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Stroke OWL: Cross-sectorally organized care management of complex chronic diseases using the example of strokes by stroke pilots in the pilot region Ostwestfalen-Lippe

Stroke is one of the diseases with the most extensive socio-medical consequences and is the leading cause of permanent disability in adulthood. Strokes are characterized by a lengthy course of the disease with a high risk of re-infarction.

In addition, there are considerable supply deficits:

  • The documentation of the further course of the disease after discharge from the acute hospital is insufficient.
  • There is a lack of high quality guidelines in post-stroke care;
  • There is a lack of disease management programs or validated cross-sector care programs of the payers.
  • The described deficits are expressed in the high 1-year mortality after the first attack and in a lower quality of life of the patients compared to the age group.

Stroke OWL's goal is to optimize the care of stroke patients through the comprehensive implementation and evaluation of cross-sector care management after stroke.

The operationalization is carried out by stroke pilots, who accompany the affected persons coordinating one year after the initial stroke event. In a population-based approach, the complete supply path is integrated. For this purpose, a network of regional service providers, consisting i.a. from stroke units, rehabilitation partners and resident physicians as well as therapists. A quality and data management system accompanies the process and enables the collection of cross-sector data on health services research. The stroke pilots are equipped with tablets and an app developed by OFFIS to document the care and recovery process. OFFIS also implements a concept for the data protection-compliant storage and processing of patient data as well as for the exchange and assignment of this data between the involved project partners.

Funding / Cooperations

Partners

OFFIS e.V., Bereich Gesundheit
Stiftung Deutsche Schlaganfall-Hilfe
Universität Bielefeld, Fakultät für Gesundheitswissenschaften
Techniker Krankenkasse
IKK Classic
Innovation Health Partners (IHP)

Funding

The project is funded by the Innovationsfonds of G-BA (10/17 – 09/20)
own sources (AMT)

 

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