The focus of this study was to understand the impact of organizational factors on the spoke & hub model of spinal cord injury and disorders (SCI/D) care in VA, with a specific emphasis on communication between providers who manage patients with pressure ulcers (PrUs). All persons with SCI/D are at risk for developing PrUs due to immobility, lack of sensation, and many other risk factors. PrUs have also become the second most common cause of rehospitalization after an SCI, with estimated annual costs amounting to $1.4 billion in the US. Among patients with neurological impairments, PrUs occur with an incidence of 7-8% annually, with a lifetime risk estimated to be 25-85%. In VA, patients with an acute severe (stage III/IV) ulcer may be referred to an SCI Hub center for inpatient treatment, where it is not at all unusual for inpatient treatment of a severe ulcer to take 3-6 months and in many cases, up to a year. Managing patients with a serious complex illness like a severe PrU across hub and spoke sites, often at great distances from one another can pose a number of communication challenges under the best of circumstances.
Specific study objectives included: 1) a description of the relationship between the spoke & hub model for delivery of SCI care for pressure ulcers (PrUs) in the VA; 2) an assessment of organizational factors that can either facilitate or create barriers to providing high quality PrU care; and 3) recommendations about how to manage the impact of these barriers, facilitators, and organizational factors on veterans with SCI/D at these sites.
Qualitative interviews were conducted with Hub and spokes site clinicians. Interview participants included spoke site coordinators (n=7), physicians (n=5), and a nurse practitioner.
Semi-structured interviews. Participants were asked questions about how different aspects of PrU treatment and prevention were currently being delivered as well as their views of the barriers and facilitators to communication that they experienced in managing patients with and at-risk for PrUs.
Data Analysis. Interviews were audio recorded and transcribed. Qualitative analyses were conducted and approved by the study team. Each transcript was coded separately and any differences were discussed and reconciled by the study team.
Several themes emerged from the participant interviews that inform this question. Each is presented below, along with illustrative and supportive quotes taken from the coded interview transcripts: 1) There are a variety of factors at different levels that influence where SCI patients with severe PrUs receive care; 2) The availability of resources necessary for managing severe PrUs varies between the Hub and Spoke sites and 3) Various factors act as barriers or facilitators to communication about managing PrUs between Hub and Spoke sites. Recommendations addressing the need for educating providers about VA Handbook 1176.1, optimal use of technology to enhance communication between Hub and Spoke sites and the need to increase preventative care are made.
Our study results raise some important questions: Do PrU outcomes vary for patients cared for at a Hub vs. a Spoke site? Does living close to a Hub site (and the accompanying increased access to care) improve outcomes of individuals with PrUs? Does living closer to a Hub site increase a patient's access to preventative care for PrUs? Based on the study results, preventative care for community-dwelling patients with SCI at risk for PrUs appears to be very limited.
Impact Statement: A better understanding of the barriers and facilitators associated with organizational factors and relationships of the spoke & hub model will enable providers, policy-makers and researchers to develop innovative strategies to enhance the delivery of care and services to veterans with SCI/D and PrUs.
None at this time.
Organizational issues, Practice patterns, Spinal cord injury