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GP role in new national stroke care standard
The GP-patient relationship provides an ideal opportunity to support people through the ‘long tail’ of care after a stroke.
The guidance defines what ‘gold standard care looks like’, including treatment when people transition home after stroke.
The role of GPs in helping rebuild patients’ lives after stroke has been given greater focus in a new national standard aimed towards supporting patients through the ‘long tail’ of care.
The Australian Commission on Safety and Quality in Health Care has released an updated Stroke Clinical Care Standard with new guidance to support people recovering from stroke after they leave hospital.
It’s the first update of the standard since 2019 and includes a stronger focus on rehabilitation, individualised care planning and follow-up.
GP and Medical Advisor for the Commission, Dr Lee Fong, describes stroke as having a ‘long tail’, since the impacts can be long-lasting and affect a person’s ability to carry out usual activities such as work, study or caring responsibilities.
‘The rehabilitation, the care planning, the follow-up – life that continues after discharge and I think that’s particularly important from a GP perspective, and where GPs have a really central role,’ he told newsGP.
The new Stroke Clinical Care Standard features eight ‘quality statements’ to guide care:
- Early assessment and urgent transport to hospital
- Time-critical therapy
- Stroke unit care
- Rehabilitation
- Minimising risk of another stroke
- Practical assistance for families and support people
- Individualised care plan
- Follow-up assessment and review
Dr Fong said there are two broad categories for GPs in these standards – what GPs can expect for a patient who has been discharged from hospital after stroke and what should happen afterwards.
‘We should expect that there’ll be an individualised care plan, so a comprehensive care plan that’s been given to the patient, and we get copied in to as their GP,’ he said.
‘The other thing that we should expect, and that is emphasised in this revised clinical care standard, is the six-month follow up. In other words, that there’s going to be a follow-up assessment or review with a multidisciplinary team within six months of the stroke diagnosis, which is organised before they get discharged from hospital.
‘That’s the expectation that as GPs, we should have.’
Dr Fong said the next step as GPs is, ‘what can we provide?’.
This, he said, comes down to secondary prevention, exploring function issues that may be hidden, and making sure people don’t become lost in the system.
‘Prevention is about reducing the risk of another stroke. If we know that classic atrial fibrillation is a cause for stroke, then we’re providing anti-coagulation, other aspects of secondary prevention, like blood pressure, lipid control, diabetes control. That’s the prevention side of things,’ Dr Fong said.
‘Then we’re looking at function. These are often symptoms and issues which aren’t necessarily surfaced or can be missed.
‘As GPs we’re in a particularly good position because we know the patients, we have a relationship with the patients where we can ask about the detail of physical changes, cognitive changes, emotional changes, social changes that have happened in the context of the stroke.
‘And then there’s a follow-up aspect to it, so making sure there’s the rehabilitation that they need, that the specialist reviews have been occurring, the care plan actually has happened, and medication reviews are occurring.’
Dr Fong said GPs should also keep in mind that many patients report feeling lonely after a stroke.
‘As GPs, having that relationship means being able to come alongside and provide assurance to patients that they aren’t alone, that they are continuing to be provided care in the context of their stroke,’ he said.
‘Another really important aspect that GPs can provide is to help patients navigate any ongoing care needs they might have, particularly [in cases where] that hasn’t already been organised at the time of discharge, or if it’s an emerging issue that comes post-discharge.
‘This might include allied health referrals, it might include driving assessments, it might involve NDIS, it might involve mental health support, and so on.
‘This comes back to the holistic role of GPs when it comes to healthcare, and we’re in a perfect position to provide this kind of assistance to our patients.’
Neurologist Professor Tim Kleinig, who is immediate past-President of the Australian and New Zealand Stroke Organisation said that despite improvements in treatment, ‘follow-up care after stroke is patchy across Australia’.
‘The updated standard shows us what gold standard care looks like, during treatment in ambulances and hospital, and when people transition home after stroke,’ he said.
‘The goal is to create a foundation for people to resume their normal life in the community, as much as possible.’
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