G45 I60 I61 I63 I64
Conditions
Interventions
Group 1: Coordinated care through face-to-face case management for high-risk patients (serious functional impairments and care dependency): initial visit at home for assessing patient needs and develo
follow-up telephone calls every month and home visits every three months
support and coordination by the local health care provider network.
Group 2: Coordinated care through telephone-based case management: information and advice on stroke-specific health care and health
if necessary support with appointments or applications
follow-up calls every three months
support and coordination by the local health care provider network.
Sponsors
Qualitätsverbund Netzwerk im Alter Pankow e.V. - QVNIA e.V.
Eligibility
Sex/Gender
All
Age
55 Years to No maximum
Inclusion criteria
Inclusion criteria: 1) Stroke or TIA within the last 6 months; 2) living in the district of Berlin-Pankow
Exclusion criteria
Exclusion criteria: no sufficient German language skills
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Utilization of outpatient neurologists in favor of secondary prevention and rate of recurrent strokes within 12 months after stroke/TIA; measured by using claims data. | — |
Secondary
| Measure | Time frame |
|---|---|
| Readmissions and mortality within 12 months after stroke/TIA; measured by using claims data. | — |
Countries
Germany
Contacts
Public ContactKatja Dierich
Qualitätsverbund Netzwerk im Alter Pankow e.V. - QVNIA e.V.
Outcome results
None listed