117 - Patient Centered Medical Home Model: a model of comprehensive coordinated care for people with spinal cord injury

Case Diagnosis: C6 AIS A traumatic spinal cord injury (SCI) who has complex medical and psychosocial care needs.

Case Description: This case report follows a 23-year-old Veteran with a C6 AIS A SCI due to an all-terrain vehicle accident. He was dependent on his spouse for bladder management with intermittent catheterization every 4-6 hours, lift transfers, and bowel management. His goal was to maximize his independence and reduce care from his spouse. A Patient Centered Medical Home (PCMH) model was utilized that allowed for integrated, comprehensive and coordinated care. Through specialty healthcare teams, he underwent bilateral upper extremity nerve and tendon transfers, ileocystoplasty with continent catheterizable cutaneous stoma, laparoscopic colostomy lower extremity botulinum toxin injections and mental health care. Each step allowed for more function and progress to greater independence. He now transfers with minimal assistance using a transfer board, is independent with bladder catheterization, manages his colostomy with reduced assistance and has returned to work.

Discussions: The PCMH is a model of care (rather than a physical location) where patients are at the center of the care provided. The primary care team coordinates care throughout the health care system to meet the patient’s values, needs, culture and preferences. This coordinated understanding of the patient’s needs allows for the exploration of a much broader scope of care available to reach their functional goals, and ultimately, their quality of life.

Conclusions: By working together in a PCMH, we can utilize the strengths of each team to optimize patient care based on their unique needs and values. This is a case where we could present each component of this patient’s procedures and care individually as its own unique case with interesting findings. However, the story reveals that it is necessary for multiple disciplines and teams to come together in order to optimize patient care.