Enhanced Post-discharge Home-based Care Program (EHP) for Stroke Survivors in Harbin China

This project will empirically test an innovated care delivery model, an enhanced post‐discharge home‐based care program (EHP) to address the challenges facing China on post‐stroke care. The study will adopt a randomized controlled trial design to assess the effects of the EHP compared with usual care for post‐discharged stroke survivors. Economic evaluation will be parallel with the trial. Eligible participants will be recruited from the neurology units of a large general hospital in Harbin, China. Consented participants will be randomly assigned to receive either usual care or usual care plus EHP intervention. The EHP has two key components: pre‐discharge coaching and post‐discharge home follow‐up which involves five intervention protocols for assessment, treatment and procedures, teaching, guidance and counselling, case management and surveillance, addressing on home‐based rehabilitation training and self‐care. The 12‐week EHP will be provided by a trained nurse case manager with the support of a clinical team. All participants will be follow‐up for 12 months with three assessments on study outcomes, including quality of life, self‐efficacy, activities of daily living, anxiety and depression, adherence, satisfaction and healthcare utilization after baseline data collection. The incremental cost‐effectiveness ratio and cost will also be calculated and compared between the two groups. In addition, focus group interviews will be conducted to gain an in‐depth understanding of stakeholders' experience on post‐stroke care.