Models of Care and Primary Care

After an 8 week inpatient rehabilitation stay, Mr. LM is eager to return home. His parents have rented a wheelchair accessible home and are in the process of selling their home and purchasing a new one closer to the University. Together with government provided home care services, Mr. LM’s mother will help with care giving, hoping that tort funds will be available in the future.

Mr. LM’s new home is a 3 hour drive from a tertiary care spinal cord centre. Mr. LM is interested in the models of care available to patients with spinal cord injuries.

Describe different models for integrating rehabilitation and primary care in individuals with SCI.
Models integrating rehabilitation and primary care in individuals with SCI are:
1. Clinic approach
2. Self-management
3. Case management
4. Shared care
5. Outreach
6. Community based rehabilitation
Describe the evidence supporting primary care clinical interventions for individuals with SCI.
1.  A transmural care program (nurse liaison) program may not be effective in reducing pressure sores, urinary tract infections or hospital re-admission rates.
2. A telemedicine program is one form of outreach that may be useful for information on bladder and bowl care and other important self care activities which people with SCI might not otherwise receive.
3. An annual Comprehensive Preventive Health Evaluation visit may improve the perception that people with SCI believe that their medical, psychosocial, and equipment needs are being met.
4. A nurse led clinic may provide up-to-date and readily applicable knowledge about bowel and bladder issues and skin breakdown.
5. Clinician adherence to bowel and bladder guidelines may improve with targeted implementation plan.
6. There is a lack of expertise among community providers and the lack of coordination among parts of the health care system with respect to secure health care information and access for people with SCI.
7. A multidisciplinary Health Maintenance Education program may improve patient satisfaction with primary care and may increase knowledge about the prevention and treatment of respiratory complications, autonomic hyperreflexia/dysreflexia, prevention of spasticity, effects of aging with SCI and availability of community resources
8. Receiving case management may lead to better education of local providers, family involvement in rehabilitation, contact with local community resources, specialist support, and skill acquisition and transfer.

For more information please see: Primary Care