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Table 2 Summary Of Expected Outcomes For the Integrated Care Pathway for Post Stroke patients (iCaPPS) residing at home in the community (Reproduced with permission from Aznida FAA, 2015)

From: The integrated care pathway for post stroke patients (iCaPPS): a shared care approach between stakeholders in areas with limited access to specialist stroke care services


Care Plan


Treatment Targets/Screening schedulesa


Stroke risk factor(s) management


Lifestyle changes if BP between 130-139 mmHg systolic and/or 80–89 mmHg diastolic.

Treat medically if BP >140/90 mmHg

Target BP for diabetics is ≤ 130/80 mmHg

Hypertension should be treated in the very elderly (age > 70 years) to reduce risk of stroke.


For patients with ischaemic stroke:

High risk group: keep LDL-cholesterol < 2.6 mmol/l or 2.0 mmol/L (considered in category of CVD or CHD risk equivalents)

For patients with haemorrhagic stroke, the evidence is inconclusive.

Diabetes mellitus

Tight glycaemic control is advised:

HbA1c <6.5%

Fasting blood sugar 4.4–6.1 mmol/L

Renal impairment/Chronic Kidney Disease

eGFR should be monitored at least annually, as in monitoring for patients with diabetes ellitus



Please check if patient has been referred for rehabilitation prior to discharge from hospital.

If patient has been referred, check compliance and ensure or organise annual review by Rehabilitation Physician. Goals for rehabilitation are based on discussion with patient and/or caregiver and Rehabilitation team. Refer to iCaPPS-Rehabilitationa algorithm for further details.

Occupational Therapy

Speech & Language Therapy

For patients on oral feeding, please check if screening for dysphagia was done during admission for acute stroke (includes evaluation by SLP). If not done, please check for symptoms of dysphagia at initial and subsequent visits.

If patient is on nasogastric tube feeding at initial consultation, please check for duration and long-term feeding plans. Refer to iCaPPS-swallow* for further details.


Mental Health assessment


Screen patient for depression at initial and subsequent visits, using the TQWHQ.

If positive, please proceed to use PHQ9 to determine level of intervention.


Screen with ECAQ for patients ≥ 60 years old. If score is <5, proceed with M- MMSE testing.

M- MMSE for patients < 60 years old. If Score ≤ 17, to refer to Psycho-geriatrician for further evaluation and intervention.

  1. aBased on recommendations by iCaPPS Expert Panel, Clinical Practice Guidelines of the Malaysian Academy of Medicine and Ministry of Health
  2. BP blood pressure, eGFR calculated Glomerular Filtration Rate, SLP Speech and Language Pathologists or Therapists, TQWHQ Two Question with Help Questionnaire, PHQ9 Patient Health Questionnaire (nine items). M-MMSE Mini Mental State Examination (Malay version)