Transmural collaboration in lifestyle care: views of healthcare professionals and individuals with spinal cord injury, cauda equina syndrome, or spina bifida

PURPOSE: Individuals with spinal cord injury, cauda equina syndrome or spina bifida often face challenges in maintaining a healthy lifestyle. A coordinated lifestyle care pathway beginning in the rehabilitation center and continuing into primary care may support the conditions needed for sustainable lifestyle behavior. This study aimed to identify determinants to inform the development and implementation of a lifestyle care pathway.

METHODS: We conducted semi-structured interviews with 19 healthcare professionals and 24 individuals with spinal cord disorders. Separate topic guides were developed for each group to explore experiences, needs and views to identify determinants for implementing lifestyle care across the rehabilitation continuum and a transmural pathway. Transcripts were analyzed thematically.

RESULTS: Determinants spanned three main phases of the pathway. In rehabilitation: embedding integrated lifestyle care within treatment, defining professional responsibilities, coordinating lifestyle care through collaborative, patient-centered practices. In the transition phase: building networks between rehabilitation and primary care, integrating lifestyle support into transition processes, securing sustainable financial structures. Post-rehabilitation: increasing knowledge on condition-specific lifestyle needs, promoting a coaching attitude among professionals, strengthening collaboration and community support.

CONCLUSIONS: The findings emphasize that successful delivery of lifestyle care requires coordinated, well-aligned efforts among professionals and settings throughout the entire care trajectory.