Bridging the gap between primary and specialist care--an integrative model for stroke

Area of Science:

• Neurology
• Public Health
• Healthcare Management

Background:

• Stroke is a leading cause of death and disability globally and in Singapore.
• Effective chronic disease management programs are crucial for seamless stroke care across diverse healthcare settings.
• Existing evidence supports efficacious interventions for stroke management through randomized controlled trials.

Purpose of the Study:

• To evaluate an integrated system for stroke care delivery, focusing on continuity of care from acute management to long-term rehabilitation.
• To test the Wagner model of chronic care delivery adapted for stroke patients.
• To assess the impact of the 3-year Integrating Services and Interventions for Stroke (ISIS) project.

Main Methods:

• Implementing a chronic care model involving self-management support, shared clinical information systems, and redesigned delivery systems.
• Facilitating collaboration between specialists, family physicians, and allied healthcare professionals.
• Harnessing community resources and clinic-based stroke nurses for enhanced service provision and coordination.

Main Results:

• The integrated model aims to right-site patients for appropriate care across the continuum.
• Improved communication and trust are identified as key to overcoming integration barriers.
• Audits will monitor care provision and drive quality enhancement.

Conclusions:

• An informed and motivated patient is central to successful integrated stroke care.
• Collaboration across healthcare professionals and settings is essential for optimal patient outcomes.
• The ISIS project will provide insights into the effectiveness of this integrative system for stroke survivors.