Integrated Care Pathways After Stroke

Abstract

Time wise, the most common distinction of stroke is division to (1) acute phase, (2) rehabilitation phase, and (3) chronic/long-term care phase. There are not always clear-cut boundaries, but generally the nature and treatment goals of these phases differ substantially. The different phases of care provision, delivered by various independent providers and in different locations can make the patients’ pathway rather fragmented. Integrated care can be a solution to this fragmentation by trying to achieve better connectivity, alignment and inter-sectoral cooperation. It is used synonymously to terms like coordinated or seamless care. Care organized in coordinated or integrated networks is a relatively new organizational form. It is not a ‘classical’ form of an organization, with a hierarchical (vertical) structure and clear decision powers. Networks are rather a joint venture, in which work is based on common goals, building relationships and trust, horizontal structure and particular provider transcending purpose. There is no hierarchical relationship in a network and no ‘power’ to get things done; for this it requires substantive motivation of all parties involved. Currently several approaches to measure the maturity or development of integrated care exist. For example, Minkmans’ Development Model for Integrated Care takes a clinical or organisational perspective and focuses on nine elements (clusters) that are important for successful development of integrated care. By better care coordination or integrating providers into a network of systematically cooperating organisations, care can be improved (Mur 2003; Goodwin 2014). In this chapter we also provide examples of integrated care systems.