MAESTRO: the effects of a multidisciplinary care programme for elderly persons with stroke who are admitted to a nursing home for rehabilitation and return home after discharge.

Stroke is one of the major causes of loss of independence, decreased quality of
life and mortality among elderly people. Each year, about 41,000 people in the
Netherlands suffer a stroke and the associated functional impairments. The
incidence of stroke strongly increases with age. Among persons aged 65 to 69,
the incidence of stroke is 5.1 per 1000 people, rising to 37.7 per 1000 among
those aged 95 years or over. Due to the multidimensional problems related to
stroke, care for stroke patients is complex, even more so for elderly stroke
patients because of multimorbidity. The Dutch health council recently
recommended that special attention be paid to older people with multimorbidity.
Furthermore, the Dutch associations for stroke patients (Samen Verder) and
people with non-congenital brain damage (Cerebraal)) also draw attention to an
important problem in the care for this group of senior citizens: the lack of
adequate aftercare after rehabilitation in a nursing home. Of those
experiencing stroke about 85% is admitted to hospital. After discharge from
hospital, 8% is admitted to a rehabilitation centre, and 15% to a nursing home
for rehabilitation. The group of patients admitted to a nursing home is older,
frailer and have more complex care needs compared to the younger, more vital
patients referred to a rehabilitation centre. Both groups receive
rehabilitation treatment for a certain period in order to be able to function
(largely) independently again. Compared to younger stroke patients who continue
rehabilitation at home through a tailor-made day care programme after discharge
from the rehabilitation centre, care for elderly patients discharged from
nursing homes is far less tailored to their specific individual situations and
needs, while their health problems are substantially more complex. Elderly
stroke patients usually receive primary healthcare after discharge from nursing
homes. Cooperation between the various primary care professionals, however, is
often limited, with the multidimensional health problems that in the subacute
phase led to admission to a nursing home for multidisciplinary treatment being
continued by individually working healthcare professionals. In general,
however, these primary care professionals have insufficient experience with the
required integrated treatment, care and support of older stroke patients with
complex care needs. This lack of tailor-made, specialized aftercare following
rehabilitation in nursing homes results in this patient group being
insufficiently able to cope with the remaining physical, cognitive and/or
psychosocial impairments in their home environment. This prevents them from
performing normal day-to-day activities, fulfilling social roles and
maintaining the achieved functional level. Besides having negative consequences
for these patients, these problems may also increase the burden of care for
their informal caregivers. In recent years, many studies have focused on
improving the quality and coordination of care
for stroke patients. The results of these studies have led to considerable
improvements in the continuity of care for stroke patients in the acute and
subacute stages. Currently, in the Netherlands, about 70 stroke chains of care
have been implemented in regular care, and many hospitals, nursing homes and
rehabilitation centres now house specialised stroke units. But aftercare for
stroke patients still receives insufficient attention.
Although the introduction of care coordinators in Dutch primary care has led to
an improvement in the logistic coordination of care, this is still insufficient
in view of the target group*s complex care needs, which prevents them from
reaching and remaining optimal levels of functioning.

Primairy objective:
The primary objective of this study is to get insight in the effect of the
multidisciplinary integrated care programme on self-help, social participation
and experienced quality of life of elderly stroke patients. And the effect on
the reduction of burden of care of carers.

Secondary objective(s):
The secundary objective of this study is to get insight in the effect on the
adjustment of stroke care between health care professionals ans the health
care consumption and its related costs.

The study design is a multicentre randomised controlled trial (RCT). Study
participants will be randomly allocated in the intervention or control group.
The participants in the intervention group will receive the new
multidisciplinary integrated care programme. The control group will receive
care as usual. The study duration will be 36 months. The inclusion period will
be 18 months and the intervention will have the duration between 2 and 6 months
(depending of the patients issues). There will be a follow-up period of 12
months. The study will be conducted in four nursing homes in the South of the
Netherlands.

The transmural integrated care programme consists of three care modules;
1) working on recovery and learning to deal with impairments
2) self-management after stroke
3) education programme for patients and carers

The main goal of the programme is to give optimal support and treatment to as
well the patients as the carers. This will be provided in the nursing home and
at the patients home. The main objectives of the programme are improving
self-help, social participation and quality of life of the patients. An other
important objective is to reduce the burden of care of the carer. The programme
has a duration of minimum 2 and maximum 6 months. The first care module will
take place in the nursing home and the second care module at the patients'
home. The part of the programme which wille take place in the nursng home will
have a duration of minimum 1 and maximum 2 months. Th part of the intervention
at the patients'homes will have a duration (depending of the exact problem) of
minimum 1 and maximum 4 months. The exact duration will be variabel and
depending of the health status and further demands of the patient and the
carer.

We expect that the study will only form a minor burden for the participants.
Both patients and their informal caregivers receive three measurement during a
periode of 12 months. Data from the patients are collected by means of face to
face and telephone interviews. Data from the informal caregivers are collected
by means of self-administered questionnaires. For the patients allocted to the
intervention group, after discharge, the new multidisciplinary integrated care
programme will take place largely at the participants' home by a team of health
care professionals. The risks related to the programme are comparableto the
risks related to usual care. So there are no extra risks associated with the
new programme. The new programme aims to support the patients in a way that
leads to a positive effect on the ability to live independently, functional
status, social participation, and quality of life of the patient. Furthermore
the programme aims to support the informal caregivers and to reduce their care
burden.