Abstract Body: BACKGROUND:
The STRACK project aims to improve post-stroke patient management and the transition from acute to primary care thanks to improvements in patient pathways and monitoring cardiovascular risk factors: heart failure, diabetes, atrial fibrillation, dyslipidemia and hypertension. Collaboration between primary care centers and hospital staff was essential for the project’s success by delivering personalized care and home monitoring devices to patients through access to a digital platform. STRACK was launched with a european value-based contracting process and Roche Diag. as partner.

METHODS: The three-year project was launched in May 2021, during first year all specialties and professionals participated in the development and planning of the project and were trained in the use of the devices and own digital platform.
First STRACK patient was enrolled in May 2022. Once these post-stroke patients have been identified, they are given a personalized monitoring plan depending on the individuals’ risk factors, the personalized care and rehabilitation plans are tracked and followed. For a year post-discharge, a nursing and administrative team follows the data that the patient enters remotely or is automatically available on their mobile application.

RESULTS:
STRACK has evolved the continuum of care by 421patient in July 2024 and ongoing, by integrating comprehensive monitoring of cardiometabolic risk factors (heart failure, diabetes, atrial fibrillation, dyslipidemia, hypertension) into a patient discharge plan, identified as key to avoiding stroke recurrence and improving control of vascular risk factors are monitored.
Preliminary results of 231 patients (May 2022-2023) with full one year follow-up comparing with historical cohort (May 2018-2019) showed: Reduction in unnecessary visits (weighted): -26,3%. Reduction in admissions for stroke recurrence or related to stroke, (heart attack, angina, peripheral embolism, etc.): Stroke, 30days: -100%; Related to stroke, (365d: -47,7%; 30d: -57,0%). Reduction in cardiovascular admissions ( 30d: -100%; 365d: -31,4%). Best treatment adherence: 81,2% (72% previously)

CONCLUSION:
The great value of STRACK is knowing the evolution of stroke patients post-discharge through strict self-monitoring of clinical parameters, following prior health education. STRACK has managed to achieve reduction in stroke recurrence and adverse events and readmissions for cardiovascular risk factors, reducing emergency visits for vascular events.