Implementing a new model of primary care for stroke survivors living in the community: a mixed-methods process evaluation

Background: Survival after stroke is improving, leading to increased demand on primary care and community services to meet the long-term care needs of people living with stroke. Improving Primary Care After Stroke (IPCAS) is a novel model of primary care for stroke survivors living in the community. IPCAS was a complex intervention, with intervention components aimed at stroke survivors and healthcare professionals. This process evaluation aimed to explore how the intervention was delivered in context and how participants engaged with the intervention. Methods: The process evaluation was underpinned by the National Institute of Health’s Behaviour Change Consortium fidelity framework. A mixed methods design was used to assess fidelity of design, training, delivery and engagement. Methods included questionnaires, video- and audio-recordings, observations, and interviews with staff and participants. Results: The IPCAS intervention reflected its theoretical underpinnings and was substantially different from usual care. Most components of the intervention were delivered with high or moderate fidelity and training fidelity was high. In particular, the checklist was considered useful. However, other components were less valued, in particular, the direct point of contact service which was hardly used by participants and the local directory of services which had variable take up by healthcare professionals. It was not possible to facilitate communication between primary and secondary care as originally planned. Furthermore, some practices used a GP or healthcare assistant to deliver the reviews, rather than a practice nurse as planned. Several participants did not feel the intervention was relevant for them due to their recovery and the time that had passed since their stroke. Conclusions: This mixed-methods process evaluation provided novel insights into the design, delivery and engagement with a new model of primary care for stroke survivors. Despite high or moderate fidelity for delivery of most components of the intervention and high training fidelity, some components, such as the direct point of contact, were not valued and several participants did not feel the intervention was relevant for them. Trial registration: ClinicalTrials.gov Identifier: NCT03353519, registered November 27, 2017.