Transmural care in the rehabilitation sector: implementation experiences with a transmural care model for people with spinal cord injury

International Journal of Integrated Care, 2005 · DOI: · Published: June 1, 2005

Spinal Cord Injury Healthcare Rehabilitation

Simple Explanation

Transmural care aims to improve healthcare by fostering cooperation and coordination between general and specialized caregivers, sharing responsibility, and specifying delegated responsibilities to meet the patient's needs. This study focuses on developing and implementing a transmural care model for individuals with spinal cord injury (SCI) to address health problems and improve care continuity after they leave the rehabilitation center. The core of the model involves a transmural nurse who connects individuals with SCI in the community with primary care professionals and the rehabilitation center, providing support and promoting continuity of care.

Study Duration

30 Months

Participants

134 people with SCI

Evidence Level

Process Evaluation

Key Findings

1
The transmural care model was not fully implemented, with differences observed between the two rehabilitation centers.
2
Enabling factors and barriers to implementation were found at the level of individual professionals, organizational and financing aspects, and the social context.
3
The most significant weakness was the lack of sufficient time to carry out all planned activities, while the strength of the model was its ability to support patients post-discharge, aid primary care professionals, and provide feedback to clinical rehabilitation teams.

Research Summary

This study examined the implementation of a transmural care model for individuals with spinal cord injury (SCI) in two rehabilitation centers, focusing on the role of a transmural nurse in connecting patients, primary care, and the rehabilitation center. The model's implementation varied between the centers, with individual patient support being prioritized over activities promoting care continuity. Pressure sores, bladder, and bowel problems were common health issues addressed. To improve the model, the authors recommend tailoring the care more to the patients’ needs, extending the target population, providing enough education on the competencies needed and embedding the intervention in the local organisational structure.

Practical Implications

Improved Patient Support

The transmural care model facilitates the support of patients after discharge, addressing their health problems and improving their quality of life.

Enhanced Primary Care Collaboration

The model fosters collaboration and communication between rehabilitation teams and primary care professionals, ensuring continuity of care.

Informed Rehabilitation Practices

Feedback from transmural nurses can inform and improve clinical care practices within rehabilitation teams, leading to better patient outcomes.

Study Limitations

1
The content of patient contacts was based on nurses’ records and not on a full record of what had been said and done
2
The number of problems and interventions described may be an underestimation of the actual number of problems and interventions applied
3
The study was small and only included the experiences of the transmural nurses (and not those of the patients and other caregivers)

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