{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,26]],"date-time":"2026-05-26T16:07:00Z","timestamp":1779811620116,"version":"3.53.1"},"reference-count":41,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T00:00:00Z","timestamp":1778544000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To document opinions and experiences of representatives from three different interest groups regarding \u201cneeds-based healthcare\u201d of people with severe neuro-disability requiring home-based specialized intensive care nursing (HSICN) and continued community-based rehabilitation efforts, to evaluate the appropriateness of an evidence- and guideline-based clinical pathway (CP) for trans-sectoral specialist support by regional outreach follow-up teams (ROFT) from inpatient neurological early rehabilitation (NER) and its implementation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Qualitative exploratory study design: Semi-structured group-interviews with representatives of the three stakeholder groups, i.e., HSICN, therapists in the community (THER-C), and ROFT followed by a multi-stage analysis and interpretation process of their responses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Three interviews-sessions were conducted with a total of 11 group-representatives. A total of 301 individual responses (i) were documented. Based on their experience, the interview partners identified a multitude of relevant aspects for an appropriate needs-based healthcare (i = 80) of the specific clientele, as well as facilitators (i = 44) and barriers (i = 82) for its implementation. The appropriateness of the developed CP was largely confirmed (i = 20). Support by a ROFT (i = 33) was mostly positively evaluated. Additional aspects considered necessary for needs-based healthcare (i = 42) were articulated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The proposed and implemented clinical pathway as a model of \u201cneeds-based healthcare\u201d in the community for people with severe neuro-disability and the role of ROFT as an enabling specialist function supporting community healthcare were considered appropriate. The qualitative research identified several system-level constraints as barriers. Some were context-specific, i.e., remuneration for coordination time, fragmented funding streams, and incentives around decannulation\/weaning. As presumably universally relevant design principles for the trans-sectoral care approach were identified: multiprofessional workforce capacity and minimum competency standards in the community, center-based specialist support for the community, case management, structured interprofessional exchange, shared documentation, and a potential role of telemedicine. The absence of patient and caregiver perspectives is a relevant limitation to be overcome by future research.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fneur.2026.1677483","type":"journal-article","created":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T04:33:32Z","timestamp":1778560412000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Post-discharge \u201ccontinuum of care\u201d clinical pathway (CP) for persons with severe neuro-disabilities \u2013 qualitative research to model needs-based community healthcare, capture the real-life care situation, and assess the appropriateness of the CP's concept with input from community- and hospital-based healthcare professionals"],"prefix":"10.3389","volume":"17","author":[{"given":"Stephanie","family":"Reichl","sequence":"first","affiliation":[{"name":"Medical Faculty, Neurorehabilitation Research Group, University of Greifswald","place":["Greifswald, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sybille","family":"Roschka","sequence":"additional","affiliation":[{"name":"Medical Faculty, Neurorehabilitation Research Group, University of Greifswald","place":["Greifswald, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bernadette","family":"Einh\u00e4upl","sequence":"additional","affiliation":[{"name":"Medical Faculty, Ludwig-Maximilians-Universit\u00e4t M\u00fcnchen","place":["M\u00fcnchen, Germany"]},{"name":"Therapiezentrum Burgau","place":["Burgau, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danae","family":"G\u00f6tze","sequence":"additional","affiliation":[{"name":"Medical Faculty, Ludwig-Maximilians-Universit\u00e4t M\u00fcnchen","place":["M\u00fcnchen, Germany"]},{"name":"Therapiezentrum Burgau","place":["Burgau, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Sch\u00f6ssow","sequence":"additional","affiliation":[{"name":"Medical Faculty, Neurorehabilitation Research Group, University of Greifswald","place":["Greifswald, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Bender","sequence":"additional","affiliation":[{"name":"Medical Faculty, Ludwig-Maximilians-Universit\u00e4t M\u00fcnchen","place":["M\u00fcnchen, Germany"]},{"name":"Therapiezentrum Burgau","place":["Burgau, Germany"]},{"name":"Department Neurorehabilitation, Medical Faculty, University Augsburg","place":["Augsburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Platz","sequence":"additional","affiliation":[{"name":"Medical Faculty, Neurorehabilitation Research Group, University of Greifswald","place":["Greifswald, Germany"]},{"name":"BDH-Klinik Greifswald, Institute for Neurorehabilitation and Evidence-based Practice, An-Institut University of Greifswald","place":["Greifswald, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,5,12]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"344","DOI":"10.1016\/S1474-4422(24)00038-3","article-title":"Global, regional, and national burden of disorders affecting the nervous system, 1990\u20132021: a systematic analysis for the Global Burden of Disease Study 2021","volume":"23","author":"GBD","year":"2024","journal-title":"Lancet Neurol."},{"key":"B2","doi-asserted-by":"publisher","first-page":"5","DOI":"10.5334\/ijic.7617","article-title":"Perceived roles and barriers in delivering community-based care: a qualitative study of health and social care professionals","volume":"23","author":"Ge","year":"2023","journal-title":"Int J Integr Care."},{"key":"B3","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1055\/s-0043-124347","article-title":"Optimized transition from inpatient stroke rehabilitation to home care - current practice and analysis of factors influencing transition","volume":"58","author":"Saal","year":"2019","journal-title":"Rehabilitation."},{"key":"B4","doi-asserted-by":"publisher","first-page":"789","DOI":"10.1177\/1747493019897847","article-title":"Canadian stroke best practice recommendations: rehabilitation, recovery, and community participation following stroke. Part two: transitions and community participation following stroke","volume":"15","author":"Mountain","year":"2020","journal-title":"Int J Stroke."},{"key":"B5","doi-asserted-by":"publisher","first-page":"299","DOI":"10.1186\/s12913-023-09290-1","article-title":"How do stroke early supported discharge services achieve intensive and responsive service provision? Findings from a realist evaluation study (WISE)","volume":"23","author":"Chouliara","year":"2023","journal-title":"BMC Health Serv Res."},{"key":"B6","doi-asserted-by":"publisher","first-page":"634","DOI":"10.1007\/s00115-016-0093-1","article-title":"Course of rehabilitation in early neurological\/neurosurgical rehabilitation. Results of a 2014 multi-center evaluation in Germany","volume":"87","author":"Pohl","year":"2016","journal-title":"Nervenarzt"},{"key":"B7","doi-asserted-by":"publisher","first-page":"729","DOI":"10.1055\/a-1164-6516","article-title":"Quality of care for people with home mechanical ventilation in Germany: a scoping review","volume":"82","author":"Klingshirn","year":"2020","journal-title":"Gesundheitswesen."},{"key":"B8","doi-asserted-by":"publisher","first-page":"1552692","DOI":"10.3389\/fneur.2025.1552692","article-title":"Post-discharge \u201ccontinuum of care\u201d clinical pathway for persons with severe neurodisabilities-qualitative research to assess its concept and practicality after implementation","volume":"16","author":"Reichl","year":"2025","journal-title":"Front Neurol."},{"key":"B9","volume-title":"Community-Based Rehabilitation: CBR Guidelines","year":"2010"},{"key":"B10","doi-asserted-by":"publisher","first-page":"215","DOI":"10.14624\/NR2104001","article-title":"Das Team in der Neurorehabilitation","volume":"27","author":"Mokrusch","year":"2021","journal-title":"Neurol Rehabil."},{"key":"B11","doi-asserted-by":"publisher","first-page":"290","DOI":"10.1186\/s12883-022-02814-y","article-title":"Optimizing home-based long-term intensive care for neurological patients with neurorehabilitation outreach teams - protocol of a multicenter, parallel-group randomized controlled trial (OptiNIV-Study)","volume":"22","author":"Platz","year":"2022","journal-title":"BMC Neurol."},{"key":"B12","doi-asserted-by":"crossref","DOI":"10.1007\/978-3-030-58505-1","volume-title":"Clinical Pathways in Stroke Rehabilitation: Evidence-Based Clinical Practice Recommendations","author":"Platz","year":"2021"},{"key":"B13","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD006632.pub2","article-title":"Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs","author":"Rotter","year":"2010","journal-title":"Cochrane Database Syst Rev"},{"key":"B14","unstructured":"Bender\n              A\n            \n            \n              Bl\u00f6dt\n              S\n            \n            \n              Bodechtel\n              U\n            \n            \n              Eifert\n              B\n            \n            \n              Elsner\n              B\n            \n            \n              Feddersen\n              B\n            \n          \n          Berlin\n          AWMF\n          S3-LL Neurologische Rehabilitation bei Koma und schwerer Bewusstseinsst\u00f6rung im Erwachsenenalter.\n          \n          2022"},{"key":"B15","doi-asserted-by":"publisher","first-page":"453","DOI":"10.1055\/a-2148-3323","article-title":"S2k-Leitlinie Nichtinvasive Beatmung als Therapie der akuten respiratorischen Insuffizienz","volume":"78","author":"Westhoff","year":"2023","journal-title":"Pneumologie."},{"key":"B16","unstructured":"Schmidt-Wilcke\n              T\n            \n            \n              Rollnik\n              JD\n            \n            \n              Abel\n              U\n            \n            \n              Huge\n              V\n            \n            \n              Haack\n              C\n            \n            \n              Zergiebel\n              D\n            \n          \n          Berlin\n          AWMF\n          S2k-Leitlinie Prolongierte Beatmungsentw\u00f6hnung in der neurologisch-neurochirurgischen Fr\u00fchrehabilitation\n          \n          2025"},{"key":"B17","unstructured":"Deutsche\n              Gesellschaft f\u00fcr An\u00e4sthesiologie und Intensivmedizin e\n            \n          \n          Berlin\n          AWMF\n          S3-Leitlinie Lagerungstherapie und Mobilisation von kritisch Erkrankten auf Intensivstationen\n          \n          2023"},{"key":"B18","unstructured":"Deutsche\n              Gesellschaft f\u00fcr Neurologie (DGN)\n            \n          \n          S1-Leitlinie Neurogene Dysphagie\n          \n          2020"},{"key":"B19","author":"Creswell","year":"2018","journal-title":"Research Design: Qualitative, Quantitative, and Mixed Methods Approaches"},{"key":"B20","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1007\/978-3-030-58505-1_2","article-title":"Clinical pathways in stroke rehabilitation: background, scope, and methods","author":"Platz","year":"2021","journal-title":"Clinical Pathways in Stroke Rehabilitation: Evidence-based Clinical Practice Recommendations"},{"key":"B21","volume-title":"Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory","author":"Corbin","year":"2015"},{"key":"B22","doi-asserted-by":"publisher","first-page":"e929","DOI":"10.1002\/ams2.929","article-title":"Post-intensive care syndrome: recent advances and future directions","volume":"11","author":"Inoue","year":"2024","journal-title":"Acute Med Surg."},{"key":"B23","doi-asserted-by":"publisher","first-page":"1160","DOI":"10.1016\/S1474-4422(23)00277-6","article-title":"Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission","volume":"22","year":"2023","journal-title":"Lancet Neurol."},{"key":"B24","doi-asserted-by":"publisher","first-page":"1168","DOI":"10.1186\/s12913-022-08557-3","article-title":"Cross-sectorial collaboration on policy-driven rehabilitation care models for persons with neuromuscular diseases: reflections and behavior of community-based health professionals","volume":"22","author":"Handberg","year":"2022","journal-title":"BMC Health Serv Res."},{"key":"B25","doi-asserted-by":"publisher","first-page":"2482","DOI":"10.1161\/STROKEAHA.123.043605","article-title":"Virtual multidisciplinary stroke care clinic for community-dwelling stroke survivors: a randomized controlled trial","volume":"54","author":"Lo","year":"2023","journal-title":"Stroke."},{"key":"B26","doi-asserted-by":"publisher","first-page":"105382","DOI":"10.1016\/j.jstrokecerebrovasdis.2020.105382","article-title":"Feasibility of a nurse-trained, family member-delivered rehabilitation model for disabled stroke patients in Rural Chongqing, China","volume":"29","author":"Chu","year":"2020","journal-title":"J Stroke Cerebrovasc Dis."},{"key":"B27","doi-asserted-by":"publisher","first-page":"88","DOI":"10.1177\/1545968320971765","article-title":"Telerehabilitation after stroke using readily available technology: a randomized controlled trial","volume":"35","author":"Saywell","year":"2021","journal-title":"Neurorehabil Neural Repair."},{"key":"B28","first-page":"358","article-title":"Application of hospital-community-family \u201ctrinity\u201d remote rehabilitation guidance based on internet + WeChat platform in patients with stroke after discharge","volume":"30","author":"Li","year":"2024","journal-title":"Altern Ther Health Med."},{"key":"B29","first-page":"75","article-title":"Qiamuddin, Khan Z","volume":"10","author":"Ullah","year":"2023"},{"key":"B30","doi-asserted-by":"publisher","first-page":"6660296","DOI":"10.1155\/2023\/6660296","article-title":"Healthcare professionals' experiences with functional independence measure (FIM) as a structured framework for interprofessional team meetings in Danish stroke rehabilitation: a qualitative cross-sectoral collaborative study","volume":"2023","author":"Lauesen","year":"2023","journal-title":"Rehabil Res Pract."},{"key":"B31","doi-asserted-by":"publisher","first-page":"48","DOI":"10.26641\/2307-0404.2023.1.275869","article-title":"The benefits of coordinated rehabilitation in the treatment of stroke patients: a literature review","volume":"28","author":"Shuranova","year":"2023","journal-title":"Med Perspekt."},{"key":"B32","doi-asserted-by":"publisher","first-page":"6096","DOI":"10.3390\/ijerph19106096","article-title":"What competencies does a community occupational therapist need in neurorehabilitation? qualitative perspectives","volume":"19","author":"Avello-Saez","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"B33","unstructured":"Gro\u00df\n              Mea\n            \n          \n          S2k-Leitlinie \u00c4rztliche, pflegerische und therapeutische Versorgung von Personen mit au\u00dferklinischem Intensivpflegebedarf aufgrund von Erkrankungen des Nervensystems oder der Muskulatur online\n          \n          2025"},{"key":"B34","doi-asserted-by":"publisher","first-page":"342","DOI":"10.1007\/s00115-023-01598-x","article-title":"Curriculum \u201ctracheostomy management in dysphagia therapy\u201d","volume":"95","author":"Ledl","year":"2024","journal-title":"Nervenarzt."},{"key":"B35","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1055\/a-1877-4832","article-title":"The Respiratory Therapist in Neurology An Evolving Specialization in Germany","volume":"91","author":"Hornemann","year":"2023","journal-title":"Fortschr Neurol Psychiatr."},{"key":"B36","doi-asserted-by":"publisher","first-page":"28","DOI":"10.14624\/NR24S1009","article-title":"SWISSNEUROREHAB \u2013 Technologie-assistiertes Continuum of Care in der Schweizer Neurorehabilitation","volume":"30","author":"Sokolov","year":"2024","journal-title":"Neurol Rehabil"},{"key":"B37","doi-asserted-by":"publisher","first-page":"69","DOI":"10.1016\/j.zefq.2024.03.008","article-title":"A case management intervention in stroke care: evaluation of a quasi-experimental study","volume":"187","author":"Duevel","year":"2024","journal-title":"Z Evid Fortbild Qual Gesundhwes."},{"key":"B38","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/s11553-020-00789-7","article-title":"Medizinische Versorgung in Medizinischen Behandlungszentren f\u00fcr Erwachsene mit geistiger und schwerst-mehrfacher Behinderung (MZEB): eine qualitative Studie zu aktuellen Herausforderungen aus Sicht der Behandler_innen","volume":"16","author":"Rathmann","year":"2021","journal-title":"Pr\u00e4vention und Gesundheitsf\u00f6rderung."},{"key":"B39","doi-asserted-by":"publisher","first-page":"571","DOI":"10.1177\/0269215520905112","article-title":"What is rehabilitation? An empirical investigation leading to an evidence-based description","volume":"34","author":"Wade","year":"2020","journal-title":"Clin Rehabil."},{"key":"B40","doi-asserted-by":"publisher","first-page":"1147","DOI":"10.1177\/02692155241259644","article-title":"Does a service provide safe, effective rehabilitation? An evaluation method for providers and purchasers","volume":"38","author":"Wade","year":"2024","journal-title":"Clin Rehabil."},{"key":"B41","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1007\/978-3-030-58505-1_3","article-title":"Goal setting with ICF (International Classification of Functioning, Disability and Health) and multidisciplinary team approach in stroke rehabilitation","author":"Leonardi","year":"2021","journal-title":"Clinical Pathways in Stroke Rehabilitation"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1677483\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,26]],"date-time":"2026-05-26T15:54:12Z","timestamp":1779810852000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1677483\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,12]]},"references-count":41,"alternative-id":["10.3389\/fneur.2026.1677483"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2026.1677483","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,12]]},"article-number":"1677483"}}