A growing body of work in public health has demonstrated that the most effective health systems extend beyond episodic care to address prevention, risk, recovery and long-term outcomes (Kindig & Stoddart, 2003; Frieden, 2010).
Nowhere is this more relevant than in trauma care, where injuries are both predictable and preventable, where recovery is often incomplete (National Academies of Sciences, Engineering, and Medicine, 2016), and where there are often opportunities for secondary injury prevention.
In many trauma systems, however, a gap exists between hospital-based care and community-based recovery and prevention.
We call this gap the “missing middle”.
The missing middle is a disconnect in the continuum of care for injured patients. It is the point where trauma patients leave structured clinical environments and encounter fragmented or inaccessible services.
To illustrate this idea, one of us (Josephine Peterson) has developed a schematic representation of the trauma care continuum that highlights the missing middle between acute care and survivorship services (see above).
Within this framework, the missing middle becomes visible as a critical transition point where alignment is lacking and patients are required to navigate their recovery with limited support.
Critical transition point
Community-based injury prevention programs are a case in point.
These programs are often well-established, yet they operate separately from clinical care pathways (National Academies of Sciences, Engineering, and Medicine, 2016). As a result, patients who can benefit most from these programs often never access them.
This gap is particularly evident among older adults recovering from falls, where physical recovery, fear of falling and environmental risks intersect in complex ways (Florence et al., 2018).
For example, the Stay S.A.F.E. (Safe After Falls Education) Initiative was designed to connect hospitalized older adult trauma patients to a community-based fall prevention program following discharge.
However, early implementation efforts revealed a critical insight. The primary barrier to program access was not patient willingness — it was timing, recovery and system alignment. Program data showed that many patients:
- Were discharged to sub-acute rehabilitation
- Required additional recovery time before participating in the program
- Experienced changes in clinical status after discharge
These findings highlight a fundamental misalignment: trauma systems often attempt to deliver prevention interventions within clinical timelines that do not match patient readiness.
— and where targeted interventions, such as coordinated programs and digital tools, can be intentionally embedded.
From concept to system design
Addressing the missing middle is less about creating new programs and more about redesigning how existing programs are connected across the continuum of care. Key strategies include:
Aligning interventions with recovery trajectories. As noted above, early results from the Stay S.A.F.E. Initiative demonstrated that many older adults recovering from fall-related injuries are not ready to participate in community-based fall prevention programs immediately after discharge. These patients often require additional time to regain strength, mobility and confidence before participating. One possible solution: Rather than offering enrollment only during the inpatient stay, referrals can be timed to coincide with recovery and readiness.
Implementing longitudinal eligibility screening. Eligibility should not be viewed as a single decision made at discharge. Patients can be reassessed throughout recovery and, after completing one evidence-based program, matched to additional interventions based on their evolving level of fall risk. For example, our trauma center’s injury prevention program uses the National Council on Aging’s Falls Free CheckUp to guide placement into one of four evidence-based fall prevention programs. This allows participants to continue to transition between programs as their needs change.
Strengthening cross-role coordination. Successful transitions require collaboration across disciplines. During discharge planning, social workers identify transportation or technology barriers, nurse navigators monitor recovery, and injury prevention specialists facilitate connections to community-based programs. At our center, these team members meet weekly to reassess patients, coordinate referrals, and identify the most appropriate next steps.
Building structured follow-up pathways. Maintaining contact after discharge creates opportunities to reinforce prevention messaging, reassess fall risk and support continued engagement. Patients may move between evidence-based fall prevention programs as their needs evolve and, in some cases, become peer leaders for A Matter of Balance or certified Tai Chi for Fall Prevention instructors. In this way, survivors not only reduce their own risk of future injury but also become partners in preventing injury within their communities.
These approaches shift the focus from program availability to timing, coordination and continuity. Importantly, bridging this gap will likely require a combination of high-touch, patient-centered interventions and scalable infrastructure to support continuity across settings.
Complementing these efforts, emerging digital solutions may extend the reach and continuity of care.
For example, Project STEDI (Scaling Technology for Education, Dissemination, and Implementation of Fall Prevention Resources), currently in development, is designed as a web-based platform and mobile application that connects older adults and caregivers to evidence-based fall prevention resources, including exercise programs and home safety education.
When introduced during discharge and paired with structured follow-up through the electronic medical record (EMR), such tools could facilitate ongoing engagement, reinforce prevention behaviors, and strengthen linkages to community-based programs (Bashshur et al., 2016).
Technology alone cannot close this gap, but when embedded within clinical workflows and community partnerships, it can serve as a powerful facilitator of continuity. Together, these approaches illustrate how the missing middle can be operationalized through integrated, multi-level strategies that extend beyond the walls of the hospital.
Operationalizing comprehensive care
Trauma systems have long embraced the idea of comprehensive care. The challenge now is not defining the continuum but operationalizing it. Addressing the missing middle requires a shift:
- From programs to pathways
- From availability to accessibility
- From discharge to continuity
By focusing on the connection between hospital and community, and by integrating both high-touch interventions and scalable infrastructure, trauma systems have an opportunity to improve not just survival, but recovery, independence and quality of life.
If trauma systems are to achieve their full potential, the work cannot end at discharge — it must continue where patients live, recover, rebuild and ultimately become partners in prevention within their own communities.
References
Bashshur, R. L., Shannon, G. W., Smith, B. R., et al. (2016). The empirical foundations of telemedicine interventions in primary care. Telemedicine and e-Health, 22(5), 342-375.
Florence, C. S., Bergen, G., Atherly, A., et al. (2018). Medical costs of fatal and nonfatal falls in older adults. Journal of the American Geriatrics Society, 66(4), 693-698.
Frieden, T. R. (2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(4), 590-595.
Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380-383.
National Academies of Sciences, Engineering, and Medicine. (2016). A national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington, DC: National Academies Press.
