CONCENTRIC

Model

...improving transitions in care for persons with spinal cord injury

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CONCENTRIC Model Thematic Areas

Person-Centred Care Planning

Objective:

To ensure PwSCI and relevant SCI partners are consistently engaged in the development of and have access to an updated person-centred multidisciplinary care plan across the care continuum.

Core Components:

Ensure care providers engage PwSCI and their family in developing and updating a person-centred multidisciplinary care plan that includes relevant health information, goals, and available SCI resources (Rec. 2).
Provide information on SCI resources that are tailored to the need of each PwSCI in the multidisciplinary care plan (Rec. 3).
Ensure that care plans are accessible to PwSCI and all relevant partners as appropriate throughout the care continuum (e.g. easy to read, understand and obtain a copy of) (Rec. 1).
Establish clear post-discharge follow-up arrangements for PwSCI with scheduled visits to SCI specialized clinics (e.g. Physiatry) at specific intervals (Rec. 4).

Recommendations details

Focus on Healing and Recovery

Objective:

To make healing and recovery key pillars of the rehabilitation process for PwSCI as early as from Inpatient Rehabilitation. Healing refers to all the mechanisms (i.e. interventions, supports, adaptations) that help with recovery. Recovery refers to full inclusion in a meaningful life as defined by each individual.

Core Components:

Care providers and PwSCI to co-determine and agree on realistic recovery goals based on the prognosis and expectations of the PwSCI at every stage of the care continuum (Rec. 9).
Embed and integrate healing and recovery programs/principles into standard rehabilitation protocols or therapy sessions, drawing from current evidence on SCI prognosis (Rec. 11).
Create opportunities for SCI partners to learn, discuss and share current knowledge on SCI prognosis and the healing expectations of PwSCI (Rec. 11).
Integrate current services focused on healing and recovery (e.g. adapted exercise programs, which foster neuro recovery, including adapted recreation and sports programs (Rec. 10)).

Recommendations List

Communication and Collaboration

Objective:

To ensure PwSCI and relevant SCI partners in the community and hospital settings are connected and able to maintain 2-way communication as needed throughout the care continuum.

Core Components:

Develop clear communication processes, protocols or channels to facilitate communication, connection and collaboration between PwSCI, their family, community partners, and care team in SCI centres (Rec. 5).
Promote ongoing two-way communication between SCI specialists and the community care team of PwSCI after discharge (Rec. 6).
Identify and establish connection with relevant SCI partners across the care continuum, particularly those who will serve as main contacts for PwSCI at the community level (Rec. 7).
Create opportunities or platform for SCI partners to collaborate, share knowledge and network with the goal of creating and maintaining a community of practice across the acute care, inpatient, outpatient and community settings (Rec. 8).

Recommendations Details

Peer Support and Education

Objective:

To improve SCI knowledge and self-management skills for PwSCI through peer support, education, and regular relevant knowledge updates.

Core Components:

Review and modify as appropriate existing peer support programs for improving self-management skills of PwSCI (Rec. 12).
Provide training to peers on how to formally teach other peers on self-management, taking into account the variations in peer experiences (Rec. 12).
Organize education days/series in collaboration with PwSCI and partners to provide updated knowledge about SCI and SCI care (Rec. 14)
Provide education for partners, including PwSCI, on how to access SCI-specific resources throughout the care continuum (Rec. 13)

Recommendations List

Resource Accessibility

Objective:

To streamline ways for PwSCI and partners to identify and access appropriate resources (funding, supports, etc).

Core Components:

Create a centralized resource list relevant to PwSCI and other SCI partners especially those relevant to individuals in Alberta (Rec. 16).
Simplify and/or provide suitable guides or templates on the application process for resources, particularly funding with relevant partners (Rec. 15)

Recommendations List