Building the bridge from hospital to home: Phase II in the development of a pilot program to support patients with spinal cord injury/disorder (SCI/D) transition back into the community

ABSTRACT

Background: This project is the second phase of a clinical quality improvement (QI) project, which aims to develop a pilot program to provide transitional services to persons with spinal cord injury (SCI). Transitional services refer to those provided during the acute period post-discharge from inpatient rehabilitation, as persons with SCI reintegrate to community living. The first phase of the QI project is documented elsewhere. Objectives: To contribute to the holistic understanding of the barriers and facilitators that influence the transition process, and ways of supporting persons with spinal cord injury (SCI) through the transition. Methods: This project includes analysis of surveys that were distributed under the previous phase of the QI project as well as development, administration, and analysis of second round surveys. This project also includes an environmental scan and researching evaluation methods for similar projects in the published literature. Provision of services during the COVID-19 pandemic was researched. Results: There are a variety of transitional models of care from outpatient clinics to in-home and communitybased services. Survey respondents described challenges during their transition experience with emergent challenges noted by those who discharged during the COVID-19 pandemic. Community services in Calgary were described to identify gaps in support for persons with SCI during the transition. Conclusions: The transition from hospital to home must be bolstered, and context-relevant rehabilitation is needed. Future programs must be developed to weather uncertain circumstances, such as a global pandemic or inclement weather, to ensure continuous support for persons with SCI.