The Multilevel Limb-loss and Preservation Rehabilitation Continuum model (MLPRC): An evidence-based implementation model integrating multiple perspectives to improve outcomes for people facing limb loss

Background: The patient journey from threatened to actual limb loss, subsequent rehabilitation, and limb preservation through the health system is complicated and prone to delays, attrition, and inequities. A shared multi(socioecological)-level conceptualization of this journey among the multiple stakeholders is the first step for systematically improving limb care through identification of bottlenecks and gaps, contributory factors, and responsive interventions and implementation strategies. Objective: To meet this knowledge gap by presenting a novel implementation model, the Multilevel Limb-loss and Preservation Rehabilitation Continuum (MLPRC), that can be used to develop multilevel applications. Methods: MLPRC was developed in three overlapping steps: (1) design of the patient journey through the health system (horizontal element), (2) addition of multilevel perspectives along the journey (vertical element), and (3) implementation facilitation by incorporating implementation model constructs (concentric cells element). Results: MLPRC is an implementation model for limb loss and preservation with three concentric cells: inner context cell (horizontal time-ordered patient journey at patient level, based on phases of amputation rehabilitation and patient journey concepts, and corresponding care delivery at provider/organization-level, based on the continuum of care and lower limb loss rehabilitation continuum concepts, on the journey timeline), less influenceable outer context cell (community, system and policy level perspectives), and outermost implementation cell, based on Proctor Model of Implementation Research, that utilizes inner and outer context cells (concept derived from Exploration, Preparation, Implementation, Sustainment framework) information to define responsive metrics, interventions and implementation strategies. Discussion: Examples of MLPRC use as a blueprint for multilevel applications include patient level (education and navigation instruments), provider level (integrated practice clinic, referral streams), organization level (limb care continuum programs), and community, system, and policy level (interdisciplinary organizational partnerships, data repositories). Conclusion: MLPRC is among the first implementation model to present both a unified picture of the field of limb loss and preservation and a blueprint for multilevel applications.