566 A Model Of Integrated Home Care For Post-Acute Stroke Patients

Author(s): 
F Lupano 1, A Gaffuri, R Frediani, L Corbetta
1 Societa Italiana Di Medicina Generale
Text: 
Aims: To state the effectiveness of cooperation of family doctors with a Stroke Service in the Post-Stroke rehabilitation.
Design: The 'Moncalieri Stroke Service' Project began in August 2000, applying to the Health District of Moncalieri with 70.000 inhabitants about. A multidisciplinary Working team was formed with hospital doctors, rehabilitation therapists, nurses and family doctors. The family doctor of every patient with stroke was called to a meeting inside the hospital to decide the further care and rehabilitation after dismission. Every time it was possible the patients received home rehabilitation and integrated home care coordinated by their family doctor.
Results: From August 2000 to August 2001, 201 patients were dismissed from the Stroke Service: 51 received integrated home care, 56 went to post-acute rehabilitation hospitals and 94 did not need both. Comparatively to the previous correspondent period, integrated home care increased about 50%, mortality and morbidity reduced of 12%. The cost of one day in a rehabilitation hospital is seven times the cost of one day of integrated home care. The Project has led to write guidelines shared by hospital and family doctors in the managing of post-acute stroke patients, published by the Administration and sent to all doctors of the Health District.
Conclusions:
Involving family doctors in 'decision making' about their patients during hospitalization for stroke can improve prognosis and reduce costs. Shared guidelines in the management of stroke improve cooperation and coordination of family doctors with hospital doctors, nurses and rehabilitation therapists.
Literature: 
566
A MODEL OF INTEGRATED HOME CARE FOR POST-ACUTE STROKE PATIENTS