Reducing disability in older Australians through secondary stroke prevention.

1. Nurse coordinated evidence based quarterly follow up of participants in the community, in a shared care relationship between hospital based stroke specialists and community based primary care physicians. Each quarterly intervention includes a pre-visit semi structured telephone interview to assess risk factors and post stroke depression. Based on the pre-visit interview, a report is faxed to the Gp prior to the patient visit. The patient and Gp meet and complete an individualised risk factor worksheet including relevant diagnostic tests. The completed worksheet is returned to the coordinating hospital to facilitate potential shared care. Therefore, coordinated visits to the patients Gp in the first year following the index stroke. 2. Simultaneously, over the period of 1-year, participants receive risk stratified telemedicine follow-up from the nurse coordinator that includes, education and support. As calculated by a study specific risk calculation algorithm, risk is assigned as high, medium or low. High risk participants are exposed to a greater frequency of telephone follow-up i.e., weekly for 3 months, 3-weekly for 3-months and monthly for 6-months. Low risk participants receive monthly telephone calls. The frequency may be modified according to changes in individual patient needs. Components of telephone calls include a range of established behavioral modification strategies to target health related lifestyle modification, plus health education, carer support, medication compliance and the potential for referral for specialist support.