BackgroundAlthough Germany’s acute care for stroke patients already has a good reputation, continuous follow-up care is still not widely available, a problem originating in the strict separation of inpatient and outpatient care. This gap in the German health care system does not just lead to patients’ potential readmission to inpatient care and compromise the sustainability of what they have accomplished during medical rehabilitation; it also places a burden on caregivers.MethodsTo illustrate the current procedures on follow-up care of stroke patients in Germany, a systematic literature search was conducted to gather all available evidence. Research articles in the English or German language were searched between 2007 and 2017. Different study designs ranging from non-experimental descriptive studies, expert reports and opinions were included and categorised by two independent researchers. Relevant data was electronically searched through international and national databases and incorporated in a summary grid to investigate research outcomes and realise a narrative synthesis.ResultsA literature search was conducted to identify all relevant information on how current follow-up care is carried out and evaluated in Germany. We identified no systematic reviews on this topic, but included a total of 18 publications of various original studies, reviews and expert opinions. Included study populations also differed in either: experts, caregivers or stroke patients, including their viewpoints on the outpatient care situation of stroke patients; to capture their need for assistance or to investigate caregivers need and use for assistance. So far there is no standardised follow-up care in Germany, but this review reveals that multidisciplinary cooperation within occupational groups in outpatient rehabilitation is a key item that can influence and improve the follow-up care of stroke patients.ConclusionThis review was conducted to provide a broadly based overview of the current follow-up care of stroke patients in Germany. Both the new implementation of a standardised, discharge service that supports early support, to be initiated this year and numerous approaches are promising steps into the right direction to close the follow-up gap in German health care provision.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3235-2) contains supplementary material, which is available to authorized users.

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Zusammenfassung Ziel Durch einen Vergleich der Kommunikation in pflegerisch-therapeutischen Teams von 5 neurologischen Frührehabilitationskliniken eines gemeinnützigen Trägers mit ähnlichem Profil sollen fördernde und hindernde Faktoren der Kooperation identifiziert werden. Methodik Vergleich der interprofessionellen Kommunikation in 5 funktional äquivalenten Kliniken mit den Methoden der Dichten Beschreibung [1], also Architekturplänen, passiv teilnehmender mitgehender ganztägiger Beobachtungen für je eine Woche in 10 Frührehabilitationsstationen, dokumentiert in Memos (Beobachtungsaufzeichnungen). Ergänzt wurden diese Beobachtungen durch teilstrukturierte Leitfadeninterviews (n=39), in denen die Beobachtungen besprochen wurden. Teilnehmende waren Berufsangehörige der Pflege, Physiotherapie, Ergotherapie und Logopädie. Ergebnisse Feste Teams, werktägliche auch informelle Teambesprechungen, gemeinsame interprofessionelle Behandlungseinheiten, stationsbezogene Fortbildungen und informelle Gespräche beeinflussen die interprofessionelle Kommunikation positiv oder negativ (Fraktionsbildung, Kooperationslücken). Dabei haben organisatorische und bauliche Bedingungen einen vermutlich nicht zu unterschätzenden Einfluss auf die Qualität der Kommunikation zwischen den Berufsgruppen. Schlussfolgerung Kurze tägliche Teambesprechungen und die Organisation von Fortbildungen auf Teamebene fördern die interprofessionelle Kommunikation, eine auch baulich und organisatorisch verstärkte Fraktionsbildung Pflege vs. Therapie beeinträchtigt sie.

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