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Follow-up by a stroke coordinator

The most extensive part of LAST-long is a randomized controlled multicenter study, aiming to investigate whether regular follow-up meetings with a municipal stroke coordinator will prevent loss of function after stroke. We are aiming to recruit 300 participants from the stroke units at St. Olavs Hospital, Akershus University Hospital, Bærum Hospital and Ålesund Hospital. Half of all participants will be selected for follow-up by a stroke coordinator in addition to standard care. The other half of the participants will receive usual care by a GP and the municipal healthcare service. The services provided are current best practice. All participants, regardless of which group they are allocated to, will have their physical function and self-perceived health thoroughly examined upon inclusion in the study, and again at the 3 follow-up meetings every 6 months. In total the duration of the study is 18 months.


Last-LONG project questions

Patients who have been admitted to St. Olavs Hospital, Akershus University Hospital, Bærum Hospital or Ålesund Hospital with an acute stroke and who live in Trondheim, Ålesund, Bærum, Asker, Lillestrøm or Lørenskog municipality may be asked to participate in the study, when they attend their check-up appointment at the outpatient clinic three months after admission.

The main purpose of the study is to investigate whether regular long-term follow-up by a municipal stroke coordinator will prevent loss of function.

All participants, regardless of which group they are allocated to, will have their physical function and self-perceived health thoroughly examined and again at 9, 15 and 21 months after the stroke. Informal care givers or next of kin will also be asked about their experience and well-being.

Those who agree to join will be randomly selected to end up in one of two groups. The first group, the Intervention Group, are those who receive extra follow-up by a stroke coordinator in addition to regular follow-up. The second group, the control group, are those who are followed up with standard care by a GP and the municipal healthcare services.

Last-long timeline

Much research has been done to study clinical best practice within the first 3 months after a stroke. Yet, there are many open questions regarding the follow-up of people suffering from stroke in the long-term. In order to gain new knowledge on how to prevent loss of function and improve the clinical pathway, we depend on the willingness of those who are affected by stroke to participate in studies.

If you have had a stroke yourself, you may receive information about LAST-long approximately 3 months after the stroke with an invitation to participate in our study.

You will be met by a study associate, a healthcare professional , who will carry out several tests and questionnaires in collaboration with you. This is an important step to get an insight in how you are doing and your function at this time.

After the testing, you will be randomly assigned to one of two groups, and you will be informed which group you belong to..

Intervention group

Congratulations if you have been chosen to be part of the Intervention Group!

Here are three good reasons to be part of an intervention group:

  1. You are assigned to a stroke coordinator who, together with you, evaluates monthly whether you are getting the follow-up you need in your situation.
  2. You get more attentive follow-up from the stroke coordinator, which is often perceived positively by both patients and next of kin..
  3. You make an important contribution to research and thus a better follow-up after stroke in the future.

What happens when you are selected for follow-up by a stroke coordinator in the municipality?

The information from the tests carried out at the hospital and other information of importance for further follow-up is transferred to the municipal stroke coordinator. The coordinator will make an appointment with you either at his office or visit you at home. Sometimes meetings are also done via telephone or video. In the meetings, you go through issues that are important for you to address. At this meeting, your next of kin can also highlight their needs.

The purpose of this meeting is to find out which services the individual needs, and which are best suited for maintaining optimal function. The services main focus can be physical activity and exercise, social and mental stimulation, help with medication or other lifestyle factors.

Control group

Congratulations if you have been chosen to be part of the Control Group.

Here are three good reasons for you to be part of the Control Group:

  1. It is the best follow-up according to today’s best practice
  2. You will receive an extra thorough examination 9, 15 and 21 months after the stroke. If there are any deviations in the tests, you will be informed, so you can contact your GP.
  3. You make an important contribution to research to improve follow-up after stroke.

Based on your needs, you will receive standard follow-up from the municipality.

In this meeting you will be given the same surveys and assessment as in the first test, so we are able to compare your results.

Intervention group

Since the last testing, you have had monthly meetings with the stroke coordinator, either in person or by telephone.

Nine months after the stroke, you show up at the time for testing. Here you will do questionnaires and tests. If there is anything in a test that deviates from the norm, you will be informed of this so that you can contact your GP.

Control group

Nine months after the stroke, you show up at the time for testing. Here you will do questionnaires and tests. If there is anything about a test that deviates from the norm, you will be informed of this so that you can contact your GP.

You will receive the same examinations as in exam 1 and 2 for us to be able to compare your results.

Intervention group

Since the last exam, you have had monthly meetings with the stroke coordinator, either in person or by telephone.

Fifteen months after the stroke, you show up at the time for testing. Here you will do questionnaires and tests. If there is anything about a test that deviates from the norm, you will be informed of this so that you can contact your GP.

Control group

Fifteen months after the stroke, you show up at the time for testing. Here you will do questionnaires and tests. If there is anything about a test that deviates from the norm, you will be informed of this so that you can contact your GP.

You will receive the same examinations as in tests 1, 2 and 3 for us to be able to compare your results.

Intervention group

In the period since the last test, you have had monthly meetings with the stroke coordinator, either in person or by telephone.

Twenty-one months after the stroke, you show up at the time for testing. Here you will do questionnaires and tests. If there is anything about a test that deviates from the norm, you will be informed of this so that you can contact your GP. This is the end of the follow-up in the LAST-long study.

Control group

Twenty-one months after the stroke, you show up at the time for testing. Here you will do questionnaires and tests. If there is anything about a test that deviates from the norm, you will be informed of this so that you can contact your GP. This is the end of the follow-up in the LAST-long study.