Rotterdam pilot

The Rotterdam pilot will be focused on older adults who have had a TIA or ischemic stroke, their caregivers, and health and social care professionals. In 2018, a partnership was established between the local academic hospital (Erasmus Medical Centre), two rehabilitation clinics and a nursing home to encourage the delivery of integrated, value-based care for stroke patients in Rotterdam and the wider region. In ValueCare, this partnership will be extended with stakeholders in primary care (GPs, physiotherapists), social care (municipality), and informatics (IT experts). Together with patients who have had a TIA or ischemic stroke, their caregivers, and health and social care professionals, these stakeholders will be invited to share their experiential knowledge and expertise in a process of co-creation to develop the ValueCare intervention.

Examples of core elements that are adopted as part of the ValueCare intervention in Rotterdam are:

· Ongoing assessments using questionnaires to measure patient-reported health outcomes;

· A personalized care plan based on the outcomes of the assessment;

· Support of mobile health solutions to encourage patients to reach their goals regarding, for example, rehabilitation, medication adherence and/or healthy lifestyle.

Eligible patients will be asked for their consent to participate in the intervention by the community stroke nurse soon after discharge from one of the participating hospitals in the Rotterdam region to home. Each patient will be followed for 14 months.

At several points in time, patient-reported outcomes are measured with an adapted version of the ValueCare questionnaire to the Rotterdam context. In addition, we ask patients, caregivers and health and social care professionals to share their experiences with the ValueCare approach.