GPs play an important role in the detection and management of stroke risk factors such as hypertension, diabetes mellitus and hyperlipidaemia.
For the prevention of stroke in the primary care setting, it would be helpful to provide patients who are identified to be at risk with advice such as dietary modifications, exercise programmes and medication where required.
GPs also play a critical role in ensuring optimal care for post-stroke patients recovering at home and in the community. They can provide monitoring for secondary stroke prevention.
A long-term, primary care driven stroke care service that provides post-stroke management at the community level can yield favourable outcomes for stroke patients.
Our Stroke ICP Programme aims to coordinate and integrate care for stroke patients across the care continuum. Conditions of stroke patients who are enrolled in the programme will be managed in a holistic approach by our multi-disciplinary team, which includes a neurologist, neurosurgeon, case manager, thrombolysis nurse, physiotherapist, occupational therapist, speech therapist, pharmacist, psychologist, medical social worker and dietitian.
Our programme provides GPs and stroke patients with easy access to expert advice as well as an easy point of contact via our case manager.
Under our Stroke ICP Programme, a case manager will:
- Monitor and assess the progress of stroke patients who have been discharged from the hospital at periodic intervals
- Monitor patients' adherence to evidence-based therapy
- Provide patient education to patients and caregivers
- Provide step-down care and end-of-life care resources to patients and caregivers
This collaborative partnership between our multi-disciplinary team and the GPs in the community can bring about better care as well as coordination of care for stroke patients in the west.
Only direct referrals from JurongHealth Campus' GP partners will be accepted for our Stroke ICP Programme.
Contact our Stroke Integrated Care Pathway Programme team for more information.
