title: Bridging the gap between primary and specialist care--an integrative model for stroke.
abstract: Stroke is a major cause of death and disability in Singapore and many parts of the world. Chronic disease management programmes allow seamless care provision across a spectrum of healthcare facilities and allow appropriate services to be brought to the stroke patient and the family. Randomised controlled trials have provided evidence for efficacious interventions. After the management of acute stroke in a stroke unit, most stable stroke patients can be sent to their family physician for continued treatment and rehabilitation supervision. Disabled stroke survivors may need added home-based services. Suitable community resources will need to be harnessed. Clinic-based stroke nurses may enhance service provision and coordination. Close collaboration between the specialist and family physician would be needed to right-site patients and also allow referrals in either direction where necessary. Barriers to integration can be surmounted by trust and improved communication. Audits would allow monitoring of care provision and quality care enhancement. The Wagner model of chronic care delivery involves self-management support, shared clinical information systems, delivery system redesign, decision support, healthcare organisation and community resources. The key and critical feature is the need for an informed, activated (or motivated) patient, working in collaboration with the specialist and family physician, and a team of nursing and allied healthcare professionals across the continuum of care. The 3-year Integrating Services and Interventions for Stroke (ISIS) project funded by the Ministry of Health will test such an integrative system.
authors.affiliation: Department of Neurology, National Neuroscience Institute, Jalan Tan Tock Seng, Singapore. ramani_nv@nni.com.sg
authors.forename: Narayanaswamy
authors.initials: N
authors.lastname: Venketasubramanian
authors.forename: Yan Hoon
authors.initials: YH
authors.lastname: Ang
authors.forename: Bernard Pl
authors.initials: BP
authors.lastname: Chan
authors.forename: Parvathi
authors.initials: P
authors.lastname: Chan
authors.forename: Bee Hoon
authors.initials: BH
authors.lastname: Heng
authors.forename: Keng He
authors.initials: KH
authors.lastname: Kong
authors.forename: Nanda
authors.initials: N
authors.lastname: Kumari
authors.forename: Linda Lh
authors.initials: LL
authors.lastname: Lim
authors.forename: Jonathan Sk
authors.initials: JS
authors.lastname: Phang
authors.forename: Matthias Phs
authors.initials: MP
authors.lastname: Toh
authors.forename: Sutrisno
authors.initials: S
authors.lastname: Widjaja
authors.forename: Loong Mun
authors.initials: LM
authors.lastname: Wong
authors.forename: Ann
authors.initials: A
authors.lastname: Yin
authors.forename: Jason
authors.initials: J
authors.lastname: Cheah
mesh_terms: D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D019317:Evidence-Based Medicine; D006801:Humans; D002546:Ischemic Attack, Transient; D008511:Medicine; D008875:Middle Aged; D017146:Models, Organizational; D009462:Neurology; D011320:Primary Health Care; D019145:Rehabilitation Nursing; D012846:Singapore; D013038:Specialization; D020521:Stroke / Q000451:nursing; D000071939:Stroke Rehabilitation