A number of models have been proposed in the literature for enhancing access and quality of primary care for people with disabilities.  This review found evidence only regarding outreach models, where expert providers, usually from an institutional rehabilitation setting, reach out to supplement the resources of community primary care settings.  Table 2 presents information on four such multidisciplinary outreach programs.

Table 2: Outreach programs

Discussion

The highest quality evidence found in this review showed no effect of an outreach program for maintaining health after discharge from rehabilitation (Bloemen-Vrencken et al. 2007).  Bloemen-Vrencken and associates (2007) saw no difference in complications, readmissions, or quality of primary care when a nurse provided liaison from rehabilitation to community primary care. 

Another approach to outreach involved a nurse-led clinic aimed at enhancing bowel and bladder care.  Participants reported more up-to-date and practical information was obtained from nurses than from their usual primary care providers (Williams 2005). 

Beck and Scroggins (2001) also describe an educational intervention aimed at people with tetraplegia and their caregivers.  They found significant increases in knowledge and skills related to respiratory complications, autonomic dysreflexia, spasticity, reportable symptoms, effects of aging and availability of community resources.

Other strategies for improving primary care to people with spinal cord injuries include the use of home visits.  Prabhaka and Thakker (2003) showed a decrease in readmissions, and an increase in functional status and quality of care using a home visiting program. 

Conclusions

• There is level 2 evidence that an outreach program (Transmural care - nurse liaison from rehab to primary care) does not appear to be effective in reducing pressure sores, urinary tract infections or hospital re-admission rates  (Bloemen-Vrencken et al. 2007)
• There is level 4 evidence that outreach in the form of home visits from a multidisciplinary team from the rehab centre led to fewer re-admissions and improved rehab outcomes (Prabhaka et al. 2003). 
• There is level 4 evidence that a multidisciplinary Health Maintenance Education outreach program improves patient satisfaction with primary care and increases knowledge of respiratory complications, autonomic hyperreflexia, spasticity, aging and community resources (Beck and Scroggins 2001).
• There is level 4 evidence that a specialised nurse-led community clinic provided up-to-date and readily applicable knowledge about bowel and bladder issues and skin breakdown, and was preferred over a medical clinic (Williams 2005).

• There is conflicting evidence about the effectiveness of outreach programs for maintaining health in the community with SCI.