Objective

HEMIPASS is a post-stroke interdisciplinary mobile home team care, which aims to provide home care services for post-stroke patients. Describe the evolution of HEMIPASS program over the past three years by looking at its level of activities. The hypothesis is that the HEMIPASS program is more in demand by liberal sector than hospital services; indeed, it increases its efficacy over time.

Materials/Patients and methods

Retrospective study design conducted from 2013 to 2015, involving all post-stroke patients enrolled in HEMIPASS program during this period. Patients’ level of participation was divided in three groups: level 1 (patients involved); level 2 (patients less involved, but relatives helping), and level 3 (little implication from patients, relatives not helping).

Results

227 patients have been followed over the last three years. Patients’ mean age was 67 years; stroke delay was lower than one year in 76% of patients, and the Barthel Index average was 76/100. The average length of follow-ups is between three and six months for 2013 and 2014, and six and twelve months for 2015. Applications came from Physical Medicine and Rehabilitation Services (40%), as well as Neurology Services (20%) from Limoges Hospital Center. The 40% remaining was from community, outside the Hospital. For the latter, there was an increase in applications from social services annually. More often, the follow-up was multidisciplinary (e.g., medical doctor, nurse, occupational therapist, neuropsychologist), with an annual progression from 65% to 73% in 2013 and 2014, and 76% in 2015. Patients’ participation level increased in group 1 and 2, from 71% to 82% in 2013 and 2014, and 86% in 2015. Lastly, the percentage of succeeded projects progressed from 79% to 82% in 2013 and 2014, and 86% in 2015.

Discussion/Conclusion

Over these three years, the number of applications increased progressively from the social services due to a better collaboration between those structures and HEMIPASS program. The multidisciplinary follow-up was represented by the complementary and expertise of each members of the team. Therefore, we note a higher level of patients’ involvement expressed in a better success of their live projects. Our results take into account the importance about the cooperation between all the stakeholders.