LAUSR

BACKGROUND To avoid long-term care after stroke and to promote occupational reintegration as well as to continue improving rehabilitation results, a good inpatient and outpatient care is necessary. More importantly a gapless transition into aftercare is required. The aim of this study was to gather expert opinions and experiences on the current care process during rehabilitation discharge and aftercare as well as to identify barriers and to discuss possible solutions. METHODS Clinicians from inpatient neurological rehabilitation, general practitioners and physiotherapists working in outpatient rehabilitation from Baden-Württemberg (BW) and Bavaria (BY) took part in an online survey on poststroke care (n = 77). The following topics were addressed: discharge process into follow-up care, follow-up care after rehabilitation; as well as cooperation and communication in the discharge process and during follow-up care. The online survey was conducted between 1 June 2017 and 3 August 2017 and was descriptively analyzed. RESULTS The perceptions of inpatient and outpatient experts with respect to significance and barriers of the factors involved in the discharge process and in the aftercare were mainly discrepant. In particular, the interdisciplinary cooperation and communication were criticized. Differences were mentioned depending on the occupational group, when asked about the leading cause that makes it difficult for the patient to return to their home environment. DISCUSSION Practitioner networks and standardized communication pathways can help to strengthen intradisciplinary and interdisciplinary cooperation and communication and thus achieve an improvement in the discharge process as well as in the aftercare system.