Primary care-based interventions for post-stroke follow-up for long-term care: a systematic review

Life after stroke is managed by primary care to prevent recurrent stroke and ensure that stroke survivors live well within the community. Unfortunately, stroke survivors do not always receive timely follow-up from clinical services, which leads to unaddressed and hidden unmet needs. It is not clear what follow-up interventions would be helpful for stroke survivors in the community once discharged from specialist services.

The aim of this systematic review was to investigate current pathways and interventions used in primary and community care to support patients in their lives after stroke.

The review was registered on PROSPERO (CRD42024575490). Four databases were searched (MEDLINE, Embase, CINAHL, and The Cochrane Library) from 2008 to July 2024. All study types were eligible and included if based around a review of a stroke patient's care and delivered within primary care and community settings. The Effective Practice and Organisation of Care (EPOC) taxonomy was used to classify the interventions, and the outcomes were synthesized.

The initial search identified 17 893 articles; 12 articles were included. These were categorized as follows: (i) coordination of care and management of care process (shared decision making n = 4, teams n = 3, and disease management n = 1); (ii) who provides care and how the healthcare workforce is managed (self-management, n = 2); and (iii) information and communication technology (smart home technologies, n = 2).

Despite the current evidence, more focus is required particularly to target the hidden and unmet emotional and mental health needs of stroke survivors. The multidisciplinary nature of primary care can help to provide this holistic care.