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

Aznida Firzah Abdul Aziz,Syed Mohamed Aljunid,Noor Azah Abd Aziz,Saperi Sulong,Mohd Fairuz Ali,Nor Azlin Mohd Nordin

doi:10.1186/s12913-016-1963-8

Aznida Firzah Abdul Aziz, Syed Mohamed Aljunid + Show 4 more

Open Access

https://doi.org/10.1186/s12913-016-1963-8

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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).

Highlights

Lack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase
Post stroke care delivery requires the coordination of multidisciplinary service provision; intersectoral collaboration within the public health care delivery system is vital to ensure that patients continue to receive optimal post stroke care once they are discharged from hospital following acute stroke
The Integrated Care Pathway for Post Stroke Patients (iCaPPS) design mainly focused on the stroke care providers’ perspective, and used the input from the stroke patients and their caregivers’ perspective from an earlier study as a basis for discussion by the expert panel [20]. This was a two-phase process: (i) Phase 1 aimed to outline the current care process for the management of patients presenting with stroke to the public health care facilities in Malaysia. This is because the current existing clinical practice guidelines did not address issues of transfer of care beyond acute stroke care, long-term care, or further rehabilitation of stroke survivors at the community level. (ii) In Phase 2, the panel was asked for their opinion on the management of stroke patients at the community level, so as to include recommendations based on the current evidence and to determine the panel’s suggestions for best care practices that would be suited for the local public health care system

Summary

Introduction

Lack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. Post stroke care delivery requires the coordination of multidisciplinary service provision; intersectoral collaboration within the public health care delivery system is vital to ensure that patients continue to receive optimal post stroke care once they are discharged from hospital following acute stroke. Developing countries face added challenges in terms of access to specialized stroke care services and the lack of adequately trained staff members to provide continuity of stroke rehabilitation once patients are back in the community [1, 5,6,7,8]. A review of the 10th Malaysian Plan revealed problems associated with access to and inequity in specialized care (such as stroke care services), and consolidation of the current health care service has been identified as a solution [10, 11]

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