I-SLEPT: Integrated Sleep and Life Engagement Program for Transitions

Sleep is essential to functional recovery in rehabilitation settings; however, sleep is likely to be disrupted during rehabilitation admissions. Adverse effects of these disruptions do not subside after discharge, leading to additional consequences such as poor physical function. Veterans are particularly impacted by poor sleep and medical complexities that can lead to injuries requiring rehabilitative care to support their recovery. This may be more apparent in older Veteran populations. After discharge, Veterans must re-acclimate to their home environment while facing potential changes in their sleep, life engagement (e.g., pleasant activities, physical function), and health. This study will create the I-SLEPT (Integrated Sleep and Life Engagement Program for Transitions) intervention, which will support Veterans by stabilizing their sleep and by maximizing participation in meaningful activities during a critical and vulnerable period of recovery.

Inclusion Criteria: * Admitted to and discharged from VA Boston Community Living Center subacute rehabilitation * English-speaking * Discharged to a home setting * Has capacity and does not have severe cognitive impairment * Obtains a score \>= 8 on the Brief Interview for Mental Status (BIMS) * Endorses at least 2 items as "Rarely/Never" or "Sometimes" on the RuSATED measure AND/OR endorses they are achieving their goals at a "much worse" or "a little worse" level on the What Matters Most Tool. Exclusion Criteria: * Discharged from Long-Term Care, Hospice and Palliative Care, or Spinal Cord Injury bed specialty * Moderate to severe dementia diagnosis, delirium, or active psychosis * Healthcare proxy is activated in electronic health record * A diagnosis of a disorder of hypersomnolence, non-REM parasomnia, or Nightmare Disorder as indicated in electronic health record * High acute risk for suicide