Promoting seamless transfer-of-care for stroke patients in primary care: development of the integrated care pathway for post stroke services

Abstract

Introduction Post-stroke care after hospital discharge suffers from lack of intersectoral collaboration within public health sectors. Hence, primary care remains the only option in managing stroke patients in underserved areas in Malaysia. A seamless transfer of care model known as integrated Care Pathway for Post Stroke patients (iCaPPS) was designed to address this issue. The iCaPPS would provide a detailed guide designed by local experts based on a shared care approach with primary care to manage post stroke patients in underserved areas while utilising available resources within community. Methods Expert panel discussions comprising Family Physicians, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from both Ministry of Health and acadaemia were conducted. Modified Delphi technique was employed to resolve practice variances requiring further literature support. Care algorithms were designed around existing work schedules and available resources at public healthcentres. Results Care algorithm including appropriate tools were summarised to guide primary care team to identify patients requiring further multidisciplinary rehabilitation interventions. The multidisciplinary interventions included rehabilitation assessment for the uninitiated and leisure intervention for those indicated, screening for swallowing disorders as well as mental health disorders. Indications for referral Specialist Stroke care team were outlined. Periodic screening for stroke related complications were scheduled into the iCaPPS. Conclusion The iCaPPS would facilitate coordinated post stroke care for patients residing at home in the community and patients lacking access to Specialised Stroke care. The role of the primary care team as coordinators of post stroke care at community level is well defined. Clinical outcomes and cost effectiveness of iCaPPS can be evaluated for benefit of stakeholders and stroke survivors. (Table Presented).