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Background: Around 45.000 individuals per annum suffer of a Cerebral Vascular Accident CVA in the Netherlands. The aftercare following a CVA is often prolonged and complex. The provided aftercare does not always meet the desires and needs of the CVA patient. The problem of a mismatch in the CVA aftercare is caused by factors of both patient and the professional environment. Objective: The aim of this project design is to ensure that within two years the CVA aftercare in the primary care setting, following rehabilitation in the Rijnlands Rehabilitation Centre RRC, matches both in content and in organisation with the desires and needs of the CVA patient. Metho: The 5-step “Model for structured health education and behavioral change” is applied. Step 1 till 3 are completed, focusing on the analysis of the problem through review of the literature and field research. Steps 4 and 5 have been conducted on the basis of the outcome of the problem analysis. The following three actions were hereby executed: I an iterative desk literature identification and desk search aimed on the analysis of the best intervention for collaboration in the CVA aftercare; II an implementation diagnosis and knowledge management scan KM-scan, with the aim to establish the most fitting implementation strategy; III a cost and break-even analysis BEA, aimed at analysing the financial feasibility of the intervention. Results:  I There is no evident answer as to which form and application of collaboration is best. A network is being suggested as the best fitting intervention for collaboration in this context. The “Development Model for Integrated Care” DMIC is the best model for developing the network. The application of the existing networks is very diverse and focused on content and organisational actions. II The proposed intervention the CVA network strongly carries the features of a team and result oriented configuration. These strong features are lacking in the current organisation. The results of the KM-scan demonstrate that 5 out of the 6 knowledge processes in the Knowledge Value Chain KVC are insufficient. III The cost price of the development of the CVA network comes in at €12.450, -. The break-even point has been determined at 23 network members. Conclusion: Developing a CVA network on the basis of the evidence-based “Development Model for Integrated Care” is the most suitable intervention for the improvement of the collaboration between the RRC and the primary care health professionals, aimed at matching the CVA-aftercare with the desires and needs of the CVA patient. To increase the chance of success of the implementation of the network, specific attention needs to be given to “personal relationships” and the availability of the financial means. The development and implementation of the CVA network is financially feasible and defendable. It is recommended to conduct further research to demonstrate to which extent the CVA network truly matches with the desires and needs of the patient.

Collaboration in CVA aftercare: CVA-network RRC/ primary care