SCI Centers provide the full spectrum of health care needed by the population. Services must include: acute stabilization; acute and sub-acute rehabilitation; acute and sub-acute medical and surgical care; preventive health care; respite care; hospice care, as appropriate; and long- term care consistent with VHA policy.
All patients at the SCI Centers are carefully evaluated by the interdisciplinary treatment team.
An individually tailored comprehensive treatment plan must be initiated for each patient and must reflect direct input and goal setting from the patient.
Documentation of the plan must be complete within 5 working days of admission.
Revision of the plan takes place as needed; however, at a minimum, it must be re- evaluated every 2 weeks, and it must reflect input from the patient.
Treatment conferences (initial or intake, family or discharge planning) are expected to include the patient, and when deemed appropriate, members of the Veteran's local SCI/D PCT using Telehealth technology or other means.
The patient is permitted to have any family member, representative, or other requested individual present during treatment conferences, discussions with staff, and the development or revision of the treatment plan. Patient privacy and confidentiality must be respected during all interactions, treatment conferences and health care rounds.
The Veteran with SCI is assigned to an SCI physician who is responsible for the care of the Veteran for as long as the patient receives care at the medical center. NOTE: This approach promotes continuity and quality patient care.
If the complexity and acuity of the Veteran's care warrants physical transfer to a specialty ward outside the SCI Service, the patient's SCI physician must ensure that SCI/D needs are addressed. This requires the SCI physician and SCI nurse to visit the patient on a daily basis and document their findings in the progress notes. When medically stable, the patient is transferred back to the SCI Service.
After having undergone surgery, patients must be returned to the SCI Center within 24 hours after leaving the recovery room, except in extenuating circumstances. In these cases, the patient's SCI staff physician and appropriate SCI team members must visit the patient, and document their findings in the progress notes. Achievement of optimal functional ability of the Veteran with SCI/D is expected following each course of hospitalization.
Patient education sessions provide the foundation for patient empowerment and responsibility in health maintenance, and these sessions are expected to continue throughout the rehabilitation course of treatment. Appropriate educational topics must include, but are not limited to: spinal cord function, skin care, bladder and bowel management, health maintenance and prevention of medical complications, psychological health, prosthetic awareness, nutrition, activities of daily living, sexuality and fertility, vocational issues, recreation, community accessibility, management of attendants, and equipment maintenance.
Absences from the hospital during an episode of care can be authorized when, in the judgment of the patient and SCI treatment team, time at home would enhance and speed the patient's rehabilitation, or when necessary to facilitate a discharge plan.
After maximum hospitalization benefits have been obtained at the SCI Center, the patient is discharged to a suitable and appropriate environment. In the event the patient requires further hospitalization without SCI specialty care, the spoke referring medical center must accept the return of the patient.
Upon transfer, all pertinent records and x-rays must be available electronically, sent with the patient, or mailed in time to be received before the patient's arrival. The patient's discharge summary and discharge planning progress notes must be provided to the SCI PCT at the time of discharge from the SCI unit for coordination of care and follow-up needs.
Follow-up care is scheduled as clinically indicated for all discharged patients, and managed by the SCI/D PCT.
A patient may choose to stop hospitalization against medical advice (AMA). All AMA discharges are tracked in the QI Program of the SCI Center. When feasible, supportive services or referral to community resources may be provided.
An SCI physician must be on call at all times for assistance and consultation. Medical house staff at facilities having SCI Centers must have appropriate training in SCI emergencies and basic SCI care before assuming on-call duties. SCI physicians must be available for on-call consultations during non-duty hours.