Focus on Healing and Recovery
OBJECTIVE
To make healing and recovery key pillars of the rehabilitation process for PwSCI as early as from Inpatient Rehabilitation. Healing refers to all the mechanisms (i.e. interventions, supports, adaptations) that help with recovery. Recovery refers to full inclusion in a meaningful life as defined by each individual.
Core Components
Person-centred Care Planning
Core Components
Ensure care providers engage PwSCI and their family in developing and updating a person-centred multidisciplinary care plan that includes relevant health information, goals, and available SCI resources (Rec. 2).
Provide information on SCI resources that are tailored to the need of each PwSCI in the multidisciplinary care plan (Rec. 3).
Ensure that care plans are accessible to PwSCI and all relevant partners as appropriate throughout the care continuum (e.g. easy to read, understand and obtain a copy of) (Rec. 1).
Establish clear post-discharge follow-up arrangements for PwSCI with scheduled visits to SCI specialized clinics (e.g. Physiatry) at specific intervals (Rec. 4).
Communication and Collaboration
Core Components
Develop clear communication processes, protocols or channels to facilitate communication, connection and collaboration between PwSCI, their family, community partners, and care team in SCI centres (Rec. 5).
Promote ongoing two-way communication between SCI specialists and the community care team of PwSCI after discharge (Rec. 6).
Identify and establish connection with relevant SCI partners across the care continuum, particularly those who will serve as main contacts for PwSCI at the community level (Rec. 7).
Create opportunities or platform for SCI partners to collaborate, share knowledge and network with the goal of creating and maintaining a community of practice across the acute care, inpatient, outpatient and community settings (Rec. 8).
Focus on Healing and Recovery
Core Components
Care providers and PwSCI to co-determine and agree on realistic recovery goals based on the prognosis and expectations of the PwSCI at every stage of the care continuum (Rec. 9).
Embed and integrate healing and recovery programs/principles into standard rehabilitation protocols or therapy sessions, drawing from current evidence on SCI prognosis (Rec. 11).
Create opportunities for SCI partners to learn, discuss and share current knowledge on SCI prognosis and the healing expectations of PwSCI (Rec. 11).
Integrate current services focused on healing and recovery (e.g. adapted exercise programs, which foster neuro recovery, including adapted recreation and sports programs (Rec. 10)).
Peer Support and Education
Core Components
Review and modify as appropriate existing peer support programs for improving self-management skills of PwSCI (Rec. 12).
Provide training to peers on how to formally teach other peers on self-management, taking into account the variations in peer experiences (Rec. 12).
Organize education days/series in collaboration with PwSCI and partners to provide updated knowledge about SCI and SCI care (Rec. 14)
Provide education for partners, including PwSCI, on how to access SCI-specific resources throughout the care continuum (Rec. 13)
Resource Accessibility
Core Components
Create a centralized resource list relevant to PwSCI and other SCI partners especially those relevant to individuals in Alberta (Rec. 16).
Simplify and/or provide suitable guides or templates on the application process for resources, particularly funding with relevant partners (Rec. 15)