Decreasing re-hospitalizations and emergency department visits in persons with recent spinal cord injuries using a specialized medical home

This study explores whether a specialized medical home can help people with spinal cord injuries (SCI) avoid returning to the hospital or emergency department (ED) in the first year after they leave inpatient rehabilitation. The medical home provided comprehensive support, including pre-discharge communication, medication education, a 24/7 hotline, and multidisciplinary outpatient follow-up. The results suggest that these interventions may indeed reduce the rate of readmission and ED visits for SCI patients.

• 1
  Thirty percent of the individuals were readmitted within the first year after discharge from an IRF, and 24% were readmitted within the first year after onset.
• 2
  The incidence of readmission was 0.46 within one year of IRF discharge and 0.36 within one year of onset.
• 3
  Forty-one percent of the 176 participants visited the ED within the first year after discharge from an IRF, and 36% visited the ED within the first year after onset.