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Spinal Cord System of Care Follow-Up

  • Life-long care for people with spinal cord injury/disease (SCI/D) and associated conditions

    Spinal Cord Program Continuity Clinic

    Our goal is to help people with SCI/D achieve the best possible health and well-being by avoiding common general health complications. During he appointment, we will check neuromuscular issues, bowel and bladder management, skin care, wheelchair positioning, bone and joint health and safety. The follow-up involves an interdisciplinary approach to long-term health needs, with input from physical therapists, occupational therapists, therapeutic recreation specialists, psychologists, social workers and other clinical staff as needed. A nurse coordinator, dedicated to helping people with SCI/D is available to answer questions or provide assistance with pre-visit planning. Findings and recommendations are shared with clients and their physicians, as well as caregivers or other stakeholders, as requested by the client.

    An initial visit is composed of:
    1. a six-hour therapy evaluation
    2. a comprehensive exam by your physician and discussion

    Subsequent visits involve a shortened therapy day, examination by your physician, and discussion of findings and recommendations. 

    Therapy evaluation

    The therapy evaluation is typically scheduled one to two weeks prior to the comprehensive provider appointment. During that day the client will meet with an occupational therapist, physical therapist, psychologist, social worker and therapeutic recreation specialist.

    Common recommendations from the therapy evaluation include:

    • therapy needs or interventions to help achieve better health and independence
    • community resource options
    • equipment needs to improve self-care and mobility
    • life-long care plans which estimate medical and non-medical needs over a lifetime
    • financial resources
    • psycho-social needs
    • vocational status and needs
    • wellness (including weight management), leisure and exercise options
    • aging-related changes

    Comprehensive provider exam

    Some of the topics addressed during the comprehensive provider appointment include:

    • a general health and wellness check
    • neurological classification changes
    • joint health
    • bowel and bladder management
    • skin care management
    • wheelchair positioning
    • community and financial resources
    • safety¬†

    Bringing it all together

    At the end of the comprehensive exam day, clients will meet with their rehabilitation provider for a final comprehensive medical exam and discussion.

    Topics can include:

    • results of diagnostic lab and imaging tests
    • results and recommendations from the therapy evaluation
    • prescription updates or changes
    • pain management
    • orders or referrals for additional testing or equipment
    • referral to the nurse clinician for any final educational needs identified by the doctor or therapy team