Bridging the gap: The effectiveness of teaming a stroke coordinator with patient's personal physician on the outcome of stroke

Nancy E. Mayo, Lyne Nadeau, Sara Ahmed, Carole White, Roland Grad, Allen Huang, Mark J. Yaffe, Sharon Wood-Dauphinee

Research output: Contribution to journalArticlepeer-review

49 Scopus citations


Objectives: to test the hypothesis as to whether persons newly discharged into the community following an acute stroke and assigned a stroke case manager would experience, compared to usual post-hospital care, better health-related quality of life (HRQL), fewer emergency room visits and less non-elective hospitalisations. Design: a stratified, balanced, evaluator-blinded, randomised clinical trial. Setting: five university-affiliated acute-care hospitals in Montreal, Quebec, Canada. Participants: persons (n=190) returning home directly from the acute-care hospital following a first or recurrent stroke with a need for health care supervision post-discharge because of low function, co-morbidity, or isolation. Intervention: for 6 weeks following hospital discharge a nurse stroke care manager maintained contact with patients through home visits and telephone calls designed to coordinate care with the person's personal physician and link the stroke survivor into community-based stroke services. Measurements: the primary outcome was the Physical Component Summary (PCS) of the Short-Form (SF)-36 survey. A secondary outcome was utilisation of health services. Also measured was the impact of stroke on functioning. Measurements were made at hospital discharge (baseline), following the 6-week intervention and at 6-months post-stroke. Results: the average age of the participants was 70 years. Discharge was achieved on average 12 days post-stroke and most participants had had a stroke of moderate severity. There were no differences between groups on the primary outcome measure, health services utilisation, or any of the secondary outcome measures. Conclusion: for this population, there was no evidence that this type of passive case management inferred any added benefit in terms of improvement in health-related quality of life or reduction in health services utilisation and stroke impact, than usual post-discharge management.

Original languageEnglish (US)
Pages (from-to)32-38
Number of pages7
JournalAge and ageing
Issue number1
StatePublished - Jan 2008


  • Case management
  • Co-morbidity
  • Elderly
  • Health services research
  • Quality of life
  • Stroke

ASJC Scopus subject areas

  • Geriatrics and Gerontology
  • Aging


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