SCI Navigator Pilot Project: Bridging the Gap Between Consumers with SCI and the Health Care System

Project Type
Independent
Principal Investigator Name
Alexander Libin, PhD
Principal Investigator Email
Start Date:
10/6/2006
End Date:
9/30/2011
Participating Centers:
Target Population(s):
The specific inclusion criteria of our study participants are (a) age 18 years (b) traumatic SCI within the past 6 months, (c) residence in the NCSCIMS catchment area, and (d) community dwelling prior to SCI. Exclusion criteria include (a) non-traumatic e
Project Website:
Abstract:
The purpose of the Model Spinal Cord Injury program is to study the course of recovery and outcomes following the delivery of a coordinated system of care for individuals with SCI and to demonstrate and evaluate new and improved methods essential to the care, management, and rehabilitation of individuals with SCI. We are developing an innovative pilot project that seeks to significantly reduce the occurrence of pressure ulcers (PU) and to enhance overall health and life satisfaction outcomes after discharge from rehabilitation. Consistent with our overriding NCSCIMS objective to “Add Life to Years” through PU prevention, this project is focused on the individual with newly-acquired SCI entering the community after acute inpatient rehabilitation and has the following specific objectives: 1. To develop and implement a new SCI Navigator Program 2. To reduce the occurrence of PUs through individualized self-management education and increased attendance at medical appointments 3. To improve community living, participation, and life satisfaction through better health (via Objective 2 and consistent with Bush’s New Freedom Initiative (NFI) and NIDRR agenda item) The principal strength of the program is that it employs self-management techniques (such as those used for smoking cessation, obesity management, and now secondary stroke prevention specifically focused on PU prevention while at the same time ensuring timely access to prevention-focused health care services. The project builds on experiences with the NRH-based SCI Peer Mentoring Program (PMP)[iv] and on the Patient Navigator model that has been used successfully with other chronic conditions.