title: Navigating the poststroke continuum of care.
abstract: Stroke is a significant source of death and disability worldwide. The increasing prevalence of stroke survivors forecasts substantial socioeconomic burden and a greater need for comprehensive poststroke rehabilitative services. Despite the rapidly rising burden of cerebrovascular disease, particularly in developing countries, there has been limited implementation of multidisciplinary stroke units, a proven care modality in reducing patient mortality and improving functional outcomes. Transitioning from these acute inpatient settings to in- and outpatient rehabilitation or long-term care environments has consistently been identified as an obstacle to quality stroke rehabilitation. To address the barriers preventing the seamless delivery of poststroke care, an evaluation of patient-caregiver perspectives, treatment challenges, and system-wide shortcomings is presented. The fragmentation of the current poststroke chain of care could benefit from the introduction of case managers or "navigators," discharge planning, electronic medical records, and evidence-based neurorehabilitation guidelines. By aiding in successful care transitions, these proposed efforts could advance post-acute stroke patients along the care continuum to achieve their rehabilitative goals.
authors: Clinical Department of Neurological Rehabilitation, Kliniken Beelitz GmbH, Beelitz-Heilstaetten, Germany. wissel@rehaklinik-beelitz.de
authors: Jörg
authors: J
authors: Wissel
authors: John
authors: J
authors: Olver
authors: Katharina Stibrant
authors: KS
authors: Sunnerhagen
mesh_terms: D019090:Case Management; D003131:Combined Modality Therapy; D003266:Continuity of Patient Care / Q000458:organization & administration; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration; D006801:Humans; D033183:Interdisciplinary Communication; D017146:Models, Organizational; D010348:Patient Care Team; D020127:Recovery of Function; D020521:Stroke / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000523:psychology; D000071939:Stroke Rehabilitation; D017741:Survivors; D013997:Time Factors; D016896:Treatment Outcome