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.
Specialist coaches 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.
That is the schedule this pathway is being built to. The sessions you can book today are the ones in the written weeks listed below.
| Module | Weeks | Sessions | Cadence |
|---|---|---|---|
| Module 1 | Weeks 1 to 4 | 2 | every other week |
| Module 2 | Weeks 5 to 8 | 2 | every other week |
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 below lead the weeks where their work is the focus.
Professionally, Cindy has been a clinical nurse for nearly a decade. She served in both clinical and administrative capacities throughout her career and holds a Master's degree in Nursing Leadership. As a staff nurse, nurse leader, and quality improvement specialist, she led multidisciplinary teams in academic medical settings throughout Boston, New York, and Ohio to deliver high-quality care to patients across complex diagnoses.
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 Coach |
| ISI | Onboard, q4 weeks | Sleep Coach |
| RTW readiness checklist | Wk 10 | Career Coach + 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