J Clin Outcomes Manage
Improving stroke outcomes: implementation of a postdischarge care management model
Allen K, Hazelett S, Jarjoura D, Wright K, Clough L, Weinhardt J
Abstract Objective: To describe the theoretical basis for an interdisciplinary poststroke care management model currently being tested for effectiveness in a randomized trial. Methods: The Strategies To Enhance Post Stroke Care And REcovery (STEPS CARE) study is testing the effectiveness of a comprehensive interdisciplinary postdischarge stroke care management intervention in improving a profile of indicators of health recovery and effects of secondary prevention for 190 stroke survivors as compared with 190 patients who receive usual postdischarge stroke care. The model incorporates elements of chronic illness care models including (1) organizational leadership, incentives, and resources for providers; (2) delivery system redesign in which an advanced practice nurse (APN) functions as a care manager and performs in-home assessments and regular follow-up; (3) clinical information systems that allow assessment findings and care plans to be communicated directly to the primary care physician and others; (4) community linkages facilitated by a social worker who provides referrals to local social services; (5) self-management support provided by the APN; and (6) decision support for primary care physicians, including evidence-based protocols and academic detailing. Results: A pilot study of this model of care showed a significant positive effect of the intervention. Conclusion: A chronic illness care model can be adapted for poststroke care to improve patient outcomes.
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