Managing Aftercare for Stroke (MAS): MAS-II - A Longitudinal Complex-interventional Study in Post-rehabilitation Stroke Patients


Phase N/A Results N/A

Trial Description

After discharge from hospital, the current healthcare system in Germany allows considerable flexibility (therefore complexity) of patient access and mobility between multiple care providers in the community setting. The investigators believe this aftercare could be better coordinated by a specialized coordinated stroke aftercare service. Comprehensive coordinated multidisciplinary care is a proven concept with proven benefits in both acute and rehabilitation care provided in stroke units and neurorehabilitation centres. In this study, the investigators postulate that a similar coordinated approach to care can be extended to the phase after in-patient rehabilitation has ended (i.e. "long-term management" as opposed to "early supported discharge") for disabled patients with stroke living in the community.



  • Comprehensive multidisciplinary stroke care Other
    Intervention Desc: Patients will be treated in the pathological domain. Some of this treatment will be applied by the outpatient clinic itself (i.e. changes in medical secondary prevention or additional prescriptions, social work interventions), whereas most of it will be referred to other providers, if possible in vicinity to the patients' home. In order to ease treatment prescriptions and allow to measure treatment uptake, patients will also enrol in the case management system "Ambulanzpartner". This allows the outpatient center to streamline prescription processes and measure uptake of therapies.
    ARM 1: Kind: Experimental
    Label: comprehensive multidisciplinary stroke care


Type Measure Time Frame Safety Issue
Primary "EuroQol five dimensions questionnaire" (EuroQoL-5D) 12 Months
Secondary Post Stroke Checklist (PSC) 12 Months
Secondary modified Rankin Scale (mRS) 12 Months
Secondary Barthel-Index (BI) 12 Months
Secondary modified Ashworth Scale (mAS) 12 Months
Secondary Pain Detect (PD-Q) 12 Months
Secondary Freiburg questionnaire for coping (FKV) 12 Months
Secondary Montreal Cognitive Assessment (MoCA) 12 Months
Secondary partial Aachen Aphasia Test (AAT) 12 Months
Secondary Hamilton rating scale for depression 12 Months
Secondary "Morisky Medication Adherence Scale" (MMAS) 12 Months
Secondary "Nikolaus score for evaluation of social conditions" (SoS) 12 Months
Secondary "Häusliche Pflegeskala" (HPS) 12 Months
Secondary Hospital Anxiety Depression Scale (HADS) 12 Months