We have developed a community organization of stroke care with coordinated inter-institutional service, which provides a critical and predictable pathway of acute and rehabilitation hospital treatments for patients suffered from stroke. After adequate treatment in stroke unit and ward, patients with moderate or sever disability are transferred to a multidisciplinary rehabilitation hospital with the programmed total care period of 60 days, 90 days, or 180 days according to the disability. The patient’s medical and functional information such as Functional Independence Measure (FIM) are shared among the hospitals by internet-based, information collaboration software, Microsoft Office Groove^®, in secure and decentralized manner, providing a seamless service for the patients.
The hospital stays were shorter for patients assigned this service than for those assigned conventional care both in the acute hospital by 37% and in the rehabilitation hospital by 24%. It is, however, not yet clear whether this service improves outcome of the patients compared with traditional rehabilitation service.