A health-coaching program for stroke survivors and their family caregivers during the hospital to home transition in Chongqing, China

A two-stage intervention for the intervention group will be conducted as described in the following: Stage I: Interventions at hospitals Individualised health coaching: the intervention nurses will provide stroke survivors and their family caregivers with two face-to-face individualised health coaching sessions (20-30 minutes each time) that include: (1) how to set out realistic and achievable care goals; (2) self-care skills demonstration; (3) safety home environment demonstration; (4) functional recovery plan; (5) prevention of complications and secondary stroke; chronic condition management and (6) medication management. All health coaching sessions will be based on the “Health coaching intervention program guide” to standardise interventions in the study. The “Health coaching intervention program guide” is designed specifically for this study and is based on a systematic review and meta-analysis prior to the development of this study protocol. The “Post-stroke follow-up checklist” is designed specifically for this study to monitor intervention fidelity. 1. Stroke survivors and caregivers will be invited to establish their transition care goals and develop personal action plans. A ‘Health coaching diary-Patient/caregiver version’ and a ‘Health coaching record- intervention nurse version’ will be used to record the goals, actions, progresses, problem solving and outcomes. 2. Prior to discharge, the intervention nurse will demonstrate self-care skills or skills that are required for participants in providing activity of daily living (ADL), instrumental activity of daily living (IADL) and social engagement when appropriate 3. Before discharge to home-care setting, stroke survivors and caregivers will be invited to participate one of the two face-to-face individualised health coaching sessions to discuss a safe home environment, including safety toileting, walking, sleeping. Home environment modification will be undertaken prior to discharge when it needed. 4. Individualised functional recovery and exercise plan will be conducted based on the plan provided by the patient’s medical specialist. Intervention nurse will discuss the plan and demonstrate skills when appropriate. The functional recovery plan will be recorded in the “Health Coaching Diary-Patient/caregiver version”. 5. Prior to discharge, stroke survivors will be given individualized treatment and rehabilitation plan ordered by the medical specialists, have opportunities to discuss and clarify the plan and receive medication education from the intervention nurse. The treatment and rehabilitation plan will be recorded in the “Health Coaching Diary-Patient/carer version”. 6. The intervention nurse will demonstrate how to prevent, identify and manage stroke-related complications. Stage II: Follow-up Interventions in the first 12 weeks after discharge to homecare setting The intervention nurse will provide the stroke survivor-caregiver dyads with phone support and face-to-face meetings in outpatient clinics in a 12-weeks period after discharge from hospital. 1. Weekly Telephone support Stroke survivors and caregivers will receive weekly telephone call at home from the intervention nurse. The coaching via phone conversations will be conducted based on the “Post-stroke follow-up checklist” to discuss concerns and problems arising from the transition care, the approaches, resources and strategies to resolve the problems. The “Post-stroke follow-up checklist” is designed specifically for this study to monitor the intervention fidelity. . The coaches will also motivate stroke survivors and caregivers to monitor their care activities and outcomes towards their transition care goals. Each phone call lasts about 10-15 minutes. Participants will be encouraged to make phone contact with their health coaches to seek help when necessary. 2. Bi-weekly face-to-face coaching activities at the outpatient departments Stroke survivors will engage in rehabilitation or appointment with specialists at the outpatient clinics bi-weekly. The intervention nurses will use the opportunity to have a bi-weekly meeting with survivors-caregiver dyads. Participants will be asked to bring their coaching diary to the meeting. The intervention nurses will analyse the coaching diary, discuss with them about concerns and problems they have, coaching them problem-solving skills based on their needs, introduce resources they need, reinforce self-care knowledge and skills, and motivate them to self-monitor the process and outcomes towards their care goals. Each bi-weekly face-to-face coaching activities lasts about 20 minutes.