Extended stroke unit service in Bergen. A RCT looking at the collaboration between hospital service and primary health care.

Stroke is the most commen cause of lasting disability in Norway and consumes substantial health resources. The best possible outcome of rehabilitation after stroke is therefore essential both for the individual patient and for society. Previous studies ha ve indicated that acute treatment in a stroke unit, followed by early supported discharge to the patient's home, may be superior to conventional treatment with in-patient rehabilitation. In this study stroke patients will be randomized to one of three di fferent treatment arms, after acute stroke unit treatment. The concept of early supported discharge wil be used in two of the arms, with two different out-patient follow up schemes: Either treatment in a day institution, or a similarly intensive treatment with base in the patients' homes. In both these treatment arms the patients will in addition be followed closely by a coordinating ambulatory team for the first 5 weeks after discharge, and they will be offered a structured follow-up with a multi-disipli nary team in an out-patient setting at fixed points in time after discharge. The third treatment arm will be treated according to today's routines and principles. The patients in all three arms will be systematically evaluated during a two-year period fo llowing discharge, with pre-defined measuring instruments and objective tests. The primary objectives of the study is to delineate which components of the ESD concept which are beneficial and responsible for the supposed better outcome after this treatme nt, and to build a well-functioning rehabilitation chain including all stages from the acute stroke to a final stabilized situation. As a consequence of the study, a multi-disiplinary out-patient clinic as well as an ambulatory team will be established in our department, thus optimizing the rehabilition for stroke patients in our district.