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| Name | Class |
|---|---|
| Center for Stroke Research Berlin | OTHER |
| Hebrew University of Jerusalem | OTHER |
| NeuroCure Clinical Research Center, Charite, Berlin | OTHER |
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After discharge from hospital, the current healthcare system in Germany allows considerable flexibility (therefore complexity) of patient access and mobility between multiple care providers in the community setting. The investigators believe this aftercare could be better coordinated by a specialized coordinated stroke aftercare service. Comprehensive coordinated multidisciplinary care is a proven concept with proven benefits in both acute and rehabilitation care provided in stroke units and neurorehabilitation centres. In this study, the investigators postulate that a similar coordinated approach to care can be extended to the phase after in-patient rehabilitation has ended (i.e. "long-term management" as opposed to "early supported discharge") for disabled patients with stroke living in the community.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| comprehensive multidisciplinary stroke care | Other |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| comprehensive multidisciplinary stroke care | Other | Patients will be treated in the pathological domain. Some of this treatment will be applied by the outpatient clinic itself (i.e. changes in medical secondary prevention or additional prescriptions, social work interventions), whereas most of it will be referred to other providers, if possible in vicinity to the patients' home. In order to ease treatment prescriptions and allow to measure treatment uptake, patients will also enrol in the case management system "Ambulanzpartner". This allows the outpatient center to streamline prescription processes and measure uptake of therapies. |
| Measure | Description | Time Frame |
|---|---|---|
| "EuroQol five dimensions questionnaire" (EuroQoL-5D) | questionnaire for self-completion by patients for use as a measure of health outcome | 12 Months |
| Measure | Description | Time Frame |
|---|---|---|
| Post Stroke Checklist (PSC) | checklist that helps identify post-stroke problems | 12 Months |
| modified Rankin Scale (mRS) | scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Andreas Meisel, Prof. Dr. med. | Charite University, Berlin, Germany | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| NeuroCure Clinical Research Center (NCRC), Charité | Berlin | 10117 | Germany |
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| ID | Term |
|---|---|
| D020521 | Stroke |
| ID | Term |
|---|---|
| D002561 | Cerebrovascular Disorders |
| D001927 | Brain Diseases |
| D002493 | Central Nervous System Diseases |
| D009422 | Nervous System Diseases |
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|
| 12 Months |
| Barthel-Index (BI) | scale is used to measure performance in activities of daily living | 12 Months |
| modified Ashworth Scale (mAS) | scale is used as a measure of spasticity | 12 Months |
| Pain Detect (PD-Q) | questionnaire for self-completion by patients for the identification of neuropathic pain | 12 Months |
| Freiburg questionnaire for coping (FKV) | questionnaire is used to assess disease processing modes at the levels of cognition, emotion, and behavior | 12 Months |
| Montreal Cognitive Assessment (MoCA) | cognitive screening test in the detection of mild cognitive impairment | 12 Months |
| partial Aachen Aphasia Test (AAT) | test is used to diagnose and describe aphasic disturbances | 12 Months |
| Hamilton rating scale for depression | questionnaire is used to provide an indication of depression | 12 Months |
| "Morisky Medication Adherence Scale" (MMAS) | questionnaire is used to assess patients' medication-taking behaviour | 12 Months |
| "Nikolaus score for evaluation of social conditions" (SoS) | score is used to assess patients' social work intervention | 12 Months |
| "Häusliche Pflegeskala" (HPS) | questionnaire is used to assess social work Intervention and couple's counselling | 12 Months |
| Hospital Anxiety Depression Scale (HADS) | questionnaire for self-completion by patients to determine the levels of anxiety and depression | 12 Months |
| D014652 | Vascular Diseases |
| D002318 | Cardiovascular Diseases |