Stroke is the loss of oxygen and subsequent death of brain tissue due to ischemia (lack of blood flow) or hemorrhage (bleeding into brain tissue) causing stroke to be classified as either ischemic or hemorrhagic. At its worst, stroke can cause permanent neurological damage and even death. Although there is no immediate cure for stroke, timely emergency room treatment and post-stroke rehabilitation can effectively lessen disability and improve long-term quality of life.
Proper management of stroke requires evaluation and management of all aspects of the disease. We believe the best approach to achieve comprehensive care is through a multi-disciplinary, team-based approach that employs teams of medical providers who are specially trained to care for stroke patients patients.
Core Team members to Include:
- Stroke Neurologist (team leader)
- Stroke Nurse Practitioner
- General Medicine Nurse Practitioner
- Stroke-certified Case Manager
- Social Worker
- Medical Assistant
- Team Medical Clerk
Long-term care for stroke patients after the acute phase is aimed at reversing disability and preventing complications. The degree of disability and the severity of symptoms vary from patient to patient. Stroke patients may need physical therapy, occupational therapy, speech therapy, management of post-stroke depression and/or help in making lifestyle adjustments.
Treatment that is comprehensive and individualized with tailored regimens focusing on rehabilitation can achieve better results for all stroke patients. Comprehensive care requires the input of many partners, and coordination among providers in a patient-centered environment. The “Core Team” is ideally supported by a “Coordination Team” that ensures all aspects of care within and outside the facility are arranged for and covered.
Coordination Team members:
- Patient Navigator
- Community Partner Coordinator
- Education Coordinator
- Hospital/Transition of Care Coordinator
Comprehensive care clinics are dedicated to the highest quality of patient care while still bridging the gap to patient and caregiver education, social services and care coordination. Ideally, patient, family and caregiver involvement in shared decision-making enhance the total care of the patient.