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Primary care-based interventions for post-stroke follow-up for long-term care: a systematic review
Hannah Ravenhall1, Serena Sabatini2,3, Rhiannon De Ivey1
1Population Health Sciences Institute, Newcastle University, Newcastle NE2 4HH, United Kingdom.
Family Practice
|July 28, 2026
Summary
Primary care follow-up for stroke survivors is crucial for preventing recurrent strokes and addressing unmet needs. Interventions focus on care coordination, self-management, and technology, but emotional and mental health support requires more attention.
Area of Science:
- Neurology
- Public Health
- Healthcare Management
Background:
- Primary care manages post-stroke life to prevent recurrence and ensure community well-being.
- Stroke survivors often face delayed clinical follow-up, leading to unaddressed needs.
- Effective community-based interventions for stroke survivors post-discharge remain unclear.
Purpose of the Study:
- To systematically review primary and community care pathways and interventions for stroke survivors.
- To identify current support strategies for individuals after stroke in community settings.
Main Methods:
- Systematic review registered on PROSPERO (CRD42024575490).
- Searched four databases (MEDLINE, Embase, CINAHL, Cochrane Library) from 2008 to July 2024.
- Included all study types focusing on stroke patient care in primary/community settings; interventions classified using EPOC taxonomy.
Main Results:
- 17,893 articles identified; 12 included in the review.
- Interventions included care coordination (shared decision-making, teams, disease management), self-management support, and information/communication technology (smart home tech).
- Categorization covered care process management, healthcare workforce roles, and technology integration.
Conclusions:
- Evidence highlights the need for enhanced focus on emotional and mental health needs of stroke survivors.
- Multidisciplinary primary care settings are well-positioned to offer holistic support.
- Further research is needed to optimize community-based stroke aftercare.
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