Trauma rehabilitation and the Transmural Trauma Care Model
A mixed-methods study looked at the implementation of the Transmural Trauma Care Model. Q&A with Suzanne Wiertsema.
Your study looks at how we can better manage adults after trauma. Why is this such an important issue?
Since mortality after severe trauma decreased with the development of specialised trauma centres, the focus of trauma care has shifted from reducing mortality to improving trauma patients’ health-related quality of life.
There is a growing interest in improving the quality of trauma rehabilitation.
However, rehabilitation after trauma is challenging for several reasons.
There are many different causes of trauma and huge variety in the impact and severity of traumatic injuries; in patient characteristics such as age, gender, socioeconomic status and health status prior to the injury; and in recovery trajectories.
There is currently a lack of tailored programs and guidelines for the rehabilitation of trauma patients following their medical treatment.
Your study involved a process evaluation of the Transmural Trauma Care Model. Can you explain what this model is?
The Transmural Trauma Care Model (TTCM) is an advanced transmural rehabilitation model for mild, moderate and severe trauma that aims to improve patient outcomes and reduce costs.
The TTCM guarantees a high-quality rehabilitation process for every trauma patient.
It consists of four linked core components: a multidisciplinary team at the outpatient clinic (trauma surgeon and physiotherapist), individual functional goal setting for each patient, a network of specialised primary care physiotherapists and secured email traffic between the hospital team and the primary care network physiotherapist.
You had previously established that the model had benefits. What were those benefits?
In our previous feasibility study, we provided preliminary evidence that the TTCM improves patient-related outcome measures, such as disease-specific health-related quality of life, functional status and patient satisfaction among mild, moderate and severe trauma patients, with at least one fracture compared with regular care.
We found that the secondary healthcare costs were generally lower among patients treated with the TTCM compared to those receiving regular care.
On the other hand, costs related to primary healthcare, medication, absenteeism and unpaid productivity were higher in the TTCM group.
Suzanne Wiertsema's research aims to improve quality of life through a new model of trauma care.
When all costs were considered, the data suggested that implementation of the TTCM may have the potential to result in lower costs to society, but the uncertainty of these estimates is fairly high.
We are currently carrying out a multicentre study to identify the effects and costs more precisely.
What did the process evaluation involve?
This mixed-method process evaluation was conducted alongside the feasibility study.
We evaluated to what extent the TTCM was implemented as intended by assessing its reach, dose delivered, dose received and fidelity.
To explore the barriers and facilitators associated with the implementation of the TTCM, we organised focus groups with trauma patients, trauma surgeons, hospital-based physiotherapists and primary care network physiotherapists.
The ‘constellation approach’ was used to categorise barriers and facilitators into three categories: structure, culture and practice.
Did the stakeholders have recommendations about how the model could be implemented more faithfully?
Yes, several recommendations for clinical practice were given.
Among others, the most important recommendations for implementing the TTCM are:
- clearly describe organisational structures for care providers at the outpatient clinic and for primary care network physiotherapists (such as communication pathways and templates for standardised documentation)
- clearly describe duties and responsibilities of the participating care providers in a manual
- arrange an appropriate and structural embedded reimbursement system for the hospital-based physiotherapist, who acts as a case manager within the TTCM
- develop several rehabilitation pathways for mild, moderate and severe trauma patients respectively (but be aware that the main goal and strength of the TTCM is the individually tailored rehabilitation path).
Where does research in this area need to progress now?
An important recommendation for future research is to include input from healthcare decision-makers and insurers when planning future studies aimed at implementing care models like the TTCM.
In our case, this may have led to better financial structures in general and reimbursement structures for the physiotherapist at the outpatient clinic in particular.
Future studies could probably give more attention to the aftercare of frail older trauma patients, with a focus on prevention.
>> Suzanne Wiertsema is a clinical physiotherapist in Amsterdam University Medical Center with a special interest in major trauma patients’ rehabilitation. In 2021, Suzanne obtained her PhD with a thesis based on the cost-effectiveness of the Transmural Trauma Care Model. She developed and evaluated this rehabilitation model in cooperation with trauma surgeons and clinical physiotherapists. The results of her thesis were used to further improve the TTCM and to set up a multicentre trial, which is currently running.
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