TCSI intervention
stroke, TIDieR
ADVERSE EVENTS, STROKE
The 6-month intervention was developed using the Medical Research Council Framework [Two study governance structures facilitated the active engagement of patient, providers, and decision-maker stakeholders: Patient Advisory Committee, and the Steering Committee. The Patient Advisory Committee consisted of older adult stroke survivors (excluding trial participants) living in the two study regions. The Steering Committee consisted of decision-makers (e.g., from provincial health branches), representatives from provincial and national stroke networks, patient research partners, directors, and managers from the two study sites, and research team members. The involvement of key stakeholders at each of the study sites and organizations involved in the delivery of community-based stroke rehabilitation was critical to designing the intervention to ensure that all viewpoints were considered.The description of the intervention follows the TIDieR guidelines [To support intervention fidelity, the health care providers received virtual training by the principal investigator and the research coordinator prior to initiation of the intervention to convey key intervention activities, research study procedures, and underlying theories. A standardized training manual was developed from best evidence that included key content pertaining to all aspects of the intervention. Training was adapted to the providers based on a needs assessment completed at each of the sites and included education and role-playing to enhance skills in strengths-based practice. Monthly outreach meetings were conducted to enable the principal investigators, the research coordinator, and the intervention teams to support and monitor intervention implementation and strategize to address any challenges [The TCSI was designed to improve both the quality and experience of hospital-to-home transitions. The core components of the intervention were based on the literature (as described in the introduction) [The IP team’s main activities during the virtual visits included: 1) conducting a comprehensive assessment of the health and social care needs of older adult participants using standardized tools [During and between the virtual visits, the care coordinator provided system navigation support that consisted of: 1) identifying and addressing any risk factors for adverse events, e.g., hospital readmissions; 2) arranging community services and follow-up health-care appointments; 3) facilitating communication between the patient, their family caregiver, and their health care team; 4) supporting linkages and referrals to relevant health and social service providers; and 5) developing an individualized patient-centred plan of care [