Referral system for stroke in Kumamoto

Abstract

We built the stroke medical treatment network (regional inter-hospital referral model for stroke) by front cooperation with the family medicine and rear cooperation with a rehabilitation specialty hospital. We have reinforced the stability cooperation between specialty hospitals to accept stroke patients without declining them because of minimal staff and for the immediate nature period to utilize local health resource with in-hospital systems construction effectively. We were able to solve many problems by network construction. Furthermore, for the cooperation of convalescence and the maintenance period, the development of the liaison critical pathways for stroke and the construction of the operative network, the establishment of the Kumamoto Zaitaku Doctor Net was performed, and network construction advanced more. As for the horizontal cooperation between Kumamoto city public hospitals, various actions in regional alliances meeting (meeting of the regional alliances room) were established. We became able to analyze much data with the liaison critical pathway by being computerized. We developed construction of the integrated community care system, making and using advanced directives and the stroke notebook for a stroke patient perform self-administration now.