Erika was 78 years old, lived with his wife and was independent in his activities of daily living when he had a stroke that caused moderate hemiparesis and aphasia. Erik received initial care in a stroke unit, where he stayed for 5 days; this period was followed by 44 days in a geriatric rehabilitation ward specializing in rehabilitation after stroke (Fig. 1). The same day he was discharged and returned home, a physiotherapist (PT) and an occupational therapist (OT) from a stroke team, organized by the primary-care centre, visited him at home for his first rehabilitation session. Erik faced activity limitations with regard to activities such as getting dressed, cutting his food and walking independently, and he was unable to climb stairs. His aphasia had improved, but he still had difficulties communicating. Initially, the PT and the OT visited him almost daily; thereafter these sessions were less frequent, but the rehabilitation sessions in Erik’s home with the stroke team continued throughout the first three quarters of the year. Supplementing his training with the stroke team, Erik’s wife and the home-help service daily encouraged his attempts to regain independence and to resume previously valued activities.|
In addition to the home rehabilitation, Erik also received rehabilitation treatment at the hospital’s geriatric out-patient clinic. The initial focus on physiotherapy and occupational therapy had by the end of the year changed to speech and language therapy. During the third quarter, when the home-based rehabilitation provided by the stroke team was completed, Erik began physiotherapy and occupational therapy at the primary-care centre. One year after the stroke, Erik had improved significantly but still had difficulty climbing stairs independently and speaking when he was tired or stressed. Apart from the rehabilitation provided at the stroke unit and at the in-patient rehabilitation ward, Erik received 235 rehabilitation sessions, provided by a PT and an OT, a medical social worker, speech and language therapists and a dietician. He also had other healthcare contacts, such as primary-care physicians and district nurses.