Centralising acute stroke care and moving care to the community in a Danish health region: Challenges in implementing a stroke care reform

Abstract

In May 2012, one of Denmark's five health care regions mandated a reform of stroke care. The purpose of the reform was to save costs, while at the same time improving quality of care. It included (1) centralisation of acute stroke treatment at specialised hospitals, (2) a reduced length of hospital stay, and (3) a shift from inpatient rehabilitation programmes to community-based rehabilitation programmes. Patients would benefit from a more integrated care pathway between hospital and municipality, being supported by early discharge teams at hospitals. A formal policy tool, consisting of a health care agreement between the region and municipalities, was used to implement the changes. The implementation was carried out in a top-down manner by a committee, in which the hospital sector--organised by regions--was better represented than the primary care sector-organised by municipalities. The idea of centralisation of acute care was supported by all stakeholders, but municipalities opposed the hospital-based early discharge teams as they perceived this to be interfering with their core tasks. Municipalities would have liked more influence on the design of the reform. Preliminary data suggest good quality of acute care. Cost savings have been achieved in the region by means of closure of beds and a reduction of hospital length of stay. The realisation of the objective of achieving integrated rehabilitation care between hospitals and municipalities has been less successful. It is likely that greater involvement of municipalities in the design phase and better representation of health care professionals in all phases would have led to more successful implementation of the reform.

Early supported discharge following mild stroke: a qualitative study of patients' and their partners' experiences of rehabilitation at home

“…Acute stroke care was centralised into two hospitals with highly specialised stroke units and thrombolysis services. Multidisciplinary ESD stroke teams were established at all regional hospitals to support discharge and deliver individualised, home‐based rehabilitation of patients with mild‐to‐moderate stroke symptoms . Based on individual assessments of each patient, the stroke team visits each patient 2–7 days after discharge to evaluate the patient's needs and to outline a rehabilitation plan, if needed.…”

Optimising spatial accessibility to inform rationalisation of specialist health services

“…In Denmark, for example, there is an ongoing programme of specialisation and centralisation of care resulting in establishment of five ‘super hospitals’ by 2020 [25]. This includes reform of stroke care, which is proposed to be concentrated at two centres, selected based on patient volumes.…”

Professional groups driving change toward patient-centred care: interprofessional working in stroke rehabilitation in Denmark

“…In this article, we place interprofessional working in the context of health policy and governance reform, using stroke rehabilitation in Denmark as a case study [ 25 ]. In 2012, Central Denmark Region carried out a major reorganisation of stroke treatment and rehabilitation.…”

“…In practice, this means the following: the stroke team visit patients 2–7 days after discharge to evaluate the patient’s needs and to draw up a rehabilitation plan; based on this, relevant members of the stroke team usually visit the patient’s home 1–4 times; and for those patients who need further professional rehabilitation the team makes a referral to relevant services provided by the respective home municipality and supports the transfer. The overall rationale underlying the establishment of the stroke teams thus was to ensure greater integration between hospital and community-based rehabilitation in the patients’ home municipality [ 25 ]. The region also introduced one regional network for all teams as well as 4 mono-professional, regional networks to support the implementation of the reorganisation.…”

“…The region also introduced one regional network for all teams as well as 4 mono-professional, regional networks to support the implementation of the reorganisation. The idea was to strengthen peer support and stimulate organisational/professional development both among individual teams as new organisational entities and among members of the same professional group across teams [ 25 ]. The reorganisation of stroke treatment and rehabilitation reflects a health system that is highly integrated and where participatory modes of governance are strong, operating at different levels [ 26 ].…”