Development and Evaluation of a Patient-centered Transition Program for Stroke Patients, Combining Case Management and Access to an Internet Information Platform
Development and Evaluation of a Patient-centered Transition Program for Stroke Patients, Combining Case Management and Access to an Internet Information Platform
Due to the brutality of stroke and increasingly shorter lengths of hospital stay, patients
 and their families must adapt quickly to the patient's new state of health and the new role
 of caregiver for family members. Patients and caregivers report a significant need for advice
 and information during this transition period. Thus, the provision of information through an
 Internet platform could meet these characteristics, in association with individualised
 support by a case-manager to ensure continuity of care and improve care pathway.

 The investigating team's hypothesis is that, through comprehensive, individualized and
 flexible support for patients and their caregivers, a patient-centred post-stroke
 hospital/home transition program, combining an Internet platform and telephone follow-up by a
 case-manager, could improve patients' level of participation and quality of life.
Going back home following a stroke is a key step for the patient and his or her relatives.
 Due to the brutality of stroke and increasingly shorter lengths of hospital stay, patients
 and their families must adapt quickly to the patient's new state of health and the new role
 of caregiver for family members. Currently, 70% of patients return home directly after
 treatment in a stroke center. Following the acute phase, the patient's care path involves
 many health and social workers. However, the health care system is complex and difficult for
 patients and their caregivers to understand. A lack of support during the hospital/home
 transition has significant negative consequences for the patient (reduced functional
 prognosis, quality of life and reintegration, increased risk of recurrence) and his or her
 caregiver (increased perceived burden, decreased quality of life, socio-economic impact).

 Patients and caregivers report a significant need for advice and information during this
 transition period. They are looking for individualized, good quality information and whose
 nature evolves over time with the needs and recovery of the patient. Thus, the provision of
 information through an Internet platform could meet these characteristics, in association
 with individualised support by a case-manager to ensure continuity of care and improve care
 pathway. In France, no such program has been developed to date for stroke. Existing
 transition programmes mainly focus on home rehabilitation and do not offer a comprehensive
 approach to the situation, integrating caregivers. In addition, no programs have been
 developed in partnership with patients and families to best meet their needs.

 The investigator's hypothesis is that, through comprehensive, individualized and flexible
 support for patients and their caregivers, a patient-centred post-stroke hospital/home
 transition program, combining an Internet platform and telephone follow-up by a case-manager,
 could improve patients' level of participation and quality of life.
Inclusion Criteria:

 -  Adult patient,

 -  Having had a first confirmed, ischemic or hemorrhagic stroke

 -  Managed in the participating stroke center

 -  Whose return home directly from the stroke center is planned

 -  Presenting a modified Rankin score of 1 to 3 when deciding to leave the stroke center

 -  Having given its written consent

 -  Whose main residence is located in the Rhône department of France

 -  Aphasic patients may be included if a caregiver can follow up with the case manager

 Exclusion Criteria:

 -  Patient residing in an institution prior to stroke

 -  Supported in the gerontological field before stroke

 -  Inability to communicate by telephone with the case-manager and absence of a caregiver
 to follow up by telephone with the case-manager