The Strack programme provides intensive patient follow-up during the first year after a stroke through remote monitoring and networking with primary care as well as patient empowerment tools.
More than 50 patients have joined the project, which aims to provide a comprehensive approach to the critical phase of the disease in order to reduce readmissions for cardiovascular pathology and unnecessary visits, while increasing adherence to treatment and physical and cognitive rehabilitation.
Multidisciplinary professionals from Bellvitge University Hospital, Viladecans Hospital and 17 Primary Care Centres in the Southern Metropolitan Area of the ICS work in a network. It is estimated that one in six people could suffer a stroke, making it the world’s main cause of disability and the leading cause of death in women.
40% of stroke patients who need rehabilitation do not do it or do not start it; 30% go off their medication, and one third do not visit their Primary Care centre once they have been discharged. After a stroke, the first year is critical in determining the patient's future evolution. As a solution, the Bellvitge University Hospital (HUB), Viladecans Hospital and the Primary Care of the Southern Metropolitan Area of the Catalan Health Institute (ICS) have created the Strack programme.
Strack is a new model of comprehensive care that guarantees a personalised and remote monitoring during the first twelve months following the stroke, with an important involvement of Primary Care teams. The role of the family and community nurse is essential in this follow-up process.
So far, the acute part - just after the episode - has been very standardised thanks to the Stroke Code. Now, Strack aims to become a solution for the chronic phase, which until now has not been comprehensively addressed. "Urgent care after a stroke is key, since every minute after it, two million neurons die," according to Dr Pere Cardona, director of the Stroke Unit and the Neurovascular Programme at the HUB. However, "we realised that, in the months that followed, which were really critical, there was a lack of coordination for monitoring rehabilitation and adherence to treatment, meaning a very high risk of stroke recurrence, even fatal," adds the neurologist at Bellvitge Hospital and co-leader of the Strack programme. It is from the detection of this need by the medical professionals of the Hospital de Bellvitge - the hospital centre that attends more Stroke Codes in Catalonia - that the Strack programme has been devised.
A personalised health plan to promote stroke recovery
More than 50 stroke patients who have been discharged from the Bellvitge Hospital in recent weeks are the first to take part in the Strack programme. It is expected that around 350 patients will be monitored up each year. At the time of discharge, the hospital nurses explain the Personalised Care Plan to the patient.
This plan includes access to an app, as well as multimedia content and technological devices, which are adjusted to the severity of the stroke, the patient's age and ability to recover.
Dr Silvia Copetti, family doctor, assistant director of the Baix Llobregat Centre Primary Care Service and co-leader of the Strack programme explains "Always approaching each case individually, we will encourage the patient to take responsibility in order to achieve better self-control, while carrying out home monitoring of glycaemia, arterial hypertension, heart rate, among other parameters, which indicate cardiovascular risk."
The Strack Care Plan also includes physical activity guidelines, rehabilitation and cognitive stimulation exercises, information on prescribed medications and questionnaires on health outcomes and overall satisfaction with the process.
Thanks to a digital solution, a team of multidisciplinary professionals from the hospital and primary care will monitor the patient based on the data and statistics they receive, and will be able to prescribe new content. Neurologists, nurses, family doctors, social workers, geriatricians, physiotherapists and laboratory professionals, among others, make up this intensive post-stroke monitoring team.
All elements of Strack have been designed taking into account the patient experience, based on interviews with patients, relatives and carers. In addition, working sessions and interviews have been organised with professionals from several specialties involved in the process. "The patient must achieve an optimal degree of self-knowledge and self-management of the disease, which is key to avoiding future episodes and complications," said Dr Copetti.
Roche Diagnostics is the technology partner for the project, having won the public tender launched a few months ago.
First results of Strack by the end of 2023
With the progressive enrolment of patients and based on satisfaction surveys as well as health outcomes, the results of the programme will be evaluated. Results are due to the end of 2023. If they are as expected, Strack could be scaled up. The project aims to facilitate adherence to treatment, to reduce decompensation, unnecessary visits and test repetition, as well as to facilitate decision-making and coordination between care devices.
As Dr Pere Cardona points out, Strack should lead to "better results in functional recovery after a stroke, achieve a low risk of recurrence and better control of vascular risk factors". The Strack programme is part of the Public Procurement of Innovation Projects in the Integrated Public Health System of Catalonia (SISCAT), and is subsidised by the European Regional Development Fund (ERDF) Operational Programme.