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Table 1 Guidelines for interventions based on arising 'flags'

From: From rehabilitation to recovery: protocol for a randomised controlled trial evaluating a goal-based intervention to reduce depression and facilitate participation post-stroke

Domain 'Flags' Intervention options
Post-discharge services - The services organised at discharge from inpatient rehabilitation have not commenced as scheduled - Contact relevant service to determine referral status
- Liaise with inpatient rehabilitation clinicians to verify referral status
Activity status - Decline in activity status/functional decline (including PADL, mobility, continence)
- Failure to progress in activity status in valued activities
- If participant is currently attending community-based rehabilitation services, liaise with relevant team members (such as OT/PT/SP)
- If participant is not attending any community-based rehabilitation services, refer to relevant health professional for assessment and management
- Inform participant about local services (such as exercise groups, hydrotherapy) as appropriate
- Refer to GP for review (to exclude medical basis for decline in functional ability)
- Refer to Continence Clinic, if appropriate
- Refer to ACAS, if appropriate
Cognition - Decline in cognitive function (reports from patient, family, carer)
- Safety concerns due to cognitive impairments
- Evidence of marked change in MMSE performance between assessment timepoints
- Refer for medical evaluation (such as GP/Rehabilitation Medicine Specialist/Geriatrician).
- If participant is currently attending community-based rehabilitation services, liaise with OT regarding cognitive assessment and management
- If participant is not attending any community-based rehabilitation services, refer to OT for assessment and management
- Referral to Cognitive Dementia and Memory Service as appropriate
Falls - Episodes of falls
- Fear of falling limiting function
- Monitor number and nature of falls during contacts with participant.
- If participant is currently attending community-based rehabilitation services, liaise with relevant team members. If team is unaware of falls, request a falls risk assessment.
- If participant is not attending any community-based rehabilitation services, refer to relevant health professional for a falls risk assessment and management
Mood status - GDS-15 score of ≥ 6 points, or marked change in GDS-15 score between assessment timepoints
- Evidence during contacts of depression or mood change
- Referral to GP
- Encouragement to participate in valued activities
- Encouragement to participate in physical activity (as able) and enhance social contacts
- Referral to CATS if urgent assessment required
Goals/Participation status - Failure to resume, or reduced participation in, valued activities that should be achievable post-stroke
- goals not being achieved based on GAS ratings at 6 & 12 month assessments
- identify barriers to goal achievement
- re-establish goals as required (with regard to both timeframes and attainment level)
- If participant is currently attending community-based rehabilitation services, liaise with relevant team members (such as OT/PT/SP)
- If participant is not attending any community-based rehabilitation services, refer to relevant health professional who can assist with facilitating and enhancement of participation status and goal attainment
Health/Medical status - hospital inpatient re-admission during the 12 month follow-up period - if the researcher has knowledge of the admission, contact by phone at two weeks post-discharge to monitor status.
Informal support - absence of informal supports that is resulting in evidence of loneliness or lack of emotional support - Provide information to the participant about relevant local community groups/services. Facilitate referral to group/service
- Provide information about closest Stroke Support Group
Carer status (for consented carer participants) - Evidence of reduced carer coping or stress during contacts
- GDS-15 score of ≥ 6 points
- Zarit Burden Interview > 24 points
- Aim to identify causes of reduced coping/stress
- Provide information regarding carer resources (refer to information given at inpatient rehabilitation discharge timepoint). Discuss options.
- If the patient participant is currently attending community-based rehabilitation services, liaise with relevant team members (such as SW)
- Encourage GP review
- Offer ongoing verbal support and encouragement to the carer in their role during contacts
- Continue to engage carer in the rehabilitation process
  1. PADL: Personal activities of daily living
  2. OT: Occupational therapist
  3. PT: Physiotherapist
  4. SP: Speech Pathologist
  5. GP: General practitioner
  6. ACAS: Aged Care Assessment Service
  7. MMSE: Mini-mental State Examination
  8. GDS-15: Geriatric Depression Scale (15 item)
  9. CATS: Crisis Assessment and Treatment Service
  10. GAS: Goal Attainment Scaling
  11. SW: Social Worker