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ORAL PRESENTATION Open Access
Promoting seamless transfer-of-care for strokepatients in primary care: development of theintegrated care pathway for post stroke servicesAznida Firzah Abdul Aziz1*, Noor Azah Abd Aziz2, Nor Azlin Mohd Nordin1, Saperi Sulong2,Syed Mohamed Aljunid3
From 7th Postgraduate Forum on Health Systems and PoliciesPhitsanulok, Thailand. 24-25 June 2013
BackgroundPost-stroke care after hospital discharge suffers fromlack of intersectoral collaboration within the publichealth sectors. Hence, primary care remains the onlyoption in managing stroke patients in underserved areasin Malaysia. This study aimed to identify the areas,which can be better coordinated to deliver optimal post-stroke care in community setting. A seamless transfer ofcare model known as integrated Care Pathway for PostStroke patients (iCaPPS) was designed to address thisissue.
Materials and methodsExpert panel discussions comprising of family physi-cians, neurologists, rehabilitation physicians and thera-pists, and nurse managers from both Ministry of Healthand the academia were conducted. Modified Delphitechnique was employed to resolve practice variationsthrough additional literature support. Care algorithmswere designed around existing work schedules and avail-able resources at public health centres.
ResultsIdentified areas for coordinated transfer of care include:identification of patient criteria suitable for long-termstroke management at primary care facilities, informa-tion required at transfer of care, stroke risk factors treat-ment targets, screening for stroke complications andrehabilitation guide for primary care team. Care algo-rithm including appropriate tools were summarised to
identify patients requiring further multidisciplinary reha-bilitation interventions i.e. assessment for those unini-tiated or missed out on rehabilitation and leisureintervention for those indicated, screening for swal-lowing disorders as well as mental health disorders(i.e. depression and dementia).
ConclusionsThe iCaPPS would facilitate coordinated primary care-led post-stroke management for patients residing athome in the community, hence promoting better colla-boration within public health sectors. Clinical outcomesand cost effectiveness of iCaPPS can be evaluated forbenefit of stakeholders and stroke survivors.
Authors’ details1UNU IIGH, Universiti Kebangsaan Malaysia, UKM Medical Centre Complex,Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur, Malaysia. 2UniversitiKebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras,Kuala Lumpur, Malaysia. 3United Nations University International Institute forGlobal Health (UNU-IIGH), 56000 Cheras, Kuala Lumpur, Malaysia.
Published: 29 January 2014
doi:10.1186/1471-2458-14-S1-O9Cite this article as: Aziz et al.: Promoting seamless transfer-of-care forstroke patients in primary care: development of the integrated carepathway for post stroke services. BMC Public Health 2014 14(Suppl 1):O9.
* Correspondence: [email protected] IIGH, Universiti Kebangsaan Malaysia, UKM Medical Centre Complex,Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur, MalaysiaFull list of author information is available at the end of the article
Aziz et al. BMC Public Health 2014, 14(Suppl 1):O9http://www.biomedcentral.com/1471-2458/14/S1/O9
© 2014 Aziz et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
