Document Type

Handbook, Guide or Manual (Third Edition)

Publication Date (Third Edition)

2009

Abstract

Introduction

The Spinal Cord Injury Follow-Up Care System is a program that will assist you in your lifetime care once you are discharged from the hospital. The follow-up care system is structured with primary team members being you and your family, the physiatrist (doctor who specializes in physical therapies), nurse clinician and case manager. Team members available for consultation include physical therapists, occupational therapists, recreational therapists, speech therapists, dietitians, urologists, gynecologists, plastic surgeons and podiatrists.

The nurse clinicians are available in the Spinal Cord Injury Follow-Up Clinic at Magee Rehabilitation Hospital and act as the coordinator and liaison between the spinal cord-injured person and all members of the team. The coordination of care is essential to decrease duplication of services and contradictions of management. This will provide you with a consistent person to contact.

The comprehensive follow-up service is then provided through regularly scheduled appointments — the first at one month and then annually. Your inpatient case manager will schedule your one month appointment. You will receive a reminder letter through the mail from the outpatient scheduler, giving specific instructions for your visit. At that visit, you will spend time with each of the primary team members and any consulting members that you request.

The team will discuss your current needs and problems and assist you in addressing them. Some of the commonly discussed areas include medical, equipment, transportation, vocational, educational and adjustment issues.

In addition to your formal appointments, the follow-up nurses are available for questions or problems. They will either discuss the issue over the phone or they may want to have you come in for an evaluation by your physiatrist.

The Spinal Cord Injury Follow-Up Care System also works closely with family members, support groups, family physicians, visiting nurses, therapists, consulting physicians and others involved with your care, helping them to understand spinal cord injury and your individual needs. After each scheduled appointment, a comprehensive report is written, which can be sent to anyone involved in your care.

(19 pages, 339Kb)

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