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MAS – Managing Aftercare for Stroke

This observational study is designed to evaluate remaining deficits and needs of community-dwelling patients who suffered a stroke months and years ago. The study framework aims to develop an individualized complex and multidisciplinary intervention program to improve health-related quality of life for stroke patients.

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Project description


  • Stroke is not only a life-threatening disease, but is also associated with permanent impairments and various complications
  • Few data exist on the outpatient aftercare for stroke after discharge from stroke units or rehabilitation facilities

Aims and objectives

  • Identification and quantification of impairments several months/years after acute stroke
  • Determination of unmet medical and social needs of stroke patients
  • Development of an integrated model of stroke aftercare delivery post-rehabilitation


  • After discharge, patients are invited into the clinic, examined and screened for unmet medical/social needs, that hinder social participation and undermine health-related quality of life.
  • Based on these findings, patients are presented with an individualized treatment plan, that will be facilitated and coordinated by the clinic.
  • Scheduled follow-up consultations serve to detect new unmet needs and quantify the effects of the intervention.
  • The MAS studies are conducted in close collaboration with the Service Point Stroke (SPS) of the Berlin Stroke Alliance e.V. and the NAVICARE project by the Institute for Public Health. NAVICARE investigates the current healthcare structures for stroke patients in Berlin and Brandenburg via their CoreNAVI study


  • Prof. Andreas Meisel, MD
  • PD Benjamin Hotter, MD


  • MAS-I – completed and published

Identifying unmet needs in long-term stroke care using in-depth assessment and the Post-Stroke Checklist - The Managing Aftercare for Stroke (MAS-I) study.
Hotter B, Padberg I, Liebenau A, Knispel P, Heel S, Steube D, Wissel J, Wellwood I, Meisel A.
Eur Stroke J. 2018 Sep;3(3):237-245. doi: 10.1177/2396987318771174. Epub 2018 Apr 19. Erratum in: Eur Stroke J. 2019 Dec;4(4):NP2-NP4.
PMID: 31008354; PMCID: PMC6453198.

BSA Long Term Care Study Group. Social work support and unmet social needs in life after stroke: a cross-sectional exploratory study.
Lehnerer S, Hotter B, Padberg I, Knispel P, Remstedt D, Liebenau A, Grittner U, Wellwood I, Meisel A.
BMC Neurol. 2019 Sep 6;19(1):220. doi: 10.1186/s12883-019-1451-y.
PMID: 31492151; PMCID: PMC6729017.

Unmet Need for Social and Emotional Support and Lack of Recalled Screening Is Associated with Depression in the Long-Term Course After Stroke.
Padberg I, Hotter B, Liebenau A, Knispel P, Lehnerer S, Heel S, Wellwood I, Meisel A.
Risk Manag Healthc Policy. 2020 Apr 1;13:285-293. doi: 10.2147/RMHP.S228265. PMID: 32280291; PMCID: PMC7131991.

  • MAS-II – in preparation for publication
  • MAS-III – in preparation