Collaboration in the Chain of Stroke Care: Stroke After-Care, a Gap to be Closed

Saturday, 26 July 2014: 8:50 AM

Bianca Ivonne Buijck, PhD, MScN, RN
P/A Laurens, Rotterdam Stroke Service, Rotterdam, Netherlands

Collaboration in the chain of stroke care: stroke after- care, a gap to be closed



In the Rotterdam Stroke Service (RSS), numerous hospitals, nursing homes/rehabilitation centers and a home care organization collaborate to provide the best quality of care for stroke patients in the acute and chronically phase. After a stroke, patients are confronted with physical disabilities and changes in cognition and behavior. In spite, practice based research (RSS, 2010) shows that stroke patients do not receive adequate care and support in the home environment after discharge from the hospital, nursing home or rehabilitation centre. There is a lack of specialized care and support to learn to cope with disabilities and changing roles after stroke. This may lead to an increase of complications on all life domains, such as caregiver burden, alcohol and medication abuse, mobility problems and social isolation. Caregivers, children and spouses are faced with multiple challenges related to this vulnerable patient group. Patient target analysis shows that there is an increasing percentage of foreign residents in the Rotterdam area. This population is hard to reach for care due to cultural and language barriers. Furthermore, research shows that in the Rotterdam area residents have a more risk full life style than in other parts of the Netherlands (GGD, 2010). Therefore, two of the participants of the RSS, “Rotterdam Home Care” and “Laurens”, initiated an ambitious project to improve after-care for stroke patients in their home environment.


Eight hospitals, nine nursing homes, two rehabilitation centers and a home care organization are collaborative partners within the RSS. A taskforce was formed from individuals working in these organizations. In the project phase, three organizations participated in this project. From April 2012-November 2013, the taskforce had the goal to create a shared policy, monitor infra-structure, and design a research plan. The project was funded by ZonMW. During the project patients received out-reached nursing support consisting of home visits. The nurses collected demographic data, assessed functional abilities and used standardized checklists to record a wide range of problems that patients expressed. Lastly, focus group interviews among managers and nurses were held to determine the feasibility and applicability of the project. Informed consent of patients was obtained.


One- hundred- forty –eight patients received out-reached nursing support. Patients were on average 68 years old. Sixty-eight patients were female. Of these patients, 85% have had a Cerebro Vascular Accident and 15% a Transient Ischemic Attack. The majority of the patients were discharged home from the hospital (86%). Patients had on average three contact moments with the nurse in the first three months after discharge. After stroke, patients reported changes concerning mobility of arm and leg (51% and 44% respectively), balance (42%), cognition (49%), communication (45%), emotion (32%), vision (10%) and behavior (9%). At baseline, 30% was unhappy with provided information.  One year later, only four patients were unhappy with provided information. At baseline, 75% of the patients was happy with the support provided by health care professionals, one year later 80% of the patients was happy with provided support. In the focus group interviews, managers and nurses reported that fine- tuning of care and unity in the chain of stroke- care improves healthcare delivery. Nurses are able to detect problems in an early stage and, therefore, they can respond earlier on patient en informal caregiver needs. They feel that this ultimately can result in fewer readmissions to the hospital or rehabilitation unit.


Nurses, patients and managers are convinced that the stroke after-care project was successful in improving quality of care after stroke. Nevertheless, there is a major challenge for organizations to find financial recourses to conduct this project in the future in the Rotterdam area, because so far health care insurance does not cover the costs. Nevertheless, the participants of the RSS are continuing the project, aiming at making it care as usual. And since the project results are promising, the issue may be impactful in meetings with health care insurers.