Mobile clinical teams for stroke and neurological handicaps in the community: A pilot project in the Île-de-France area

Abstract

In December 2013 the Regional Health Agency in Île-de-France (Paris city and surrounding districts) started an experimental project of mobile clinical teams for post-acute care and rehabilitation of serious neurological conditions such as stroke. This pilot project was organized in 8 departments. The goal was to coordinate health and social services in order to facilitate home transitions and home living maintenance for persons with disabilities, while enhancing persons’ independence. In this communication, we compare the organizations of these teams: their part-time team members as specialists in geriatrics or Physical Medicine and Rehabilitation, social workers, occupational therapists and secretaries; their intervention types and places (in acute or post-acute care, or in the community); the methods of referral to the teams; the tools used for evaluation, functioning and communication. Since one year, monthly global meetings of the teams have led to an harmonization of these tools and to a useful sharing of experiences. As most teams have been fully functional since September 2014, a synthesis of 6 months of activity can be drawn. The number of patients managed by each team was between 9 and 40. Main reasons for referral to the teams were assistance in the transition from hospital to home, help in home living maintenance, functional evaluations, and administrative assistance. The teams performed between 3 and 32 home visits. Through this first experiment, the added value of these mobile teams was highlighted. The multidisciplinary analysis of individual situations, which combines a functional approach to a social support, gives a comprehensive insight into the neurological handicap and its challenges at home and in the community. The acquired knowledge enables the teams to improve the management of recent stroke in preparing home transitions and to take into account the complexity of stroke-related disabilities at all ages. The limits of the interventions of these teams are related to the large geographical territories which need to be addressed, to the incomplete knowledge of care and residential possibilities, and sometimes to an under-evaluation of the medical work time required.