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

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.