Abstract W P136: SOS CARE: The Stroke East Saxony Pilot Project for Integrated Care Pathway and Case Management After Stroke
Background: We developed a standardized pathway for post-stroke care facilitated through a case manager (CM) to ensure minimization of risk factors, life-style changes and continuation of secondary prevention medication.
Methods: Consecutive acute stroke patients were prospectively assigned to a certified CM. The 1-year post-stroke care pathway comprised initial educational discussion, personal patients’ home visits and quarterly telephone contacts. Further personal contacts were conducted when judged necessary. Target values for vascular risk factors were pre-defined according to current stroke guidelines, compared with regular check-ups and intervened when necessary. A closing meeting including assessment of stroke recurrence was performed.
Results: Between 12/2011 and 07/2013 we enrolled 74 of 111 screened patients: 57% male, mean age 71+/-14 yrs, median NIHSS 2 (range 0-16), 76% ischemic, 4% hemorrhagic stroke and 20% TIA. Of 74 patients, 10 refused follow-up care. Overall, 356 home visits (4.8/patient) and 1233 phone contacts (16.7/patient) were conducted. One hundred-eighty seven specific interventions were necessary mostly due to missing medication, non-compliance and social needs. Achieved vascular risk factor goals are presented in the Table. No recurrent stroke occurred. Among screened patients who refused CM, stroke recurrence rate was 22% after 12 months.
Conclusion: The preliminary data of our pilot project suggest that case management is capable of achieving predefined goals for secondary prevention. To investigate its impact on stroke recurrence risk and prevention of long-term care dependency, we initiate a randomized controlled trial.
Author Disclosures: J. Kepplinger: None. U. Helbig: None. K. Barlinn: None. L. Pallesen: None. C. Zerna: None. T. Siepmann: None. H. Reichmann: None. V. Puetz: None. U. Bodechtel: None.
- © 2014 by American Heart Association, Inc.