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

A Call for a Stroke Referral Network Between Primary Care and Stroke-Ready Hospitals in the Philippines: A Narrative Review

BACKGROUND

The increasing stroke burden, inequity in the distribution of local neurologists, and the recent signing of the Universal Health Care Law in the Philippines provide compelling reasons for policy-makers to devise strategies to establish networks between primary care and stroke-ready hospitals. In this review, we explored the current literature and evidence that emphasized the roles of primary care providers (PCPs) and specialists, care transition, and telemedicine/teleneurology in various stages of stroke management.

REVIEW SUMMARY

Clear delegation of stroke care responsibilities among PCPs and specialists is needed. Due to the limited number of specialists/neurologists, PCPs may contribute to addressing the insufficiency of community knowledge of acute stroke symptoms/risk factors, coordination with specialists and stroke-ready hospitals during acute stroke, and continuity of care during the poststroke stage. At present, the Philippines has only 49 stroke-ready hospitals; thus, an efficient and functional referral system for the care transition between the PCPs and specialists must be organized in our country. To provide remote access to expert stroke care for underserved areas and to increase thrombolysis utilization, the establishment of an effective telestroke system is indispensable. The empowerment of PCPs in teleneurology may assist in strengthening communication and networking with specialists with the ultimate goal of improving patient outcomes.

CONCLUSIONS

In the era of Universal Health Care in the Philippines, the roles of PCP and specialists must be delineated. Increased access to stroke care through the establishment of networks among PCPs and stroke-ready hospitals (ie, via effective transition of care/teleneurology) must be prioritized especially in resource-constrained settings.

Home-based rehabilitation programs on postural balance, walking, and quality of life in patients with stroke: A single-blind, randomized controlled trial

BACKGROUND

The most challenging aspect of rehabilitation is the high costs of in-patient rehabilitation programs and poor continuity of care while patients are transferred to home. In this regard, numerous home-based rehabilitation programs have been developed. The purpose of this study was to investigate the effects of home-based rehabilitative programs on postural balance, walking, and quality of life in individuals with chronic hemiparetic stroke.

DESIGN

A CONSORT-compliant randomized controlled trial.

METHODS

Seventeen community-dwelling people diagnosed with a first stroke participated in this study. They randomly divided the home-based rehabilitative program (HBP) group (n = 9) and control group (n = 8). The HBP group received coordination exercises at home and the control group received clinic-based exercises. This study measured postural balance, walking, and quality of life using four outcome measures: 10-meter walk test, figure of 8 walk test, four-square step test, and 36 item short-form survey.

RESULTS

After analysis, it was found that the HBP improved postural balance, comfortable speed, and fast speed walking, and straight and curved walking for chronic stroke. Second, clinic-based rehabilitation services improved postural balance, comfortable speed, and fast speed walking abilities in patients with chronic stroke.

CONCLUSION

The results of this study suggest that the HBP group received positive benefits with regard to the postural balance and walking abilities of chronic hemiparetic stroke patients compared to the clinical setting exercise program.

The adaptation and validation of the satisfaction with stroke care questionnaire (Homesat) (SASC10-My™) for use in public primary healthcare facilities caring for long- term stroke survivors residing at home in the community

Background

Satisfaction with post stroke services would assist stakeholders in addressing gaps in service delivery. Tools used to evaluate satisfaction with stroke care services need to be validated to match healthcare services provided in each country. Studies on satisfaction with post discharge stroke care delivery in low- and middle-income countries (LMIC) are scarce, despite knowledge that post stroke care delivery is fragmented and poorly coordinated. This study aims to modify and validate the HomeSat subscale of the Dutch Satisfaction with Stroke Care-19 (SASC-19) questionnaire for use in Malaysia and in countries with similar public healthcare services in the region.

Methods

The HomeSat subscale of the Dutch SASC-19 questionnaire (11 items) underwent back-to-back translation to produce a Malay language version. Content validation was done by Family Medicine Specialists involved in community post-stroke care. Community social support services in the original questionnaire were substituted with equivalent local services to ensure contextual relevance. Internal consistency reliability was determined using Cronbach alpha. Exploratory factor analysis was done to validate the factor structure of the Malay version of the questionnaire (SASC10-My™). The SASC10-My™ was then tested on 175 post-stroke patients who were recruited at ten public primary care healthcentres across Peninsular Malaysia, in a trial-within a trial study.

Results

One item from the original Dutch SASC19 (HomeSat) was dropped. Internal consistency for remaining 10 items was high (Cronbach alpha 0.830). Exploratory factor analysis showed the SASC10-My™ had 2 factors: discharge transition and social support services after discharge. The mean total score for SASC10-My™ was 10.74 (SD 7.33). Overall, only 18.2% were satisfied with outpatient stroke care services (SASC10-My™ score ≥ 20). Detailed analysis revealed only 10.9% of respondents were satisfied with discharge transition services, while only 40.9% were satisfied with support services after discharge.

Conclusions

The SASC10-My™ questionnaire is a reliable and valid tool to measure caregiver or patient satisfaction with outpatient stroke care services in the Malaysian healthcare setting. Studies linking discharge protocol patterns and satisfaction with outpatient stroke care services should be conducted to improve care delivery and longer-term outcomes.

Trial registration

No.: ACTRN12616001322426 (Registration Date: 21st September 2016.

Effectiveness of home-based carer-assisted in comparison to hospital-based therapist-delivered therapy for people with stroke: A randomised controlled trial

BACKGROUND

The benefits of engaging informal carers or family in the delivery of therapy intervention for people with stroke have not been well researched.

OBJECTIVES

To assess the effectiveness of a home-based carer-assisted in comparison to hospital-based therapist-delivered therapy for community-dwelling stroke survivors.

METHODS

An assessor blinded randomised controlled trial was conducted on 91 stroke survivors (mean age 58.9±10.6 years, median time post-onset 13.0 months, 76.5% males) who had completed individual rehabilitation. The control group received hospital-based group therapy delivered by physiotherapists as out-patients and the test group was assigned to a home-based carer-assisted therapy. Targeted primary outcomes were physical functions (mobility, balance, lower limb strength and gait speed). A secondary outcome index was health-related quality of life. An intention-to-treat analysis was used to evaluate outcomes at week 12 of intervention.

RESULTS

Both therapy groups improved significantly in all the functional measures; mobility (p < 0.01), balance (p < 0.01), lower limb strength (p < 0.01), gait speed (p < 0.05), and in the quality of life score (p < 0.05) at trial completion. No statistical differences were found between the two groups in any outcome indices (all p > 0.05).

CONCLUSIONS

The home-based carer-assisted therapy is as effective as the hospital-based therapist-delivered training in improving post-stroke functions and quality of life.

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

Data on post stroke outcomes in developing countries are scarce due to uncoordinated healthcare delivery systems. In Malaysia, the national stroke clinical practice guideline does not address transfer of care and longer term post stroke care beyond tertiary care. Hence, post stroke care delivery may be delivered at either tertiary or primary care facilities. This study aimed at describing patients' characteristics and outcomes of post stroke care delivered by the primary care teams at public primary care healthcentres across Peninsular Malaysia. Multi staged sampling was done to select public primary care health centres to recruit post stroke patients. At each health centre, convenience sampling was done to recruit adult patients (≥18 years) who received post stroke care between July-December 2012. Baseline measurements were recorded at recruitment and retrospective medical record review was done simultaneously, for details on medical and / or rehabilitation treatment at health centre. Changes in the measurements for post stroke care were compared using paired t-tests and Wilcoxon Rank test where appropriate. Total of 151 patients were recruited from ten public primary care healthcentres. The mean age at stroke presentation was 55.8 ± 9.8 years. Median duration of follow up was 2.3 (IQR 5.1) years. Majority co-resided with a relative (80.8%), and a family member was primary caregiver (75.%). Eleven percent were current smokers. Almost 71.0% of patients achieved BP ≤ 140/90 mmHg. Only 68.9% of the patients had been referred for neurorehabilitation. Percentage of recorded data was highest for blood pressure (88.1%) while lowest was HbA1c (43.0%). For clinical outcomes, systolic and diastolic blood pressure, triglyceride level and calculated GFR (eGFR) showed statistically significant changes during follow up (p < 0.05). Post stroke care at public primary care healthcentres showed benefits in stroke risk factors control (i.e. hypertension and dyslipidaemia) but deterioration in renal function. A more structured coordination is needed to optimise post stroke care beyond acute phase management for patients who reside at home in the community.

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

BACKGROUND

Lack 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.

METHODS

Expert 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.

RESULTS

Indication 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.

CONCLUSION

Coordinated 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 REGISTRATION

No.: ACTRN12616001322426 (Registration Date: 21st September 2016).