Feasibility study of a primary care-based model for stroke aftercare.

BACKGROUND A new primary care model for stroke aftercare has been developed to address the longer-term needs of patients who have had a stroke and their families. AIM To test the feasibility and acceptability of the new model on patients who have had a stroke and their carers. DESIGN OF STUDY An observational feasibility study. SETTING Patient and carer assessments and interviews conducted in patients' homes. METHOD Patients who have had a stroke, and their carers, were assessed using a purposely developed primary care stroke model. Qualified health- and social-care professionals acted as stroke care coordinators and carried out the assessments. Four evaluations were undertaken as part of the study: analysis of care plans, a survey of unmet needs, focus group sessions for staff, and patient/carer interviews. RESULTS Forty-seven patients and 21 carers were recruited to the study. Analysis of care plans indicated that the assessment process was successful in identifying patient and carer problems (n = 219). Actions were instigated against 190 of these problems and, at 3 months after the assessment, 75% of the problems had been resolved. Patients/carers thought that the review process would be more valuable if conducted sooner after hospital discharge. CONCLUSION The model was acceptable to professionals, encouraging them to work in a manner more consistent with the expressed needs of patients and carers who were adjusting to the longer-term impact of stroke. Essential aspects informing the care process were also identified. Further work is now required to investigate the effects of the intervention on patient and carer outcomes.