Integrated Primary Care for Post-Stroke Patients to Improve Long-term Outcomes Through Multidisciplinary Collaboration Volume II

Stroke remains one of the leading causes of long-term disability worldwide, creating an urgent need for care models that extend beyond the acute phase and support survivors throughout recovery. Growing evidence highlights the value of integrated primary care, in which stroke specialists, primary care providers, rehabilitation professionals, and community services work together to address the complex and evolving needs of post-stroke patients. Such multidisciplinary collaboration is essential not only for reducing recurrent stroke through better control of hypertension, diabetes, and cardiovascular risk factors, but also for improving functional recovery, psychosocial wellbeing, and long-term monitoring. Trust-based professional relationships within care teams grounded in clear communication, shared decision-making, and mutual respect which further strengthen patient engagement and adherence. Building on the success of Volume I, this second edition seeks to advance the field by placing greater emphasis on implementation strategies, health equity, patient- and caregiver-centered outcomes, digital and community-enabled care, and scalable models that can be adapted across diverse healthcare settings. Through this expanded focus, Volume II aims to further reduce fragmentation and promote sustainable, person-centered stroke care pathways.The primary goal of this Research Topic is to examine how integrated primary care approaches, supported by multidisciplinary collaboration, can improve long-term outcomes for stroke survivors and reduce the likelihood of recurrent stroke. In Volume II, we aim to move beyond foundational discussions by highlighting more advanced and practice-oriented evidence on implementation, coordination, and sustainability of integrated post-stroke care. We particularly welcome work that addresses patient and caregiver engagement, equitable access to services, use of digital health and community resources, and translation of evidence into routine practice. By bringing together research from diverse contexts, this Topic seeks to identify actionable strategies that support holistic, accessible, and resilient models of care for stroke survivors worldwide.We invite manuscripts addressing the design, implementation, evaluation, and scaling of multidisciplinary primary care models for post-stroke management. Topics of interest include, but are not limited to:• prevention of recurrent stroke and vascular risk-factor management;• coordination of care across primary care, specialist, rehabilitation, and community settings;• functional, cognitive, and psychosocial recovery after stroke;• caregiver support and patient engagement;• patient-reported outcomes and quality-of-life measures;• digital health interventions and community-enabled models of care;• health equity in access to and delivery of post-stroke services;• implementation strategies, real-world evidence, and sustainable models of integrated care.We particularly encourage submissions that provide practical implementation insights, real-world evidence, and innovative solutions that can be adapted to both high-resource and underserved settings. Topic editors: Thao Thi Phuong Nguyen, Seung Won Lee Source: https://www.frontiersin.org/research-topics/79366/integrated-primary-care-for-post-stroke-patients-to-improve-long-term-outcomes-through-multidisciplinary-collaboration-volume-ii