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As I mentioned before, the nurses take an important role in delivering care in hospital and they are the most suitable person to guide caregiver. We will choose At least 2or3 senior nurses involving in the management of stroke patients from each county hospital. But the fact is they are lack of knowledge and formal training on stroke rehab. So in our trial, firstly, the rehabilitation physicians and therapists from Peking University First Hospital in Beijing will conduct training to the nurses. And then the nurses will conduct training and give guidance to the caregivers in intervention arm. Now, here is the details of intervention package, including: health education on stroke recovery, risk identification, management of mood. operational training on physical activity and daily living such as transfer, mobilization, feeding, dressing etc. The training will take approximately 60 minutes per day for up to 3 days. according to patient’s progress, Joint goal setting with patient, caregiver, and nurse Discharge planning. During the 12 months after the stroke patients discharge from hospital, the nurses will monitor and give continuous guidance to caregiver up to 6 times through telephone or visiting to ensure the quality of the intervention, they will give additional training and emotional and psychological support when necessary. The patients in the control group, will receive conventional care. * The primary objective is to improve the health and physical function of disabled stroke patients in rural China. The outcomes of this study are used to reflect these objectives. * Let’s go back to the flowchart. After intervention, the caregivers will be followed up at 3,6 and 12 months post-baseline by the researchers , at this time outcomes will be evaluated by telephone interview and face-to-face interview. * * * * * 干预重点(巴氏指数) 进食 洗澡 梳理 穿衣 控制大便 控制小便 用厕所 床椅转移 平地移动 上下楼梯 自我护理 活动能力 大小便和用厕 10个评分项的3个分类 研究设计-结果评价 主要结果 患者出院6个月时的巴氏指数 次要结果 患者出院6个月时的功能性步行分级 患者出院6个月时的EQ-5D 患者出院3个月和
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