Outreach Programs
A number of models have been proposed in the literature for enhancing access and quality of primary care for people with disabilities. This review found evidence only regarding outreach models where expert providers, usually from an institutional rehabilitation setting, reach out to supplement the resources of community primary care settings. Table 2 presents information on multidisciplinary outreach programs, including telehealth.
Discussion
The highest quality evidence found in this review showed no effect of an outreach program for maintaining health after discharge from rehabilitation (Bloemen-Vrencken et al. 2007). Bloemen-Vrencken et al. (2007) saw no difference in complications, readmissions, or quality of primary care when a nurse provided liaison from rehabilitation to community primary care.
Another approach to outreach involved a nurse-led clinic aimed at enhancing bowel and bladder care. Participants reported more up-to-date and practical information was obtained from nurses than from their usual primary care providers (Williams 2005).
Beck and Scroggins (2001) also describe an educational intervention aimed at people with tetraplegia and their caregivers. They found significant increases in knowledge and skills related to respiratory complications, autonomic dysreflexia, spasticity, reportable symptoms, effects of aging and availability of community resources.
Other strategies for improving primary care to people with spinal cord injuries include the use of home visits. Prabhaka and Thakker (2004) showed a decrease in readmissions, and an increase in functional status and quality of care using a home visit program.
Since 2011, there have been three articles assessing telehealth programs and three discussing web-based outreach programs. These interventions were typically compared with the more resource-intensive in-person approach to outreach. Dorstyn et al. (2011) compare three published approaches to telehealth technology and applications. Based on meta-analysis, they conclude that there is strong evidence that telephone-based outreach is effective. Young-Hughes and Simbartl (2011) however found that for severe problems with significant functional implications, such as pressure ulcers, the in-person option was more effective. A recent study comparing a telephone outreach program to standard care found that the treatment groupexperienced small reductions in depression, anxiety, and stress levels immediately post-intervention, but a small to moderate increase in anxiety at a 3 month follow-up (Dorstyn et al. 2012). The telecounselling group also experienced some small to moderate improvements in emotionally adjusting to their SCI. These results suggest that telehealth shows promise but further trials incorporating longer treatment periods and larger numbers of participants are needed to definitely establish treatment effects, as well as to eliminate any pre-trial group differences.
Radomski et al. (2011) found that a 12-week weight management program helped individuals with SCI reach their weight and body measurement goals, and Myers et al. (2012) found that an intensive program involving a case manager, dietician, physician and exercise therapists resulted in improvements in some CVD risk factors though both of these studies had small numbers of participants.
Three articles described web-based information programs on general SCI issues (Hoffman et al. 2011), specific skills (Schladen et al. 2011) and treatment decisions (van Til et al. 2010). For those patients who are comfortable with internet technology, these innovative options appear to hold considerable promise.
Conclusions
There is level 1a evidence from meta-analysis that telehealth outreach is effective for meeting information needs of patients (Dorstyn et al. 2011)
There is level 1a evidence from systematic review that telecounselling is effective for managing common SCI comorbidities, including sleep difficulties and pain (Dorstyn et al. 2013)
There is level 1a evidence that telephone counselling led to improvements in anxiety, depression and coping following SCI but more powerful research is required to establish statistically significant differences (Dorstyn et al. 2012).
There is level 2 evidence that an outreach program (Transmural care – nurse liaison from rehab to primary care) does not appear to be effective in reducing pressure sores, urinary tract infections or hospital re-admission rates (Bloemen-Vrencken et al. 2007)
There is level 4 evidence that a weight management program can help individuals meet their goals for weight and body measurements (Radomski et al. 2011).
There is level 4 evidence that outreach in the form of home visits from a multidisciplinary team from the rehab centre led to fewer re-admissions and improved rehab outcomes (Prabhaka & Thakker 2004).
There is level 4 evidence that a multidisciplinary Health Maintenance Education outreach program improves patient satisfaction with primary care and increases knowledge of respiratory complications, autonomic hyperreflexia, spasticity, aging and community resources (Beck and Scroggins 2001).
There is level 4 evidence that a specialised nurse-led community clinic provided up-to-date and readily applicable knowledge about bowel and bladder issues and skin breakdown, and was preferred over a medical clinic (Williams 2005).
There is level 4 evidence suggesting an online forum is not as effective as in-person education, despite being more accessible (Hoffman et al. 2011).
There is level 5 evidence that an intensive dietary and exercise program can improve markers of CVD risk (Myers et al. 2012).
There is level 5 evidence that teleconsultation for wound care led to more outpatient encounters and higher median cost than traditional care (Young-Hughes and Simbartl 2011).
There is level 5 evidence that a web-based Decision Aid for arm-hand treatment options reduces decisional conflict and feelings of uncertainty (van Til et al. 2010).
