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Comparison of two Dutch follow-up care models for spinal cord-injured patients and their impact on health problems, re-admissions and quality of care.

Bloemen-Vrencken JH, de Witte LP, Post MW, Pons C, van Asbeck FW, van der Woude LH, van den Heuvel WJ

Rehabilitation Centre Hoensbroeck, Hoensbroek. j.bloemen@srl.nl.

Objective: To evaluate whether transmural care for people with spinal cord injury living in the community has more impact on health outcomes than traditional follow-up care within the Netherlands.Design: Quasi-experiment with 12 months of follow-up.Setting: Eight Dutch rehabilitation centres.Subjects: Thirty-one patients who received transmural care in two ;experimental' rehabilitation centres were compared with a matched sample of 31 patients having received ;usual follow-up care' in six other rehabilitation centres.Intervention: The core component of the transmural care consists of a transmural nurse, who ;liaises' between former patients living in the community, primary care professionals and the rehabilitation team. The transmural care model provides activities to support patients and their family/partners and activities to promote continuity of care.Main measures: The prevalence of pressure sores and urinary tract infections; the number and duration of re-admissions to hospital and rehabilitation centre due to pressure sores, bladder and bowel problems; and the experienced quality of follow-up care.Results: The transmural care, as implemented, did not influence the health outcomes. The prevalence of pressure sores, urinary tract infections and the number of re-admissions (due to pressure sores, bladder and bowel problems) was respectively 13, 13 and 4 in the intervention group versus 14, 15 and 6 in the usual follow-up care group. Since the transmural care had been incompletely implemented and there were methodological and practical limitations, we formulated no final conclusions regarding its effectiveness.Conclusion: Implementing the transmural care model strictly according to protocol may improve its effectiveness.

Published 6 November 2007 in Clin Rehabil, 21(11): 997-1006.
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