Integration of Ambulatory Aftercare into the Eastern Saxony Network for Stroke (INAN-SOS)


The Eastern Saxony network for Stroke (SOS-NET) has developed a reference application for the ICT-supported care for the acute stroke in the stationary area. Essential components are an integrated care pathway (SOS-Care), which extends over rehabilitation up to one year, into the period of ambulatory after-care. The technological foundation is being created since the middle of 2015 by the CCS-Telehealth East Saxony (CCS-THOS), which the Carus Consilium Saxony GmbH is developing jointly with T-Systems International GmbH. It is additionally supported by the European Union and the Free State of Saxony with ERDF funds. This pathway is quality-assured for the care and documentation, which is technically implemented using the acute and rehabilitation clinics. Within the scope of a follow-up program, the patient is looked after by one or more case managers by using this pathway.

Presently, however, neither house doctors, specialists nor specialist groups (speech therapists, nurses, physiotherapy) are as technically involved, which leads to the loss of information and documentation. In order for the reference application SOS-Care, to provide important impulses for the strengthening and consolidation of the Saxonian healthcare industry regarding the competence of the realisation of innovative eHealth solutions, the INAN-SOS project is designed to close this gap and provide a technical connection between the already used technological platform THOS and the systems of the house doctors and specialists of the ambulatory aftercare.

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