The integrated care pathway for post stroke patients (iCaPPS): a shared care approach between stakeholders in areas with limited access to specialist stroke care services

Abstract

BackgroundLack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking.MethodsExpert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres.ResultsIndication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems.ConclusionCoordinated post stroke care monitoring service for patients at community level is achievable using the iCaPPS and its components as a guide. The iCaPPS may be used for post stroke care monitoring of patients in similar fragmented healthcare delivery systems or areas with limited access to specialist stroke care services.Trial registrationNo.: ACTRN12616001322426 (Registration Date: 21st September 2016).

Reabilitação pós-AVC: identificação de sinais e sintomas fonoaudiológicos por enfermeiros e médicos da Atenção Primária à Saúde

“…Besides that, approximately 90% of stroke survivors have functional sequelae (2) , and only 5% to 20% of patients achieve full functional recovery (3) . A stroke is not only one of the most common disease today but also a global public health concern in terms of mortality, disability, and demand for medical and social overheads (4,5) .…”

“…However, studies around the world show that the ongoing patient care in the community is far from ideal, highlighting the variations in the delivery of health services, unmet needs of specialties, and the lack of long-term care guidelines (13,5) . Moreover, these studies highlight that there is a sharing of knowledge and ongoing care between hospital and community teams when related to chronic diseases.…”

“…In developed countries where Primary Health Care is consolidated, as multidisciplinary monitoring and management (13) accelerate the treatment of patients and decrease the time in waiting for the treatment (11,5) , family health professionals work in primary care centers to provide quality treatment and rehabilitation, besides carrying out the necessary referrals. Developing countries face additional challenges in terms of accessing specialized services in stroke care, and a lack of adequately trained staff to provide ongoing rehabilitation (5) .…”

Facilitating Exercise Engagement among Community Dwelling Stroke Survivors: Is a once Per Week Group Session Sufficient?

“…Stroke significantly impacts the physical functioning of survivors. Studies have shown that between 35% and 80% of stroke survivors exhibit certain forms of physical dysfunction following the onset of acute stroke [5,6]. Among the survivors measured at later stage post-stroke, more than half have difficulty in walking, and nearly one-fifth were dependent on others for activities in daily living [5,6,7].…”

“…Studies have shown that between 35% and 80% of stroke survivors exhibit certain forms of physical dysfunction following the onset of acute stroke [5,6]. Among the survivors measured at later stage post-stroke, more than half have difficulty in walking, and nearly one-fifth were dependent on others for activities in daily living [5,6,7]. These physical dysfunctions are often associated with the presence of post-stroke impairments, resulting in an increased energy demand and oxygen consumption to perform simple day-to-day tasks.…”