Background/Aims: Home-based stroke rehabilitation, including bed-substitution services (BSS) and early supported discharge (ESD), is expanding across Australia. Unlike inpatient rehabilitation, there is no routine monitoring of guideline-recommended care in these settings. This study quantified guideline adherence in home-based services and explored referral decision-making.
Methods: An explanatory sequential mixed-methods study was conducted across three public health networks in Victoria. In Phase 1, medical records were audited against Stroke Foundation rehabilitation audit indicators. An individual-level composite adherence score was calculated as the proportion of applicable indicators met per person. Results were compared descriptively with published national inpatient data. In Phase 2, semi-structured interviews with clinicians and service leaders explored referral pathways and allocation decision-making.
Results: Across 181 episodes (BSS n=108; ESD n=73), median individual-level adherence ranged from 54–63% across sites and models. Goal setting (BSS 94%; ESD 96% vs 90% inpatient), mood assessment (95–96% vs 66%) and discharge planning (91–92% vs 83%) met or exceeded inpatient benchmarks. Gaps were identified in upper limb task-specific training (59–62% vs 84%), circuit class therapy (0–3% vs 35%) and carer training (74% BSS; 33% ESD vs 84%). Interviews (n=13) identified four considerations influencing allocation: (1) capacity of the stroke survivor–carer dyad to manage at home; (2) dyad preferences; (3) perceived fit between service capability and stroke severity; and (4) service and system factors.
Conclusions: Home-based stroke rehabilitation shows strengths in person-centred care but gaps in therapy-specific and secondary prevention indicators. Findings identify opportunities to improve referral pathways and broaden access.