Process outcomes | Patient | Informal caregiver | Care professionals | ||
---|---|---|---|---|---|
SI | SAQ | RF | SSQ | GI | |
Performance of the programme according to protocol and participation in the programme | |||||
Module 1: inpatient neurorehabilitation treatment for patients (2 months) | |||||
 Development of rehabilitation goals |  |  | X | X | X |
 The use of the simplified goal attainment scaling method to set rehabilitation goals |  |  | X | X | X |
 Introduction meeting of stroke care coordinator |  |  | X | X | X |
 At least one home visit by 1) physical therapist and/or 2) occupational therapist to check for home adjustments |  |  | X | X | X |
 At least two therapy sessions in the patient’s home |  |  | X | X | X |
Module 2: home based self-management training for patient and informal caregiver (4 months) | |||||
 Practicing self-management skills |  |  | X | X | X |
 Involving informal caregiver in self-management training |  |  | X | X | X |
 At least two home visits to the patient by the stroke care coordinator |  |  | X | X | X |
 At least 50% of the treatment sessions by 1) physical therapist and/or 2) occupational therapist at home |  |  | X |  | X |
 Number of patients and informal caregivers participating in the intervention group (module 1 & 2) |  |  | X |  | X |
Module 3: stroke education for patient and informal caregiver | |||||
 Number of education sessions performed |  |  | X |  | X |
 Number of patients and informal caregivers attending the education sessions (module 3) |  |  | X |  | X |
Opinion of patients, informal caregivers and Care professionals on the programme | |||||
 Patients’ and informal caregivers |  |  |  |  |  |
Module 1: inpatient neurorehabilitation treatment for patients (2 months) | |||||
 Perceived benefit of 1) setting rehabilitation goals, 2) therapy sessions in the patients’ home, 3) guidance of the stroke care coordinator | X | X |  |  |  |
Module 2: home based self-management training for patient and informal caregiver (4 months) | |||||
 Perceived benefit of 1) therapy sessions in the patients’ home, 2) home visits of the stroke care coordinator, 3) training self-management skills, 4) developing action plans to fulfil self-management training | X | X |  |  |  |
Module 3: stroke education for patient and informal caregiver | |||||
 Perceived benefit of the four education sessions | X | X |  |  |  |
Care professionals | Â | Â | Â | Â | Â |
Opinion multidisciplinary team | |||||
 Benefit of 1) home visit to check whether home adjustments are needed (module 1), 2) the development of rehabilitation goals, 3) use of goal attainment scaling method (module 1 & 2), 4) therapy sessions in the patients’ home (module 2) |  |  |  | X | X |
Opinion stroke care coordinator | |||||
 Benefit of 1) development of rehabilitation goals (module 2), 2) use of goal attainment scaling method (module 2), 3) use of a workbook (module 2), 4) practising self-management skills, 5) home visits after discharge (module 2), 5) personal guidance of the stroke care coordinator (module 1 & 2), 6) four education sessions (module 3). |  |  |  | X | X |