Bridging the gap between primary and specialist care--an integrative model for stroke.
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.
Venketasubramanian
Narayanaswamy
N
Department of Neurology, National Neuroscience Institute, Jalan Tan Tock Seng, Singapore. ramani_nv@nni.com.sg
Ang
Yan Hoon
YH
Chan
Bernard Pl
BP
Chan
Parvathi
P
Heng
Bee Hoon
BH
Kong
Keng He
KH
Kumari
Nanda
N
Lim
Linda Lh
LL
Phang
Jonathan Sk
JS
Toh
Matthias Phs
MP
Widjaja
Sutrisno
S
Wong
Loong Mun
LM
Yin
Ann
A
Cheah
Jason
J
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