Post-stroke coordination team to support non specialized rehabilitation hospital in French setting.

OBJECTIVE: Access to a specialized rehabilitation is limited for most of post stroke patients who are often transferred in non-specialized rehabilitation hospitals. We have set up a multidisciplinary mobile team working in these hospitals. The aim of this pilot study was to describe the contribution of our mobile team specialized in post acute care of stroke.

MATERIALS/PATIENTS AND METHODS: We collected the changes in the management of rehabilitation for 31 patients hospitalized in non-specialized rehabilitation hospital referred to our mobile team. We assessed the training of healthcare workers that we provided and the impact on the care pathway.

RESULTS: Our team permitted for almost all patients a specialized assessment (occupational therapy, referred for a psychological or neuropsychological assessment, a social evaluation, further evaluation, including specific neurovascular investigations). Therapeutic was changed, including learning self-rehabilitation methods, physiotherapy, and speech therapy. An adaptation of the care pathway has been done (neurovascular consultations, change of place of life project, accompanying a return home and reorientation in specialized rehabilitation unit). The team also permitted a training of the paramedical crew. All the doctors who requested the team declared this intervention as facilitator for admission of post-stroke patients in their hospital.

DISCUSSION/CONCLUSION: These results show that our rehabilitation mobile team provides a large and diverse contribution to the non-specialized hospitals. This support covers all medical and social aspects. Beyond the individual impact, it helps, with training, to improve overall care and quality of care for non-specialized hospitals. Our results also suggest our mobile team is a facilitator for admission in post acute post-stroke unit.