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
INTERVENTIONAL
Allocation
NA
Purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Enrollment
61
Patients will be treated in the pathological domain. Some of this treatment will be applied by the outpatient clinic itself (i.e. changes in medical secondary prevention or additional prescriptions, social work interventions), whereas most of it will be referred to other providers, if possible in vicinity to the patients' home. In order to ease treatment prescriptions and allow to measure treatment uptake, patients will also enrol in the case management system "Ambulanzpartner". This allows the outpatient center to streamline prescription processes and measure uptake of therapies.
NeuroCure Clinical Research Center (NCRC), Charité
Berlin, Germany
"EuroQol five dimensions questionnaire" (EuroQoL-5D)
questionnaire for self-completion by patients for use as a measure of health outcome
Time frame: 12 Months
Post Stroke Checklist (PSC)
checklist that helps identify post-stroke problems
Time frame: 12 Months
modified Rankin Scale (mRS)
scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability
Time frame: 12 Months
Barthel-Index (BI)
scale is used to measure performance in activities of daily living
Time frame: 12 Months
modified Ashworth Scale (mAS)
scale is used as a measure of spasticity
Time frame: 12 Months
Pain Detect (PD-Q)
questionnaire for self-completion by patients for the identification of neuropathic pain
Time frame: 12 Months
Freiburg questionnaire for coping (FKV)
questionnaire is used to assess disease processing modes at the levels of cognition, emotion, and behavior
Time frame: 12 Months
Montreal Cognitive Assessment (MoCA)
cognitive screening test in the detection of mild cognitive impairment
Time frame: 12 Months
partial Aachen Aphasia Test (AAT)
test is used to diagnose and describe aphasic disturbances
Time frame: 12 Months
Hamilton rating scale for depression
questionnaire is used to provide an indication of depression
Time frame: 12 Months
"Morisky Medication Adherence Scale" (MMAS)
questionnaire is used to assess patients' medication-taking behaviour
Time frame: 12 Months
"Nikolaus score for evaluation of social conditions" (SoS)
score is used to assess patients' social work intervention
Time frame: 12 Months
"Häusliche Pflegeskala" (HPS)
questionnaire is used to assess social work Intervention and couple's counselling
Time frame: 12 Months
Hospital Anxiety Depression Scale (HADS)
questionnaire for self-completion by patients to determine the levels of anxiety and depression
Time frame: 12 Months
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