Objective: 

To ensure PwSCI and relevant SCI partners are consistently engaged in the development of and have access to an updated person-centred multidisciplinary care plan across the care continuum.

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Recommendations:

1.    Ensure accessibility of multidisciplinary care plan post-discharge by patient and relevant partners across the care continuum
2.    Co-develop and revise multidisciplinary care plan in a timely manner with PwSCI, their family and relevant partners
3.    Provide PwSCI individualized information on SCI resources in multidisciplinary care plan in preferred accessible format
4.    Establish and communicate to PwSCI clear arrangement for post-discharge follow-up before discharge e.g. SCI Physiatry clinic follow-up at a set interval and then yearly thereafter