Post-Stroke Disease Management - Stroke Card

"Standard Care plus~extended training with access to weekly educational lectures (education of patients and relatives), implementation of My Stroke Card containing (a) an adopted version of the 'post-stroke checklist' (ascertainment of post-stroke complications), (b) self-administered internet-based tools for risk factor monitoring and reinforcement of target level achievement, and (c) information and educational materials.~3-Mo outpatient appointment with standardized assessment of risk factors and screening for complications, health problems and residual deficits, estimation of the patient's demand for nursing services and support, guideline-conform secondary prevention with full achievement of target levels, assessment of patient adherence to drug prescriptions.~6-Mo and 9-Mo visits on the discretion of the study team in case of medical needs.~12-Mo clinical visit and outcome assessment."

"In-hospital training (education of patients, next of kin and caregivers on risk factor management and assessment, life style improvement, and compliance).~Complimentary provision of a book / information material dealing with patient and caregiver relevant aspects of stroke care.~Advise by a dietitian (general advise and individualized recommendations in patients with diabetes and obesity).~Standardized information materials (e.g. for OAK or NOAK therapy). Support for smoking cessation and weight reduction if necessary or requested. Detailed medical reports (doctor's letter for the general practitioner and patient) at discharge containing target levels for risk factor management.~AF detection at the Stroke Unit (1-5 day monitoring) and/or at the ward (24-hour ECG).~12-Mo clinical visit and outcome assessment."