Stroke Clinical Care Standard

Using validated screening tools at first clinical contact in the community, pre-hospital or hospital setting can quickly identify suspected stroke and enable rapid access to time-critical treatment in the hyperacute phase. Note that F.A.S.T. is a useful tool for identifying stroke, particularly for non-clinicians. However, other tools may have greater accuracy in detecting acute ischaemic stroke (see Related Resources).

Once a patient is suspected of having an acute (clinical signs less than 24 hours) stroke, expedite primary emergency transport (usually by ambulance) to a hospital capable of providing time-critical stroke therapy. Features of stroke services capable of providing time-critical therapy appropriate to the patient’s needs are described in the National Acute Stroke Services Framework, and include rapid assessment, access to computed tomography (CT) and hyperacute therapy such as thrombolysis. 

Pre-hospital clinicians, including ambulance services, should use pre-notification systems and bypass to access hospitals capable of providing appropriate time-critical stroke therapies (including thrombolysis) when required. Further assessment of stroke severity (such as the likely presence of large vessel occlusion), and suitability for time-critical care may be necessary to identify the most appropriate destination hospital. Alert the hospital to the patient’s clinical condition and provide adequate patient identifiers to facilitate timely admission and imaging. Follow local recommended protocols to help prepare the patient for rapid treatment, which may include documenting symptom discovery, last known ‘well’ time, time of ambulance arrival on scene and medication history, as well as insertion of an intravenous cannulation. 

Hospital-based teams should prepare for patient arrival when pre-notified, by obtaining medical records and a best possible medication history, contacting next of kin for more details, activating a ‘Code Stroke’ alert system, and facilitating access to CT imaging for urgent assessment.

All clinicians should be aware of local stroke network and referral pathways, including how to access the telestroke service to support decision-making about where to transport or transfer the patient. Exceptions include patients for whom transfer would not be consistent with their goals of care or advanced care plan, such as palliative care patients. 

Ensure that protocols support the use of a validated screening tool, such as F.A.S.T., to enable the appropriate triage and transport of people with suspected stroke to an appropriate hospital as described in the National Acute Stroke Services Framework. The National Acute Stroke Services Framework describes capabilities of appropriate stroke services such as for rapid assessment, on-site CT imaging and protocols for providing timely hyperacute therapy such as thrombolysis. 

Note that F.A.S.T. is a useful tool to identify stroke, including for non-clinicians, however other tools may have greater accuracy in detecting acute ischaemic stroke (see Related Resources).

Ambulance and retrieval services should use screening tools to identify patients with suspected stroke and ensure that they are treated as a time-critical emergency. This includes priority dispatch of ambulances and transport of patients directly to hospitals capable of providing appropriate time-critical stroke therapies. Ambulances should have agreed bypass protocols to transport people to a Comprehensive Stroke Centre (CSC) in the case of patients with suspected large vessel occlusion.

Emergency departments can use screening tools to trigger urgent assessment of patients who arrive at hospital independently. More detailed stroke severity scales (for example, National Institutes of Health Stroke Scale [NIHSS]) may be used in hospital but are not recommended in the pre-hospital setting. 

Healthcare services without onsite medical stroke specialists should ensure that clinicians are aware of the local stroke network and referral pathways, which should include access to telestroke to support decision-making. 

Hospitals capable of providing time-critical stroke therapies should have effective protocols in place to respond to pre-notification of patients with suspected stroke to enable rapid assessment and treatment. This includes activating ‘Code Stroke’ alert systems, facilitating access to CT imaging for urgent assessment, obtaining medical records and a best possible medication history, and contacting next of kin for more details. 

If you or another person has any of the signs below, call 000 for an ambulance immediately. F.A.S.T. is an easy way to remember the main signs of stroke and the response needed:

• Face – check their face. Has their mouth drooped?
• Arms – can they lift both arms equally?
• Speech – is their speech slurred? Do they understand you? Can they speak?
• Time – is critical. If you see any of these signs, call 000 straight away.

If the ambulance or emergency services think you may be having a stroke, they will arrange for you to get to a hospital as fast as possible for early, accurate diagnosis and time-critical therapy. This may mean going to a hospital that is able to treat stroke, even if it is not the closest hospital to you.

Explain the rationale for assessment, tests, transport, and interventions to the patient, their family and their support people in a culturally safe way.

Recognise and address individuals’ potential barriers to care by, for example, providing culturally appropriate stroke awareness and recognition information to the community and suitable ways to access rapid care. This is especially important for people whose access to services and infrastructure is limited.

Recognise and respond to any concerns associated with diagnosis and treatment, including the potential need for hospitalisation off Country. Where clinically safe, prioritise care on Country and minimise unnecessary transfers. If transfer is required, plan early for return to Country to support wellbeing. Ask for consent to transport to hospital, which may involve consulting the patient’s family and community members.

Ensure processes for ambulance and hospital intake provide an opportunity for patients to self-identify and for services to capture and act on identification data.

Validated stroke screening tools include (in alphabetical order):

• BE-FAST – Balance, Eyes, Face, Arms, Speech, Time
• CRESST – Canberra pREhospital Stroke Screening Tool
• F.A.S.T. – Face, Arms, Speech, Time
• MASS – Melbourne Ambulance Stroke Screen
• ROSIER – Recognition of Stroke in the Emergency Room

Other validated tools used in the assessment of stroke include (in alphabetical order):

• ACT-FAST – for identification of large vessel occlusion
• HUNTER-8 or NIHSS-8 – for quantifying the impairment caused by stroke
• Modified Rankin Scale or mRS – for measuring premorbid function
• RACE – Rapid Arterial Occlusion Evaluation (large vessel occlusion identification tool) 

Urgently assess the patient and arrange vascular imaging, such as a CT scan or MRI, to determine whether the patient may benefit from time-critical therapy. Consider the patient’s comorbidities, circumstances and preferences, and discuss the potential benefits and risks of treatment options with the patient and their family or carer. If time-critical therapy is not provided, document the reason in the patient’s medical record.

Ischaemic stroke

Consider reperfusion treatment for all patients with ischaemic stroke. As clinically indicated, offer thrombolysis and/or endovascular thrombectomy within the time frames recommended in the current Living Clinical Guidelines for Stroke Management. 

To enable appropriate reperfusion, use multimodal imaging (Non-Contrast CT [NCCT], and both CT angiogram and CT perfusion) when possible to identify candidates for endovascular thrombectomy or surgical treatments. If you refer a patient to a Comprehensive Stroke Centre for an endovascular thrombectomy, ensure a prompt and coordinated transfer of care, in consultation with the receiving team, so the patient arrives at the service without delay. As part of this transfer, ensure all imaging (including any CT angiogram) is transferred to the treating hospital rapidly to facilitate treatment on arrival.

In hospitals that do not provide 24-hour, on-site access to stroke specialists, use telestroke systems to assist with patient assessment and decision-making regarding acute thrombolytic therapy and possible transfer for endovascular thrombectomy. 

Intracerebral haemorrhage

If an intracerebral haemorrhage is identified after imaging, and if clinically indicated, promptly initiate control of blood pressure and reversal of coagulopathy within the targets and timeframes recommended in the current Living Clinical Guidelines for Stroke Management. 

Other neurosurgical interventions may be time-critical for some patients. Arrange urgent vascular imaging (such as CT angiography, magnetic resonance angiography or digital subtraction angiography) to identify patients who may need specific specialist treatment, such as management of bleeds secondary to vascular malformations. Refer for neurosurgical consultation using your local stroke network and referral pathway.

Ensure clinicians know of and use the Living Clinical Guidelines for Stroke Management when managing suspected stroke.

Have systems, protocols and processes in place to offer time-critical imaging and treatment for stroke in line with your organisation’s stroke capability and within the targets and time frames recommended in the Living Clinical Guidelines for Stroke Management. Protocols should include pathways for time-critical therapy for both ischaemic stroke and intracerebral haemorrhage. 

Healthcare services that transfer patients to a Comprehensive Stroke Centre for endovascular thrombectomy must establish protocols to ensure timely and coordinated transfer of care, so that patients arrive at the service without delay and are able to receive the procedure as soon as clinically appropriate. Ensure all imaging (including CT angiogram) is transferred to the treating hospital rapidly to facilitate treatment on arrival.

Ensure there are local referral pathways for neurosurgical consultation for patients with intracerebral haemorrhage or who may require neurosurgical interventions.

Monitor achievement of recommended timeframes and address barriers.

There are two types of stroke: those that occur when a blood clot blocks a blood vessel, and those caused by bleeding in the brain. 

A brain scan will be done urgently to look for signs of a stroke and to work out the type of stroke. A computed tomography (CT) scan and magnetic resonance imaging (MRI) are different types of scans that take pictures of your brain and can show areas of damage and swelling. After the scans, your healthcare team will discuss treatment options with you and your family or support people. The treatment you receive will be based on your type of stroke, your clinical condition and history, and your wishes, and will follow national evidence-based recommendations. 

Stroke caused by a blood clot (ischaemic stroke)

If a stroke is caused by a blood clot blocking a blood vessel, treatment to restore blood flow in the brain should be urgently considered. If your clinicians think this treatment could help, it should be offered as soon as possible after a stroke to prevent brain cells from dying (‘time is brain’).

The treatment may involve medicines to dissolve the blood clot (thrombolysis) or surgery to remove the blood clot (endovascular thrombectomy). These treatments are not suitable for everyone with a stroke caused by a blood clot. They cannot be used if it has been a long time since your stroke. They must not be used if the stroke is caused by bleeding in the brain.

Stroke caused by bleeding in the brain (intracerebral haemorrhage)

If a stroke is caused by bleeding in the brain, treatment should be urgently considered. If your healthcare team thinks treatment could help, it should be offered as soon as possible.

If your blood pressure is high, you will be given medicines to lower your blood pressure. This may help stop the bleeding in the brain from spreading and may prevent any brain injury from getting worse. 

If you were taking a blood thinning medicine before your stroke, a medicine may be given to reverse the effects of the blood thinning medication and prevent more bleeding.

Other urgent treatments or surgery may also be recommended, according to individual needs and the cause of the stroke.

Provide the person with access to Aboriginal and Torres Strait Islander Liaison Officers or other relevant workers and clinicians who can discuss potential concerns about urgent treatment, such as reperfusion therapy, either in the patient’s language or in a way that is culturally safe for the person.

• The Australian and New Zealand Living Clinical Guidelines for Stroke Management.
• Stroke and transient ischaemic attack [published 2025 Dec]. In: Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited; accessed Jan 2026. https://www.tg.org.au
• In palliative and end-of-life care, management may differ and should align with the National Consensus Statement: Essential elements for safe and high-quality end‑of‑life care. 

Intravenous thrombolytic therapy

Endovascular thrombectomy 

Acute intracerebral haemorrhage management

Ensure that patients with stroke are promptly transferred to a stroke unit, as defined in the National Acute Stroke Services Framework. Stroke unit care is organised care within a specific ward in a hospital. It is provided by a multidisciplinary team who specialise in stroke management, coordinating diagnostic work-up and treatment, early mobilisation and rehabilitation and secondary prevention. This team works with the patient and family during the inpatient stay. Care quality is recorded and guided by established protocols. People with stroke who receive care in a dedicated stroke unit are more likely to be alive, living at home, and independently looking after themselves one year after their stroke. 

Intensive care units (ICUs), high dependency units (HDUs) or similar locations are appropriate alternatives to stroke unit care for patients requiring critical care management.

If there is no stroke unit at the healthcare service, patients should receive guideline-recommended care and protocols in the nearest similar unit able to meet the requirements for stroke unit care. This may include management on the ward where the patient is located, with access to a telestroke service and allied health assessment. 

Follow local protocols, in line with the recommendations in the current Living Clinical Guidelines for Stroke Management to ensure patients with stroke receive early care to minimise or prevent complications and maximise recovery. This should include: 

• screening for swallowing difficulties within four hours of arrival to hospital using a validated screening tool before giving patients food, fluids or oral medications
• monitoring and prompt management of pyrexia and hyperglycaemia for the first 72 hours
• screening for communication difficulties
• ensuring appropriate venous thromboembolism (VTE) prophylaxis
• following escalation pathways within the above protocols (such as review by a speech pathologist if swallowing or communication difficulties are identified), and notifying medical officers if the patient has body temperature or glucose levels outside the recommended parameters
• other recommended protocols for care of patients after stroke as described in the National Acute Stroke Services Framework and the Living Clinical Guidelines for Stroke Management. 

All clinicians should use supportive communication techniques with patients who have communication difficulties. This improves patient consent processes, patients’ ability to express their needs and preferences, and patient engagement with care. 

Ensure that systems and infrastructure are in place for patients with stroke to be treated by a multidisciplinary team in a stroke unit as soon as possible. Ensure that these comply with the recommendations to enable best practice care outlined in the National Acute Stroke Services Framework. The Australian Stroke Coalition has a system for stroke unit certification in Australian hospitals, which healthcare services can participate in.

ICUs, HDUs or similar locations are appropriate alternatives to stroke unit care for patients requiring critical care management.

If there is no stroke unit at the healthcare service, ensure patients receive guideline-recommended care and protocols in the nearest similar unit able to meet the requirements for stroke unit care. This may include management on the ward where the patient is located, with access to a telestroke service and allied health assessment. 

Ensure local protocols align with the current Living Clinical Guidelines for Stroke Management. Protocols should include:

• screening for and management of swallowing difficulties
• monitoring and prompt early management of pyrexia and hyperglycaemia for the first 72 hours of care
• screening for communication difficulties
• ensuring appropriate VTE prophylaxis
• escalation pathways for patients with temperature and glucose outside recommended parameters or with swallowing or communication difficulties identified on screening
• other recommended protocols for stroke unit care.

Ensure relevant staff are trained to use validated screening tools to screen for swallowing and communication difficulties.

A stroke unit is a special hospital ward for patients with stroke. Being treated in a stroke unit by a team of health professionals who specialise in stroke care will increase your chances of a good recovery. Your specialised team may include doctors, nurses, occupational therapists, physiotherapists, speech pathologists, dietitians, social workers, pharmacists, and a stroke coordinator. 

You should be offered treatment in a specialised stroke unit whenever possible. The ambulance should take you directly to a hospital with a stroke unit or your hospital should transfer you to one if necessary. You (and your family or support people) should be given the opportunity to discuss your wishes regarding transfer to a place that provides stroke unit care.

If there is no stroke unit in your area, and transfer is not feasible, you may receive care in the nearest hospital that provides recommended stroke care without a stroke unit. For example, the healthcare team may have regular videocalls with stroke health professionals at another hospital (telehealth) rather than face-to-face visits onsite. This may allow you to receive specialist care closer to your home. 

Your healthcare team will offer the best care for you, based on national or local recommendations. Soon after you arrive at hospital, your healthcare team will check your ability to swallow to make sure you can drink, eat and take medicines safely. If you have trouble swallowing, a speech pathologist will develop a plan with you and your family or support people. Your healthcare team will regularly check your blood sugar levels and body temperature and treat them when necessary.

• FeSS (Fever, Sugar and Swallowing) clinical treatment protocols and implementation strategy (bundle of care for monitoring and managing pyrexia, hyperglycaemia and swallowing difficulties)
• Venous Thromboembolism Prevention Clinical Care Standard (for VTE prophylaxis)
• Aphasia screening tools from the Australian Aphasia Rehabilitation Pathway, including validity and reliability data to guide the choice of a screening tool for non-speech pathologists
• The Aphasia Rapid Test (used to screen for communication difficulties) and resources developed and endorsed by the Queensland Aphasia Research Centre

As soon as possible and within 48 hours of admission, a multidisciplinary team should use a validated tool^[1] to assess patient deficits, current impairment, activity limitations, and rehabilitation needs. Different aspects of the rehabilitation assessment may involve clinicians from different fields. These should include, but not be limited to, medical (including rehabilitation medicine), nursing, occupational therapy, physiotherapy, speech pathology, dietetics, and clinical psychology. Document the outcome of the rehabilitation needs assessment in the patient’s medical record. 

Review and discuss the patient’s rehabilitation needs with a rehabilitation physician or other clinician with expertise in the recovery of functional independence. Discuss the results of the rehabilitation needs assessment with the patient and their family or support people, together with the multidisciplinary team, to help determine initial rehabilitation needs and begin planning. 

Start individualised rehabilitation in hospital as soon as clinically appropriate and follow the recommendations in the Living Clinical Guidelines for Stroke Management. Alternative arrangements may apply if the patient is unable or unwilling to participate in rehabilitation, or rehabilitation is not consistent with their goals of care.

Note: Intensive early mobilisation within 24 hours of stroke onset is not recommended. 

While the patient is in hospital, record functional status using a validated tool such as the Functional Independence Measure (FIM), modified Rankin Scale (mRS), Barthel Index, or Functional Autonomy Measurement System (SMAF). 

Throughout the hospital admission, the multidisciplinary team should continually re-assess the patient’s rehabilitation needs, especially before discharge. Consider changes in the patient’s mood and cognition such as difficulty with concentration, memory loss, and language issues. Document these assessments in the patient’s medical record and discuss ongoing care requirements (and the options for providing these) with patients, their families and support people. Use this information as part of a shared decision making approach to determine the most appropriate care setting for ongoing rehabilitation, such as inpatient rehabilitation, home-based therapy services, outpatient rehabilitation or telehealth.

Once the discharge destination is decided, ensure all necessary arrangements are in place before the patient is discharged from hospital. These should include providing a rehabilitation plan, confirming a bed in a rehabilitation unit or completing all referrals to community services for patients being discharged to a private residence or an aged care facility.

Ensure that policies and procedures are in place for a multidisciplinary team to assess and document the initial rehabilitation needs of patients with stroke within 48 hours of admission to hospital, using a validated assessment tool to guide planning and early initiation of rehabilitation. Ensure clinicians record and discuss patient deficits, current impairment, activity limitations, rehabilitation needs, and functional status. Also ensure that the multidisciplinary team discusses findings with patients and their families or support people.

Ensure a multidisciplinary team, including medical, nursing and allied health professionals, is available (face-to-face or via telehealth) to:

• commence early and timely rehabilitation in line with the Living Clinical Guidelines for Stroke Management
• re-assess rehabilitation needs (including mood and cognition)
• make plans and arrangements for ongoing rehabilitation before discharge together with patients and their families or support people.

If you have had a stroke, you will very likely benefit from rehabilitation to help you manage its impact on your everyday life. Rehabilitation covers many different things, and your needs may be different to another stroke survivor’s. For example:

• you may need help re-learning how to eat, drink, walk, communicate or carry out your other usual daily activities
• you may need support to manage the emotional and psychological impact of any changes caused by the stroke
• some people have trouble with memory, self-identity, sexuality, paying attention and problem-solving, which can make day-to-day activities harder. 

Your rehabilitation needs will be assessed as early as possible after your stroke (and within the first two days of your arrival to hospital), so that your rehabilitation can start as soon as it is safe to do so. The initial assessment will involve your family or support people and a healthcare team tailored to your specific needs (which may include doctors, nurses, occupational therapists, physiotherapists, speech pathologists, psychologists and social workers). Your healthcare team will share the findings of your assessment with you and your family or support people. 

Rehabilitation should be started as soon as your healthcare team deem it safe and be targeted according to your needs.

While you are in hospital, your needs for ongoing rehabilitation will be assessed and documented in your medical record. Your healthcare team will discuss their recommendations with you and your family or support people. Your healthcare team will make arrangements for your ongoing rehabilitation, which may take place in hospital or at home through a home-based service, at a clinic or via telehealth. You will be given the contact details of your stroke support services, care navigator or rehabilitation team in case you have any questions about the arrangements after you leave hospital.

Develop streamlined referral pathways back to the community, particularly for those from regional, rural or remote communities who have received care away from home. Liaise with primary care clinics, including Aboriginal and Torres Strait Islander Community Controlled Health Organisations (ACCHOs), to ensure arrangements are in place for travel and for safe transition back to the community, including arrangements for ongoing rehabilitation as needed.

• The Australian Stroke Coalition’s Assessment for Rehabilitation: Pathway and Decision-Making Tool is used to assess and assist with decision-making regarding patients’ rehabilitation needs.
• Validated tools used to measure functional status include those listed below:
  • Functional Independence Measure (FIM)
  • Modified Rankin Scale (mRS)
  • Barthel Index
  • Functional Autonomy Measurement System (SMAF).
• The Rehabilitation Stroke Services Framework outlines the principles, essential elements, models of care and staffing recommendations for stroke services. It also provides guidance about systems for effective integration of stroke survivors into the community after they leave hospital. This Framework discusses workforce and resource requirements as well as requirements regarding data collection and quality improvement activities.
• Principles for goal setting – an Australian Government resource for developing person-centred goals. 

Communicate with the patient’s general practice team to gather information about previous treatments and investigations undertaken, which may inform their ongoing treatment. For example, their previous response to relevant medicines and results of cardiac monitoring.

Offer testing and assessment to investigate the mechanism of the patient’s stroke to enable targeted therapies that can minimise the risk of recurrence (for example, cardiac assessment and monitoring to screen for atrial fibrillation). When assessment is not appropriate during the acute admission, refer or arrange for the assessments to be completed promptly after hospital discharge. 

Prescribe appropriate medicines for secondary prevention, including anticoagulants for atrial fibrillation and antiplatelet, antihypertensive and lipid-lowering medicines, where indicated and in line with current guidelines. Other measures may include time-limited surgical interventions (for example, carotid endarterectomy) or closure of a patent foramen ovale in younger patients.

Assess the patient’s risk of recurrent stroke and modifiable risk factors. As part of a multidisciplinary team, provide patients with stroke and their families or support people with education and information about reducing their risk of another stroke in a way they can understand. Discuss risk factors such as uncontrolled hypertension or diabetes, smoking, poor diet, insufficient physical activity and excessive alcohol or recreational drug use, and provide written information. 

Ensure that processes are in place to investigate the mechanism of the patient’s stroke during hospital admission and arrange any recommended follow-up investigations before discharge to enable appropriate follow-up care. Support appropriate communication with patients’ usual general practice teams to obtain relevant history.

Ensure that systems are in place for preventive therapies to be prescribed or recommended in line with current guidelines and documented before patients with stroke are discharged.

Ensure that processes are in place for multidisciplinary input to assess the risk of recurrence and educate patients about reducing their risk of another stroke. Ensure that written information about reducing stroke risk is available and suitable to the patient population.

Your healthcare team may recommend follow-up tests to work out the reason for your stroke. Some tests may be done in hospital and some may be done after you are discharged.

People who have had a stroke are at high risk of having another stroke. Your healthcare team will offer you treatment and advice on how to reduce this risk. For example, they might recommend monitoring and managing blood pressure and diabetes. You may be prescribed medicines for high blood pressure, diabetes, high cholesterol, or blood-thinning medicines, which you will need to keep taking after leaving hospital. 

Your healthcare team may also recommend changes to your lifestyle to reduce your risk of another stroke. This might mean quitting smoking if you smoke or vape, limiting alcohol consumption, eating healthy foods, maintaining a healthy weight, keeping physically active, and avoiding the use of recreational drugs. 

You will be given written information and advice to help you understand what you can do to help prevent another stroke.

Provide information in a way that reflects the literacy, language, and cultural needs of the individual patient. Information should be provided in a way that builds understanding, engagement, and empowerment to manage and reduce their ongoing risk of another stroke. 

Include family, kin, community members or trusted healthcare providers in discussions, if the patient desires this. Allow time to build rapport and trust and for explanation and questions. Consider the need for multiple encounters and methods of communication, and for appropriate handover to the person’s usual health service in the community. 

Written and audiovisual material for Aboriginal and Torres Strait Islander people should be developed in partnership with the community and people with expertise in Aboriginal and Torres Strait Islander health.

Patients with stroke often experience changes in their ability to safely carry out their daily activities. They may need much more support from family and others than before their stroke. Offer information and practical guidance to families and support people to help them support the patient with any new care needs after discharge. Documenting all care given in the 24-hour period before discharge can help in identifying the patient’s support needs when they are discharged to a private residence or a residential aged care facility. 

Practical assistance includes advice, guidance and training for families and support people on how to safely support the patient with their new daily needs. Below are examples of the areas in which a patient may need support, and the types of assistance clinicians can offer to family and support people. 

• Physical care: Personal care techniques, the use of new assistive equipment, modification of food and drink to ensure safe swallowing, and safe mobilisation and transfer.
• Communication and cognition: Communication partner training, and strategies to manage changes in memory, concentration, and behaviour.
• Psychosocial wellbeing: Fatigue management, emotional support, carer self-care, and strategies for both the patient and carer to return to community life.
• System navigation: Support to access respite, carer financial aid, NDIS or My Aged Care, guidance on health and financial decision-making responsibilities, and the contact details of support services.

A range of clinicians may offer assistance and advice, including social workers, occupational therapists, physiotherapists, speech pathologists, dietitians, nurses, pharmacists, psychologists, and doctors.

If a patient is assessed as able to manage independently but does not have an identified carer or support person, offer the patient information, support and advice (in a way they can understand) to help them safely and confidently manage their daily needs.

Ensure that processes and resources are in place to provide information and assistance to the family and support people of patients with stroke before their discharge. This should enable them to safely and confidently manage the patient’s changed care needs. This should not replace arrangements for appropriate home-based services. 

All patients, families and support people should receive: 

• information about new individual patient care needs
• practical assistance to meet these needs (including personal care techniques, support with communication, use of new assistive equipment, modification of food and drink, mobilisation, safe transfers, and changes in behaviour)
• information and support to access carer financial support, NDIS or My Aged Care, and guidance on health and financial decision-making responsibilities
• details on how to access support services (for example, respite care).

Also offer information and practical support to patients who do not have family or support people to assist them on discharge but are considered able to live independently after a stroke. Ensure that systems are in place for these patients to receive information, advice, and support (in a way that they can understand and access) so they can safely and confidently manage their daily needs.

Family members and support people are often critical in the support and care of a person with stroke, whether they live independently or in an aged care home. Some people will need extra services or support that cannot be provided by family or existing support people.

If there are significant changes to the person’s capabilities or level of independence after their stroke, this can take a toll on family and support people. 

Your family and support people will be offered information and practical assistance to help support you with your daily needs after discharge, and as your needs change over time. This may include support with the following areas.

Care and daily support

• Personal care techniques
• Safe physical handling and transfers
• Use of aids and assistive devices
• Managing swallowing and dietary needs
• Managing fatigue and day-to-day activities

Communication, thinking and behaviour

• Communication difficulties, including communication partner training where needed
• Changes in thinking skills, such as memory, attention, and concentration
• Emotional wellbeing and mood changes
• Challenging behaviours, including irritability, impulsivity, or personality changes

Living in the community and care transitions

• Returning to and participating in community life (for both the person with stroke and their support people)
• Transitions of care, including respite and residential aged care options

Support services and practical matters

• Accessing carer respite services
• Carer financial support
• Access to the National Disability Insurance Scheme (NDIS) or My Aged Care
• Health and financial decision-making responsibilities

Information and support may be provided by medical, nursing, allied health staff, or a social worker. You will also receive contact details for support services and other helpful information.

Provide culturally appropriate and co-designed information resources (in local language as appropriate) and the opportunity to have questions answered by a trusted health professional. 

The Stroke Foundation has developed many resources to assist stroke survivors, their carers and health professionals in the process of discharge planning and transfer of care:

• My Stroke Journey – an information pack to give to stroke survivors and their carers before hospital discharge
• Aphasia Handbook – an information guide for people with aphasia and their families, carers and friends, which should accompany the resource ‘My Stroke Journey’ for all patients who have aphasia
• StrokeLine – a free telephone support service providing information and advice on stroke prevention, treatment and recovery, staffed by health professionals. Call 1800 787 653 or email strokeline@strokefoundation.org.au
• EnableMe – a free web-based resource providing information, a community forum and a tool to track personal goals for recovery
• Young Stroke – an initiative aimed at delivering information and resources for younger survivors of stroke aged 18 to 65 years old, their partners, families, friends and carers
• i-REBOUND After Stroke – a patient-centred education resource
• For more information, see: www.strokefoundation.org.au/what-we-do/for-survivors-and-carers 

See also:

• Carer Gateway – an Australian Government program providing free services and support for carers.

While patients are in hospital, jointly develop a written individualised care plan with them and their family or support people to ensure appropriate follow-up and ongoing care when they leave hospital. 

The individualised care plan should include:

• results from relevant rehabilitation assessments, ongoing rehabilitation needs and goals, and a plan to achieve these (see Quality statement 4)
• secondary prevention recommendations discussed, such as medicines and lifestyle modifications (see Quality statement 5), and, where possible, a medication list and education provided by a pharmacist
• information discussed and practical assistance for managing daily activities, advice on when the person may resume driving a vehicle, and contact details for support services available in the community (see Quality statement 6)
• details of referrals and follow-up appointments, including
  • scheduled appointments for any pending investigations and for ongoing care
  • when to go to their general practice for follow-up, which may include ongoing prescriptions for medicines or referrals for pending investigations and services
  • who to contact for follow-up, including for emerging or unmet rehabilitation needs post-discharge
  • a follow-up review appointment within six months of diagnosis (see Quality statement 8).

Give a copy of the care plan to patients and their families or support people. Ensure they understand the information provided and that they take a copy of the care plan before discharge. Also provide a copy to their general practice and, where appropriate, their ongoing rehabilitation team (such as a rehabilitation physician and allied health professionals) or aged care provider before or at the time of discharge. 

Stroke Foundation’s My Stroke Journey is a useful planning resource that can be given to patients before they leave hospital after a stroke. This information should be summarised and contextualised in the care plan provided to other healthcare professionals.

Ensure that processes and resources are in place for clinicians to develop an individualised care plan for patients with stroke before they leave the hospital, in collaboration with the patient and their family or support people. Ensure that systems allow for the individualised care plan to be provided at the time of discharge in a format appropriate to the patient’s general practice and, where appropriate, their ongoing rehabilitation team or aged care provider.

Care plans for patients with stroke must follow a consistent format that includes:

• results from relevant rehabilitation assessments, ongoing rehabilitation needs and goals, and a plan to achieve these (see Quality statement 4)
• secondary prevention recommendations discussed, such as medicines and lifestyle modifications (see Quality statement 5)
• information discussed and practical assistance for managing daily activities, advice on when the person may resume driving a vehicle, and contact details for support services available in the community (see Quality statement 6)
• details of referrals and follow-up appointments.

The patient must receive a copy of the individualised care plan to take with them before being discharged. 

Ensure that clinicians make referrals and appointments and that these are communicated to patients and their families or support people, general practice and, where appropriate, their rehabilitation team and aged care providers. Referrals and arrangements should be made for: 

• any pending investigations
• the patient’s general practice
• the patient’s rehabilitation team (if they will be receiving home-based therapy services, outpatient rehabilitation or telerehabilitation)
• a follow-up appointment within six months of diagnosis with appropriate multidisciplinary team input (see Quality statement 8).

Ensure that appropriate systems are in place to support the discharge process and appropriate follow-up care. This includes establishing links with primary health, community health and rehabilitation services to enable potential review by specialist rehabilitation services or periodic intensive rehabilitation when significant changes are identified on regular patient review post-discharge. 

Before you are ready to leave hospital, your doctors, nurses and other members of your healthcare team will discuss your recovery with you and your family or support people and jointly develop an ongoing care plan with you to guide your care after you leave hospital. 

The care plan will set out in writing:

• your ongoing rehabilitation needs, goals and plan
• changes to your medicines (which may include a detailed list of your medicines and information provided by a pharmacist)
• any lifestyle changes you are advised to make
• information and practical assistance to support your daily needs (including when you may go back to driving a vehicle and any equipment, assistive technologies, home modifications, communication support or other additional support you may need)
• follow-up appointments and contact details for the healthcare team that will look after you after discharge, such as your general practice or rehabilitation provider, and any follow-ups at the hospital.

You and your regular general practice will get a copy of this care plan, as will your rehabilitation or aged care provider if you have one. Your care plan will change over time as your condition changes. 

Provide documentation, including results, follow‑up appointments and future management, to the patient’s general practice, primary healthcare service or Aboriginal and Torres Strait Islander Community Controlled Health Organisation (ACCHO) in a timely fashion.

Give the patient the individualised care plan and discuss it with them and their family or support people in a culturally appropriate way. See the Stroke Foundation’s Our Stroke Journey.

Stroke Foundation’s My Stroke Journey covers all the essential elements of a care plan and includes pages for clinicians and patients to complete together. The Stroke Foundation resource My Stroke Journey is intended to be provided by hospital clinicians and discussed with patients, and their families or support people, in the first few days after their stroke, and to stay with patients in their transition from hospital to home. This resource is used by clinicians to deliver stroke education, explain treatment and care, deliver secondary prevention education, and inform the development of an individualised, comprehensive discharge care plan that can be shared with the patient and their GP. For more information, see My Stroke Journey. 

Ensure that patients who have had a stroke receive a comprehensive follow-up assessment and review, booked before discharge from hospital. This appointment should be within six months of the person’s stroke diagnosis and include relevant family members or support people. It may be face-to-face or via telehealth, and may not necessarily be the first or only follow-up with a healthcare provider. 

The patient’s needs at discharge should determine the appropriate clinician (or clinicians) to conduct the assessment and review, and its timing. It should be conducted by clinicians with relevant skills and expertise – which may include members of a multidisciplinary stroke team, acute stroke service outpatient clinic or rehabilitation service – who can access additional multidisciplinary input as required at the time of follow-up. 

At the follow-up review, assess the patient’s self-management and update the patient’s individualised care plan by addressing the following domains as appropriate.

• Medical and secondary prevention: Review medication adherence and indication, patient progress with lifestyle modifications, and any pending investigation results.
• Rehabilitation: Re-assess rehabilitation needs against the patient's goals and progress. Record functional status at follow-up using a validated tool such as the Functional Independence Measure (FIM), modified Rankin Scale (mRS), Barthel Index, and Functional Autonomy Measurement System (SMAF). Review the choice of rehabilitation pathway to ensure rehabilitation continues to meet the patient’s needs.
• Functional status: Assess cognition, vision, fitness to drive, continence and equipment needs.
• Psychosocial and vocational: Re-assess mood and, if appropriate, sexual dysfunction. Review or develop a return-to-work plan, which may include returning to voluntary work, community roles or ongoing carer responsibilities for partners, parents, children or grandchildren. Assess the person’s engagement in community life and reintegration.
• Care coordination: Review the effectiveness of existing referrals and assess the need for further appointments with allied health, rehabilitation, or other community support services.

Give the patient, their GP and their ongoing rehabilitation team an updated care plan at the end of the appointment (see Quality statement 7).

Have systems and resources in place to arrange for patients to receive a comprehensive follow-up appointment within six months of their stroke diagnosis and with the most appropriate multidisciplinary team for their needs. This may be the acute stroke or rehabilitation service. 

The follow-up appointment may be face-to-face or via telehealth and should address, as required, the following domains:

• medical and secondary prevention (including a review of medication, lifestyle modifications, and any pending investigation results)
• re-assessment of rehabilitation needs, goal and progress
• functional status (assessed and recorded using a validated tool)
• psychosocial and vocational needs
• return-to-work plan
• care coordination (including a review of the effectiveness of existing referrals and identifying the need for further appointments with allied health, rehabilitation, or other community support services).

Ensure that processes are in place for communicating the updated care plan to patients, their general practice and their rehabilitation team at the end of the appointment. 

Before you leave the hospital, your healthcare team will arrange a follow-up review for you (and your family or support people if applicable) in the first six months after your stroke. This is an important opportunity to check on your recovery, see how you are managing at home, and update your care plan with you and your family or support people.

During this follow-up review, your healthcare team may talk to you about your:

• health and recovery – including progress towards your rehabilitation goals, your medicines, lifestyle changes, and the results of any tests
• daily life – including returning to driving or work, any equipment you might need, communication or swallowing issues, and assessments of your vision and continence
• wellbeing and support – including your mood, memory and thinking, fatigue management, personal relationships (including sexuality and intimacy), identity and role changes, and any further therapy or community support you may need.

Liaise with primary care clinics, including Aboriginal and Torres Strait Islander Community Controlled Health Organisations (ACCHOs), to ensure travel arrangements are in place to support attendance at follow-up appointments. Find alternative ways to contact patients if they do not have regular access to a phone, email or postage delivery service to receive information about follow-up appointments.

Ensure that communication and materials are culturally and linguistically appropriate for the patient to support participation in stroke management and rehabilitation.

Explain the rationale for assessment, tests, transport, and interventions to the patient, their family and their support people in a culturally safe way.

Recognise and address individuals’ potential barriers to care by, for example, providing culturally appropriate stroke awareness and recognition information to the community and suitable ways to access rapid care. This is especially important for people whose access to services and infrastructure is limited.

Recognise and respond to any concerns associated with diagnosis and treatment, including the potential need for hospitalisation off Country. Where clinically safe, prioritise care on Country and minimise unnecessary transfers. If transfer is required, plan early for return to Country to support wellbeing. Ask for consent to transport to hospital, which may involve consulting the patient’s family and community members.

Ensure processes for ambulance and hospital intake provide an opportunity for patients to self-identify and for services to capture and act on identification data.

Provide the person with access to Aboriginal and Torres Strait Islander Liaison Officers or other relevant workers and clinicians who can discuss potential concerns about urgent treatment, such as reperfusion therapy, either in the patient’s language or in a way that is culturally safe for the person.

Develop streamlined referral pathways back to the community, particularly for those from regional, rural or remote communities who have received care away from home. Liaise with primary care clinics, including Aboriginal and Torres Strait Islander Community Controlled Health Organisations (ACCHOs), to ensure arrangements are in place for travel and for safe transition back to the community, including arrangements for ongoing rehabilitation as needed.

Provide information in a way that reflects the literacy, language, and cultural needs of the individual patient. Information should be provided in a way that builds understanding, engagement, and empowerment to manage and reduce their ongoing risk of another stroke. 

Include family, kin, community members or trusted healthcare providers in discussions, if the patient desires this. Allow time to build rapport and trust and for explanation and questions. Consider the need for multiple encounters and methods of communication, and for appropriate handover to the person’s usual health service in the community. 

Written and audiovisual material for Aboriginal and Torres Strait Islander people should be developed in partnership with the community and people with expertise in Aboriginal and Torres Strait Islander health.

Provide culturally appropriate and co-designed information resources (in local language as appropriate) and the opportunity to have questions answered by a trusted health professional. 

Before leaving hospital, a patient with stroke and their family or support people are involved in the development of an individualised care plan that describes the ongoing care required. This care plan is given to the patient, their general practice and their ongoing rehabilitation team at the time of discharge. 

Liaise with primary care clinics, including Aboriginal and Torres Strait Islander Community Controlled Health Organisations (ACCHOs), to ensure travel arrangements are in place to support attendance at follow-up appointments. Find alternative ways to contact patients if they do not have regular access to a phone, email or postage delivery service to receive information about follow-up appointments.

Ensure that communication and materials are culturally and linguistically appropriate for the patient to support participation in stroke management and rehabilitation.