Table 1.

Guidelines for interventions based on arising 'flags'

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

PADL: Personal activities of daily living

OT: Occupational therapist

PT: Physiotherapist

SP: Speech Pathologist

GP: General practitioner

ACAS: Aged Care Assessment Service

MMSE: Mini-mental State Examination

GDS-15: Geriatric Depression Scale (15 item)

CATS: Crisis Assessment and Treatment Service

GAS: Goal Attainment Scaling

SW: Social Worker