Background/Aim:People with transient ischemic attack (TIA) or minor stroke are at risk of stroke recurrence, partly due to poor risk factor management. To address this, we aimed to implement a referral pathway from a TIA Clinic to the evidence-based cardiovascular telehealth COACH Program® delivered by Diabetes Australia in Tasmania.
Methods:This is a mixed methods implementation study. In the Preparation Phase, a focus group with TIA Clinic staff at the Royal Hobart Hospital developed strategies to establish the referral pathway. In the Implementation Phase, referral commenced with ongoing support for implementation through email/phone/face-to-face check-ins with TIA Clinic and the COACH Program® staff. The primary outcome is proportion of all TIA clinic patients referred to the COACH Program® collected through electronic medical records (eMR). Secondary outcomes include risk factors (e.g. blood pressure control from COACH®) and rehospitalization (eMR). Semi-structured interviews with clinicians and patients who complete the COACH Program®, will investigate barriers and enablers of implementation.
Results:The Preparation Phase occurred from 31st March 2025 to 30th October 2025. Co-developed strategies included an “order of operations” document, live tracking spreadsheet and e-referral form for use by TIA Clinic staff to COACH® program designed to reduce administrative barriers. The Implementation Phase began on 1st November 2025, with 12 patients recruited over 3 months and 4 patients starting the program.
Conclusion:The development of a new referral pathway may be an effective strategy to implement evidence-based interventions for TIA patients. Ongoing evaluation will examine process and evaluation outcomes among people with TIA or minor stroke.