Personalized model of transition of Hospital-Home care for patients with spinal cord injury hospitalized for intensive rehabilitation.

Abstract

Spinal cord injury generates functional alterations that require continuity of care beyond the hospital setting. Studies carried out at the National Institute of Rehabilitation "Luis Guillermo Ibarra Ibarra" between 2015 and 2024 show a predominance in men of productive age with complete ASIA A lesions, high functional dependence and high risk of secondary complications. Although several countries have developed Hospital-Home (H-H) transition models with favorable results, such as the Veterans Health Administration (VA), in Mexico this process is fragmented, programs aimed at this population are scarce, and there is also no consensus on their design, implementation, and evaluation.

Objective: To evaluate the feasibility of implementing a personalized hospital-home transition model in patients with spinal cord injury treated in a tertiary care hospital.

Methodology A pilot clinical trial-type study will be carried out, randomized, single-center, controlled and open-label, developed in three phases: pre-evaluation and design, implementation of the personalized program and final evaluation of the model. The assignment will be simple random, with a 1:1 distribution between the group exposed to the personalized Hospital-Home transition program and the control group exposed to the usual rehabilitation and hospital discharge program. Blinding will not be feasible due to the nature of the intervention. The sample will be 12 participants, six per group, in accordance with previous studies and CONSORT recommendations for pilot feasibility studies, whose purpose is to assess feasibility, not to demonstrate definitive efficacy. Patients over 18 years of age, of any sex, with stable medical and surgical condition, maximum neurological recovery after acute or subacute rehabilitation, ability to use a wheelchair and functional preservation of upper limbs will be included. Patients with conditions that prevent completion of the program or follow-up will be excluded. Feasibility variables, such as recruitment, acceptance, adherence, program compliance, follow-up, and losses, will be analyzed using frequencies, percentages, means, and standard deviation or medians and interquartile ranges. Preliminary clinical outcomes, such as days of hospital stay, number of readmissions, complications, and adaptability to the home, will be presented by group using point estimates and dispersion measures. Comparisons between groups will be exploratory in nature; for continuous variables, Student's t or Mann-Whitney U will be used, and for categorical variables, Fisher's exact test or chi-square when their assumptions are met. To reduce biases, predefined selection criteria, simple random assignment, clear operational definitions, standardized instruments, systematic recording of outcomes, documentation of follow-up losses, and description of baseline comparability between groups will be applied.

Expected results: Currently, the lack of a formal H-H transition protocol, structured discharge plans, scarcity of educational materials, and insufficient post-discharge follow-up have been identified. It is expected that the implementation of the model will be feasible for patients, caregivers and health personnel.

Conclusions: In this context, the development of a personalized nurse-led H-H transition model represents an emerging innovative proposal to strengthen the continuity of person-centered care and multidisciplinary post-discharge follow-up.