Early post-discharge nurse-led clinic for people with stroke and their families to improve wellbeing, secondary prevention, and support adjustment after stroke

Brief name Nurse-led post-discharge stroke clinic Materials The nurse-led post-discharge stroke clinic will use the following materials: • An Australian context-adapted Greater Manchester Stroke Assessment Tool (GM-SAT) 1 to be used to guide a structured, person-centred assessment of post-stroke unmet needs. • Stroke-specific educational and informational resources, including Stroke Foundation EnableMe 2 materials, provided according to identified needs. • A written implementation manual to support standardised delivery of the intervention. • An intervention fidelity checklist to be completed at each clinic visit. Procedures and processes Participants allocated to the nurse-led post-discharge stroke clinic will receive structured monthly follow-up for six months after hospital discharge. The intervention includes: • Comprehensive assessment of post-stroke unmet needs using the GM-SAT. • Review of medical history, post-stroke complications, and secondary prevention factors (e.g., blood pressure, atrial fibrillation, diabetes, medication adherence) • Provision of lifestyle modification education and stroke-specific information. • Emotional support and reassurance for the person with stroke and their family/support person. • Collaborative goal setting based on participant-identified priorities. • Referral and flagging to appropriate health, rehabilitation, and community services. • Development and review of an individualised action plan. • Ongoing access to the clinic via a contact telephone number between scheduled visits. Who delivers the intervention The nurse-led post-discharge stroke clinic will be delivered by a Stroke Nurse with at least 3 years' experience, with expertise in stroke care and post-discharge follow-up. The Stroke Nurse will receive training in: • The use of the GM-SAT • The nurse-led post-discharge stroke clinic implementation manual • Completion of intervention documentation and fidelity checklists Mode of delivery The nurse-led post-discharge stroke clinic will be delivered individually to participants: • Face-to-face in an outpatient clinic setting, where feasible. • By telephone or video consultation when in-person attendance is not possible Dose, frequency, and duration • One baseline assessment to be conducted before hospital discharge. • Monthly nurse-led post-discharge stroke clinic appointments for six months, commencing approximately one month after discharge. • Each clinic appointment will last approximately 45–60 minutes. • Participants may initiate additional contact with the clinic as required during the six-month intervention period. Location • Hospital-based outpatient clinic. • Participant’s home when delivered via telephone or video call. Tailoring and adaptation The nurse-led post-discharge stroke clinic is a person-centred intervention that is tailored to individual needs: • The content of each clinic appointment (education, goal setting, referrals) is adapted according to GM-SAT findings and participant priorities. • Mode of delivery (face-to-face or telehealth) is adapted based on participant preference and accessibility. • Tailoring occurs at each clinic visit to reflect changing needs over the six-month post-discharge period. Intervention adherence and fidelity Adherence to the nurse-led post-discharge stroke clinic will be assessed using a standardised fidelity checklist completed by the Stroke Nurse after each clinic appointment. The Chief Investigator will review completed fidelity checklists weekly to assess adherence to the intervention protocol and provide feedback to support consistent delivery. Strategies to maintain intervention fidelity include: • Training and orientation for the Stroke Nurse. • Use of a written implementation manual. • Weekly supervision and feedback between the Chief Investigator and the Stroke Nurse. • Ongoing monitoring of fidelity data to identify and address protocol non-adherence. Outcome assessment Baseline data will be collected before hospital discharge. Outcome assessments at 6 and 12 months post-intervention will be conducted by a blinded assessor for both intervention and control groups. Reference: 1. Oliver, K., Boaden, R., & Rothwell, K. (2013). Evaluation of the Greater Manchester Stroke Assessment Tool (GM-SAT). University of Manchester. 2. Stroke Foundation. Enable Me Resources 2025. Available from: https://enableme.org.au/resources.