Table 2.

Outcome measures and measurement instruments of the process evaluation

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
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

SI structured interview, SAQ self-administered questionnaire, RF research form, SSQ semi-structured questionnaire, GI group interview