Abstract
BackgroundThere is a need for follow-up care after stroke, but there is no consensus about the way to organise it. An intervention providing follow-up care for stroke patients and caregivers showed favourable effects on the level of social activities, but no other effects were found. The intervention consists of a maximum of five home visits to patients and caregivers during a period of 18 months post-discharge. The home visits are conducted by a stroke care coordinator (SCC) using a structured assessment tool. The objective of this study was to examine process-related factors that could have influenced the effectiveness of the intervention.Methods77 stroke patients, 59 caregivers and 4 SCCs participated in the study. Data on the organisational characteristics of and the satisfaction with the intervention were collected by means of structured assessments, interviews and self-administered questionnaires at 1, 6, 12 and 18 months of follow-up. The intervention was provided between April 2008 and June 2011.ResultsPatients received an average of 3.8 home visits (SD 1.4) and 55% of them had a follow-up period of a maximum of 18 months. There were 1074 problems identified and the SCCs initiated 363 follow-up care and referral options. Stroke patients and caregivers were very satisfied with the intervention. The SCCs were satisfied with the assessment tool, but would like to see a structured referral system.ConclusionsThe intervention was only partially performed in accordance with the protocol and was positively evaluated by patients, caregivers and SCCs. It is recommended to add a structured referral system to the intervention.
Highlights
There is a need for follow-up care after stroke, but there is no consensus about the way to organise it
The results showed that the intervention had a favourable effect on the levels of social activities of stroke patients, no significant favourable effects between the intervention and control group were found regarding quality of life, activities of daily life, depression and anxiety, or caregiver strain [12]
Part 1 Availability of the intervention The first part of the process-evaluation focused on the discharge destination of stroke patients after hospitalisation or inpatient rehabilitation
Summary
There is a need for follow-up care after stroke, but there is no consensus about the way to organise it. An intervention providing follow-up care for stroke patients and caregivers showed favourable effects on the level of social activities, but no other effects were found. Many stroke patients experience motor, cognitive and psycho-emotional deficits or problems with daily activities and social participation [1,2,3], which are often persistent. Allen and colleagues (2002) evaluated a standardised assessment for stroke patients one month after being discharged home, followed by an individual care plan developed by a multidisciplinary team [7]. They found that quality of life had improved after three months. The intensive therapy proved more effective in terms of quality of life
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