What is next after transfer of care from hospital to home for stroke patients? Evaluation of a community stroke care service based in a primary care clinic

Abstract

Context:Poststroke care in developing countries is inundated with poor concordance and scarce specialist stroke care providers. A primary care-driven health service is an option to ensure optimal care to poststroke patients residing at home in the community.Aims:We assessed outcomes of a pilot long-term stroke care clinic which combined secondary prevention and rehabilitation at community level.Settings and Design:A prospective observational study of stroke patients treated between 2008 and 2010 at a primary care teaching facility.Subjects and Methods:Analysis of patients was done at initial contact and at 1-year post treatment. Clinical outcomes included stroke risk factor(s) control, depression according to Patient Health Questionnaire (PHQ9), and level of independence using Barthel Index (BI).Statistical Analysis Used:Differences in means between baseline and post treatment were compared using paired t-tests or Wilcoxon-signed rank test. Significance level was set at 0.05.Results:Ninety-one patients were analyzed. Their mean age was 62.9 [standard deviation (SD) 10.9] years, mean stroke episodes were 1.30 (SD 0.5). The median interval between acute stroke and first contact with the clinic 4.0 (interquartile range 9.0) months. Mean systolic blood pressure decreased by 9.7 mmHg (t = 2.79, P = 0.007), while mean diastolic blood pressure remained unchanged at 80mmHg (z = 1.87, P = 0.06). Neurorehabilitation treatment was given to 84.6% of the patients. Median BI increased from 81 (range: 2−100) to 90.5 (range: 27−100) (Z = 2.34, P = 0.01). Median PHQ9 scores decreased from 4.0 (range: 0−22) to 3.0 (range: 0−19) though the change was not significant (Z= −0.744, P = 0.457).Conclusions:Primary care-driven long-term stroke care services yield favorable outcomes for blood pressure control and functional level.

Profile and outcome of post stroke patients managed at selected public primary care health centres in Peninsular Malaysia: A retrospective observational study

“…Confusion with the multiple clinic appointments, logistic reasons and caregiver-related issues are reasons given for the delay; explaining the wide standard deviation of the timing for first primary care consultation which was up to 252 days, (median 57 days) after discharge from acute care. This finding was almost similar to an earlier work by our group at an urban based primary care clinic in which the first contact with primary care averaged (median) at four months post discharge 10 . As such, this highlighted the need for a standardised protocol to facilitate the transfer of care of patients to community based health care centres, or to incorporate better safety netting measures during the period of transition.…”

“…Altogether, ten 10 FMS’ from total of ten primary care health centres decided to participate in the trial. The remaining six 6 FMS’ who refused participation cited reasons such as low estimated numbers of post stroke patients at the health centre or the FMS and staff at the health centre could not commit to the trial protocol.…”

“…In Malaysia, patients who receive treatment for acute stroke in tertiary or secondary hospitals, are usually managed at hospital-based specialist outpatient or primary care clinics after discharge 10 . Patients in the acute stage are admitted on average between 6.4 days to 9.8 days 8,9,11 before being discharged, mostly to be cared in their homes by family members.…”

“…Hence the need to ensure that secondary preventive measures are in place in order to reduce recurrent stroke and major cardiovascular events. The role of the primary care team in providing secondary preventive care for post stroke or completed stroke patients has been increasingly acknowledged in the past decade 10,15–17 , especially in providing supportive care for patients who have either been discharged from hospitals or reside in underserved areas where specialist stroke services are lacking or geographically challenged 18,19 .…”

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

“…Experts were given an overall briefing on the objectives of the meeting and details on the expected outcomes – i.e., developing the Integrated Care Pathway for Post Stroke (iCaPPS) for patients residing at home in the community. The researcher briefed the experts on the findings of earlier studies performed at local public primary care facilities and on self-reported practices among FMS in managing stroke patients [21, 22]. The experts outlined the usual care processes that are currently in practice in most public health care facilities across the country, describing the process of care from the acute stage until discharge from a tertiary center; they also outlined the subsequent follow-up process that continues in the outpatient setting of the multidisciplinary services required by the patients.…”