Data and care integration for post-acute intensive care program of stroke patients: effectiveness assessment using a disease-matched comparator cohort

Purpose: To assess the effectiveness of an integrated care program for post-acute care of stroke patients, the return home program (RHP program), deployed in Barcelona (North-East Spain) between 2016 and 2017 in a context of health and social care information systems integration. Design: The health outcomes and resource use of the RHP program participants were compared with a population-based matched control group built from central healthcare records of routine care data. Findings: The study included 92 stroke patients attended within the RHP program and their matched-controls. Patients in the intervention group received domiciliary care service, home rehabilitation, and telecare significantly earlier than the matched-controls. Within the first two years after the stroke episode, recipients of the RHP program were less frequently institutionalized in a long-term care facility (5% vs. 15%). The use of primary care services, non-emergency transport, and telecare services were more frequent in the RHP group. Originality: Our analysis shows that an integrated care program can effectively promote and accelerate delivery of key domiciliary care services, reducing institutionalization of stroke patients in the mid-term. The integration of health and social care information allows not only a better coordination among professionals but also to monitor health and resource use outcomes of care delivery