In this first step of the study the investigators will assess the needs, disease burden and current treatments of long-term stroke patients (phase MAS-I). The ultimate aim of the complete MAS project (MAS I, II \& III) is the development of a model of stroke aftercare delivery that can be evaluated to estimate effects in both our local and the wider stroke population.
After discharge from hospital the current healthcare system in Germany allows considerable flexibility (therefore complexity) of patient access and mobility between multiple care providers in the community setting. The investigators believe this aftercare could be better coordinated by a specialized coordinated stroke aftercare service. Comprehensive coordinated multidisciplinary care is a proven concept with proven benefits in both acute and rehabilitation care provided in stroke units and neurorehabilitation centres. In this study the investigators postulate that a similar coordinated approach to care can be extended to the phase after in-patient rehabilitation has ended (i.e. "long-term management" as opposed to "early supported discharge") for disabled patients with stroke living in the community.
Study Type
OBSERVATIONAL
Enrollment
64
Charité - Universitätsmedizin Berlin (Center for Stroke Research Berlin CSB & NeuroCure Clinical Research Center)
Berlin, Germany
Prevalence of unmet Needs
Unmet needs of patients and carers after discharge from Rehabilitation. Score of variables examined (self-reported stroke related need, post-stroke spasticity, post-stroke pain, post-stroke aphasia, neuropsychological impairment, post-stroke depression, post-stroke dementia, inadequate secondary prevention, social care need and carer burden).
Time frame: once
post-stroke checklist
Evaluation of post-stroke checklist as a valid tool to screen for relevant burden of disease after stroke.
Time frame: once
Standard practice evaluation
Comparison of Standard practice in relation to evidence-based recommendations and current Clinical Guidelines for the management of stroke.
Time frame: once
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