title: Shifting stroke care from the hospital to the nursing home: explaining the outcomes of a Dutch case.
abstract: OBJECTIVE
  Supply chains can contribute to better care for stroke patients and more efficiency. However, such outcomes are hampered when links in the chain are weak. The article aims to further the knowledge about the causes and possible improvements of weak links thereby using theory about rules for action and routines (action patterns).
  
  
  METHODS
  We executed a single case study of a chain of service delivery to stroke patients by a university hospital and a nursing home in the city of Maastricht, the Netherlands. Methods included document study, interviews, observations, process mapping, use of data matrices and performance of t-tests.
  
  
  RESULTS
  In the case, the care delivery process in the chain was redesigned to improve the flow of patients and to reduce the length of hospital stay. Length of stay was reduced. However, transfer of patients from the hospital to the nursing home was hampered. At this weak link in the chain, the redesign clashed with the routines of hospital paramedics who did not want to work according to the redesign.
  
  
  CONCLUSIONS
  The applied theory is useful to understand why a link in a supply chain is weak. Negotiations can be used to strengthen a link.
authors.affiliation: Department of Health Organisation, Policy and Economics (HOPE), School of Public Health and Primary Care: CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands. a.vanraak@beoz.unimaas.nl
authors.forename: Arno
authors.initials: A
authors.lastname: van Raak
authors.forename: Siebren
authors.initials: S
authors.lastname: Groothuis
authors.forename: Robert
authors.initials: R
authors.lastname: van der Aa
authors.forename: Martien
authors.initials: M
authors.lastname: Limburg
authors.forename: Leti
authors.initials: L
authors.lastname: Vos
mesh_terms: D003266:Continuity of Patient Care; D006785:Hospitals, University; D006801:Humans; D007297:Inpatients; D007407:Interviews as Topic; D007902:Length of Stay; D009426:Netherlands; D009735:Nursing Homes; D019370:Observation; D017063:Outcome Assessment, Health Care; D010360:Patient Transfer; D000071939:Stroke Rehabilitation