The rehaVital Stroke Network: An integrated, post-discharge, patient care model initiated by durable medical equipment specialists.

Abstract

Outpatient care for patients with chronic illnesses in Germany (e.g., stroke patients) is currently fragmented, with little interconnectivity among the different care providers. After being cared for in a highly structured inpatient environment, patients are often discharged alone with limited supportive care at home. With the goal of accompanying patients on their way back to autonomous mobility and social participation, rehaVital members developed an integrated care model. In this model, patients' perspectives and needs are recognized as central determinants in their post-discharge care. Further key features include structured interconnectivity among the various care providers with transparent treatment goals and progress demonstrated by quality indicators.