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Indication-Specific Regionally-Coordinated Post-Acute Care of People with Strokes and People with Dementia Following a Stroke in Berlin Pankow

Project duration: 01/05/2013-31/01/2014

Principal investigator: Prof. Dr. Karin Wolf-Ostermann

Project staff: Johannes Gräske, Dipl. Pflegewirt (FH),  Steve Strupeit, MScN

Project holder:  

  • Qualitätsverbund Netzwerk im Alter - Pankow e.V. (QVNIA e.V.)

Scientific partner:

  • Charité – Universitätsmedizin Berlin, Institut für Medizinische Soziologie

INDIKA aims to improve the quality of post-inpatient nursing care and counselling for stroke survivors with and without dementia (MmS/D), together with their relatives, through the use of local networks. Based on the existing structures of “Netzwerk im Alter – Pankow e.V.” [“Networks in Old Age – Pankow e.V.”] (QVNIA e.V.) in the field of health and nursing, a trans-sectoral nursing care pathway is being developed and implemented within a local healthcare network. This pathway is designed to be trans-sectoral and trans-professional, including the involvement of registered doctors, rehabilitation facilities, clinics, nursing centres, municipal administrative bodies, and self-help organisations.  

The main field of action of the project is the establishment of a trans-sectoral nursing care pathway to implement a mandatory, quality-assured and coordinated long-term care plan in selected post-inpatient nursing care settings, including the following:

  • Self-care performed by the client without the involvement of significant others or professional nurses
  • Non-professional; i.e., clients receive self-care support from  relatives and carers
  • Outpatient nursing care provided by a home care service
  • Day patient nursing care provided by a care service
  • Inpatient nursing care provided by short-term care or nursing home facilities

Indication-specific quality requirements for relevant nursing care processes are being evaluated. These requirements will be available in the future for nursing staff as evidence-based quality indicators and mandatory action guidelines for the networked care of stroke survivors with and without dementia. 

Aim of the scientific evaluation
The systematic and independent evaluation will enable the identification and refinement of single elements of the programme concepts. The ASH is examining the following research questions in a longitudinal study:

  1. Which care structures do stroke survivors or people with dementia require?
  2. How does networked care change care outcomes and processes for stroke survivors or people with dementia?
  3. How does networked care change health-related outcomes for relatives and carers of stroke survivors or people with dementia? 

Thus, the project will make a critical contribution to improving the care situation of older people in need of care following stroke and/or dementia. Furthermore, networked care saves money in nursing and medical care settings because consequences such as hospital admissions may be reduced. Additionally, the findings may be used for future approaches in research and development based on this concept, and will thereby build the foundation for nationwide generalisability of indication-specific care structures. The project will contribute to the investigation of the care situation of care-dependent people, including the sustainable improvement of their healthcare.

GKV-Spitzenverband Modellprojekt nach §8 Abs. 3 SGB XI

Prof. Dr. Karin Wolf-Ostermann, wolf-ostermann@ avoid-unrequested-mailsash-berlin.eu  
Johannes Gräske, graeske@ avoid-unrequested-mailsash-berlin.eu
Steve Strupeit, strupeit@ avoid-unrequested-mailsash-berlin.eu 

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