title: A process evaluation of a stroke-specific follow-up care model for stroke patients and caregivers; a longitudinal study.
abstract: BACKGROUND
  There is a need for follow-up care after stroke, but there is no consensus about the way to organise it. An intervention providing follow-up care for stroke patients and caregivers showed favourable effects on the level of social activities, but no other effects were found. The intervention consists of a maximum of five home visits to patients and caregivers during a period of 18 months post-discharge. The home visits are conducted by a stroke care coordinator (SCC) using a structured assessment tool. The objective of this study was to examine process-related factors that could have influenced the effectiveness of the intervention.
  
  
  METHODS
  77 stroke patients, 59 caregivers and 4 SCCs participated in the study. Data on the organisational characteristics of and the satisfaction with the intervention were collected by means of structured assessments, interviews and self-administered questionnaires at 1, 6, 12 and 18 months of follow-up. The intervention was provided between April 2008 and June 2011.
  
  
  RESULTS
  Patients received an average of 3.8 home visits (SD 1.4) and 55% of them had a follow-up period of a maximum of 18 months. There were 1074 problems identified and the SCCs initiated 363 follow-up care and referral options. Stroke patients and caregivers were very satisfied with the intervention. The SCCs were satisfied with the assessment tool, but would like to see a structured referral system.
  
  
  CONCLUSIONS
  The intervention was only partially performed in accordance with the protocol and was positively evaluated by patients, caregivers and SCCs. It is recommended to add a structured referral system to the intervention.
authors: Department of Patient & Care, Maastricht University Medical Centre+, Maastricht, The Netherlands ; CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.
authors: Manon
authors: M
authors: Fens
authors: CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands ; Department of General Practice, Maastricht University Medical Centre+, Maastricht, The Netherlands.
authors: George
authors: G
authors: Beusmans
authors: Department of Neurology, Flevo Hospital, Almere, The Netherlands.
authors: Martien
authors: M
authors: Limburg
authors: Department of Patient & Care, Maastricht University Medical Centre+, Maastricht, The Netherlands ; CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.
authors: Liesbeth
authors: L
authors: van Hoef
authors: CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands ; Department of Health Services Research, Maastricht University, Maastricht, The Netherlands.
authors: Jolanda
authors: J
authors: van Haastregt
authors: Department of Patient & Care, Maastricht University Medical Centre+, Maastricht, The Netherlands ; CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands ; Department of General Practice, Maastricht University Medical Centre+, Maastricht, The Netherlands.
authors: Job
authors: J
authors: Metsemakers
authors: Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands ; Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neurosciences, Maastricht University, Maastricht, The Netherlands.
authors: Caroline
authors: C
authors: van Heugten
keywords: Follow-up care; Nurses; Process assessment; Stroke
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