinicians rotate in, and sessions come thickest here. One change at a time, in the domains your baseline flagged.
Re-score, refresh the care plan, and check in 1:1 on what is and is not working.
The remaining domains, at a lighter cadence, and the work of making the early weeks hold under pressure.
Final re-score, relapse prevention, and the plan for what happens next.
When your sessions fall
The program is built in four-week modules. Sessions come thickest at the start, when what you decide matters most, and step down as things settle. That is 5 sessions of 45 minutes across 8 weeks, counting the visit before week 1.
| Module | Weeks | Sessions | Cadence |
|---|---|---|---|
| Module 1 | Weeks 1 to 4 | 2 | every other week |
| Module 2 | Weeks 5 to 8 | 2 | every other week |
Week by week
- Before you beginBefore you begin
This is the reading before your first visit. It covers what this pathway measures, what your discharge paperwork is actually telling you to do, and the standard your surgical care was most likely built on, so that you can tell the parts of recovery that are planned from the parts that are drifting.
- Week 1The first weeks home
Two things belong in the same week: the symptoms that mean stop reading and get help, and the ordinary miseries that are not emergencies but wreck a recovery anyway. Constipation on pain medication is the second kind, and it is the one people are least likely to raise.
- Week 2Rebuilding, alongside your PT
This week you meet Tonia Burke, DPT, a physical therapist. Her work here sits alongside the outpatient PT you may already have, not instead of it, and this week is about what the trial evidence supports, including where it is honestly weak.
- Week 3Eating to heal
Your body is doing construction work and running short of the materials. This week is the protein number this pathway uses, where it comes from, who it does not apply to, and which supplements the evidence supports and which it does not.
- Week 4Halfway: pain, and what recovery actually looks like
This week you see Cindy again and repeat the questionnaires from week 0. The reading is about the shape of a recovery curve, because the most common reason people think theirs has failed is that they were told to expect a straight line.
- Week 5Sleep and pain, in both directions
Pain wrecks sleep, and there is now prospective evidence that poor sleep raises the risk of pain that lasts. That is the whole reason sleep is a week of its own here and not an afterthought at the end.
- Week 6What your nervous system did
This week you meet Kimberly Macon, a mindset specialist, and this pathway screens for post-traumatic stress. The screen is routine here rather than a judgment about you, and this week explains what is known about how these symptoms run over the first year after an injury.
- Week 7Pain that stays
A proportion of people still have pain at six months, it varies a lot by operation, and most people are never told the number beforehand. This week is that evidence, and what it means for the questions worth asking your own clinicians now.
- Week 8Going back to work
This is the last session with Cindy and it is a handover. The review of what actually gets people back to work is unusually clear about which approaches work and which do not, and it changes who needs to be in the conversation.
Who you will work with
Your Whole Health Coach takes your first visit and closes every module, so it is the same person from the first session to the last. The specialists and clinicians below lead the weeks where their work is the focus.
Cindy is a Whole Health Coach with a background in clinical nursing and more than a decade of experience in healthcare. Her experience working closely with patients and multidisciplinary teams has given her a deep understanding of the many factors that contribute to overall health and well-being. Cindy believes that health is about more than any one diagnosis, symptom, or lab result.
Tonia is a Doctor of Physical Therapy, Integrative Nutrition Health Coach, and Certified McKenzie Spine Specialist with over 25 years of experience helping clients heal from pain, injury, and chronic conditions. She specializes in spine care, orthopedic rehabilitation, and restoring strength and vitality through personalized, science-based treatment.
Meet Kimberly Macon, Professional Certified Coach (PCC), wife, mother, and a cancer survivor specialized in helping OneVillage members build mental resilience in the face of difficult situations and life changing events. Kimberly spent more than 15 years working in various roles across the Consumer Packaged Goods Industry within Marketing, Brand Management, Sales and Business Development.
What we work on
| Domain | What this pathway does |
|---|---|
| Nutrition & Metabolism | Wound-healing nutrition: protein 1.2-1.5 g/kg, vitamin C, zinc. Hydration. Constipation mgmt on opioids. |
| Movement & Mobility | Coordinated with outpatient PT. Berg Balance and pain VAS tracked. Fall prevention central. |
| Sleep & Recovery | Pain disrupts sleep; opioids disrupt sleep. ISI q4 weeks; medication review with RN. |
| Stress & Resilience | Adjustment, anxiety about recurrence, financial stress. |
| Mind & Mood | PC-PTSD-5 mandatory in this pathway. PHQ-9 q4 weeks. PTSD prevalence 10-30% post-major-trauma. |
| Career / RTW | RTW readiness checklist; accommodations conversation early. |
How progress is measured
These are the validated tools this pathway uses: at your first visit, at the mid-program review, and at the end.
| Tool | Cadence | Owned by |
|---|---|---|
| Pain VAS | Daily during Acute; weekly Stabilize+ | WHC |
| PHQ-9 + GAD-7 | Onboard, q4 weeks | WHC; LCSW reads |
| PC-PTSD-5 | Wk 6 mandatory | LCSW |
| Berg Balance | Onboard, q4 weeks (if mobility-relevant) | Exercise clinician |
| ISI | Onboard, q4 weeks | Sleep specialist |
| RTW readiness checklist | Wk 8 | Career specialist + WHC |
The research behind this pathway
Your clinician playbook was built from the guidelines and studies below. They are listed so you can read them yourself: every one is a real, published paper and the number at the end of each line is its PubMed ID.
Guidelines this pathway follows
- Enhanced Recovery After Surgery · ERAS Society
The perioperative standard this pathway's before-and-after work follows. PMID 31663402
- Prehabilitation · Systematic review of orthopedic prehabilitation trials
Why preparation before an operation is a module and not a leaflet. PMID 37052919
Key studies
- Punnoose A et al. (2023). JAMA Netw OpenPrehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis
Pooled the randomized trials of prehabilitation before orthopedic surgery. Preparing beforehand improved function and strength going in, function coming out, and back pain before lumbar surgery. PMID 37052919
- Wainwright TW et al. (2020). Acta OrthopConsensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations
The Enhanced Recovery After Surgery consensus for hip and knee replacement, and the source of what this pathway asks of you before and after an operation. PMID 31663402
- Cullen KL et al. (2018). J Occup RehabilEffectiveness of Workplace Interventions in Return-to-Work for Musculoskeletal, Pain-Related and Mental Health Conditions: An Update of the Evidence and Messages for Practitioners
Reviewed what actually gets people back to work after illness or injury. Multi-domain programs that involve the workplace itself worked; health-care-only approaches did not. PMID 28224415
- Martinez V et al. (2024). Eur J AnaesthesiolChronic postsurgical pain: A European survey
A prospective European study of chronic pain after surgery, and the risk factors that predict it. It is why this pathway asks about pain at every visit rather than assuming it resolves. PMID 38414426
- Visser E et al. (2022). Eur J PsychotraumatolPsychological risk factors that characterize acute stress disorder and trajectories of posttraumatic stress disorder after injury: a study using latent class analysis
Followed injured patients for 12 months and mapped the different courses post-traumatic stress can take. Not everyone follows the same trajectory, which is why screening repeats. PMID 35087642