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.