A revised national stroke standard aims to improve life after hospital, with new expectations around rehabilitation, care plans and six-month reviews highlighting the important role of GPs in ongoing recovery.
Australia’s updated Stroke Clinical Care Standard is seeking to close longstanding gaps in post-stroke care by placing greater emphasis on rehabilitation, coordinated follow-up and community-based recovery.
And general practice is expected to play a central role in helping patients rebuild their lives after hospital discharge, says the Australian Commission on Safety and Quality in Health Care (ACSQHC).
The commission this week released its 2026 Stroke Clinical Care Standard, the first major revision since 2019.
While the updated standard maintains its focus on rapid diagnosis and treatment during the critical early hours of stroke, it significantly expands guidance around rehabilitation, discharge planning, secondary prevention and long-term support.
The update comes as Australia continues to grapple with the substantial burden of stroke. More than 46,000 Australians are expected to experience a stroke this year, while around 440,000 people are currently living with its effects.
Stroke remains one of the nation’s leading causes of death and disability, claiming almost 8000 lives annually.
ACSQHC medical advisor and GP Dr Lee Fong said improvements in acute stroke management had dramatically increased survival rates, but many patients were still struggling once they returned home.
“Over the past decade, there have been great strides in time-critical care for stroke patients in the crucial minutes and hours immediately after a stroke, with better treatments and more rapid coordinated acute care,” he said.
“Despite this progress, many of the after-effects of stroke are hidden and are felt deeply by patients who experience a stroke, as well as their partners, children and carers.”
Dr Fong told The Medical Republic much had changed in the seven years since the standard had been updated.
“I think the emphasis back then was particularly on acute management and the absolutely incredible treatments in terms of thrombolysis and thrombectomy.
“What we’ve been hearing from patients with stroke, carers looking after patients who have had stroke, from health professionals and allied health is a really consistent message about the long tail issue.”
This so-called “long tail” includes long-lasting and even lifelong impacts of stroke that often emerge or become more obvious after discharge from hospital and rehabilitation.
“And general practice is where that long tail actually shows up, so this standard is really highly relevant to GPs from that perspective,” Dr Fong said.
He said many stroke survivors faced ongoing challenges with mobility, fatigue, cognition, communication, mood disorders and social participation, often requiring support from multiple healthcare professionals over months, years or even a lifetime.
“What we are recognising is that rehabilitation is also time-critical – and for most patients, the earlier the better,” he said.
Under the revised standard, rehabilitation needs must be assessed by a multidisciplinary team within 48 hours of hospital admission, with individualised rehabilitation beginning as soon as clinically appropriate.
Ongoing rehabilitation needs must be continually reviewed and documented, and arrangements for continuing therapy must be established before discharge.
For GPs, one of the most significant changes is the strengthened focus on care transitions.
The standard says every stroke patient should leave hospital with an individualised care plan developed in consultation with the patient, their family and support people. That plan should be provided to the patient’s general practice and rehabilitation team at the time of discharge.
The standard also says patients should receive a formal follow-up assessment within six months of stroke diagnosis, with multidisciplinary input arranged before discharge.
Dr Fong said the goal was to ensure patients did not lose momentum in their recovery once they left hospital and rehabilitation.
“The 2026 standard emphasises that stroke rehabilitation should start in hospital, with expert therapy and planning to continue care at home or in a rehabilitation hospital,” he said.
“People may need help with speech, memory, energy, mental health, eating and drinking, as well as movement. Access to timely rehabilitation, care planning and support makes a huge difference.”
The updated standard also places renewed emphasis on secondary prevention, recommending hospitals to undertake comprehensive investigations to determine the cause of stroke and develop personalised strategies to reduce the risk of recurrence.
This includes management of hypertension, atrial fibrillation, diabetes, hyperlipidaemia and lifestyle risk factors, areas where GPs frequently assume responsibility once patients return to the community.
Professor Tim Kleinig, Stroke Network Lead for SA Health and immediate past president of the Australian and New Zealand Stroke Organisation, said the original clinical care standard had already delivered measurable improvements in acute stroke care.
“It has been fantastic to see the clinical care standard drive improvements in stroke care, with faster times to lifesaving treatment, including time-critical clot-busting therapy, even in rural areas where distance is a challenge,” he said.
National data showed the median time to thrombolysis fell from 73 minutes in 2017 to 62 minutes in 2025. Stroke unit care increased from 68% of patients in 2016 to 79% in 2024, while the proportion of patients leaving hospital with a discharge care plan rose from 59% in 2015 to 73% in 2024.
Professor Kleinig said telestroke services had been instrumental in improving equity of access, particularly for rural and regional Australians, who remained 17% more likely to experience stroke than those living in metropolitan areas.
“Telestroke in regional hospitals is helping people get diagnosed and treated quickly, with telehealth access to specialist stroke neurologists,” he said.
“The updated standard further emphasises both access and speed to treatment, including faster transfer times from regional areas.”
Professor Kleinig said the greatest opportunity for improvement to outcomes for stroke patients now lay in long-term care.
“Despite improvements in treatment, follow-up care after stroke is patchy across Australia,” he said.
“The updated standard will drive improvements in stroke follow-up. We want people to avoid having another stroke, as well as complications and disability after stroke.”
The commission hopes the revised standard will help address the lasting health and social impacts of stroke, which can include reduced mobility, chronic pain, anxiety, depression, loss of employment and increased reliance on carers.
Data from the Australian Stroke Clinical Registry indicated one in three stroke survivors reported moderate to severe disability, while one in two continued to experience significant impacts on their daily lives.
For general practice, the updated standard reflected a broader shift in stroke care from a focus on survival alone to supporting recovery, participation and quality of life. As more patients survived stroke and returned to the community, GPs were expected to play an increasingly important role in coordinating multidisciplinary care, monitoring rehabilitation progress, managing risk factors and helping patients and families navigate the often lengthy road to recovery.
“The goal is to create a foundation for people to resume their normal life in the community, as much as possible,” Professor Kleinig said.
Related
Dr Fong said GPs were the health professionals who most often knew patients best, and these therapeutic relationships were the ideal forum to tackle some of the “hidden impacts” of stroke.
“There’s a whole gamut of things that go beyond the more obvious things like speech and motor deficits; it’s the cognitive, it’s the emotional, and it’s the social issues that we should also be exploring,” he told TMR.
“With our longitudinal knowledge of the patient and their social circumstances, we are in an ideal position to explore these issues. Many patients may not raise these issues unless we ask.
“That is why the individualised care plan and six-month follow-up are so important. GPs should expect to receive a clear care plan after discharge and should be told when a follow-up review has been arranged.
“With these in mind, if problems are emerging or have not been addressed, general practice can help identify them and connect the patient back with the stroke team, rehabilitation services or other supports.”
Stroke Clinical Care Standard 2026 – quality statements include:
- Early assessment and urgent transport to hospital – a person with suspected stroke is assessed at first clinical contact using a validated stroke screening tool, such as the F.A.S.T. (Face, Arms, Speech and Time) test. When acute stroke is suspected, the person is transported immediately to a hospital capable of providing appropriate time-critical therapy. The hospital is pre-notified to enable rapid access to care.
- Time-critical therapy – a patient with acute stroke receives time-critical therapy urgently and in accordance with the Living Clinical Guidelines for Stroke Management. A patient with ischaemic stroke suitable for reperfusion therapy receives timely thrombolysis and/or endovascular thrombectomy. A patient with intracerebral haemorrhage receives urgent blood-pressure-lowering therapy and/or anticoagulation reversal where appropriate.
- Stroke unit care – a patient with stroke is promptly transferred to a stroke unit, as defined in the National Acute Stroke Services Framework. The patient receives early, protocolised care to prevent complications and maximise recovery.
- Rehabilitation – a patient’s initial rehabilitation needs are assessed by a multidisciplinary team as early as possible and within 48 hours of hospital admission for stroke. Individualised, guideline-recommended rehabilitation begins as soon as clinically appropriate during the admission. Rehabilitation needs are continually assessed and documented. Arrangements for ongoing rehabilitation are made before discharge.
- Minimising risk of another stroke – while in hospital, a patient undergoes a comprehensive assessment to determine the probable cause of their stroke. This assessment informs their ongoing care, including individualised treatment and education to promote healthy living and reduce their risk of another stroke.
- Practical assistance for families and support people – the family and support people of a patient with stroke are provided with information and practical assistance so that they can safely and confidently support the patient to manage their daily needs.
- Individualised care plan – before leaving hospital, a patient with stroke and their family or support people are involved in the development of an individualised care plan that describes the ongoing care required. This care plan is given to the patient, their general practice, and their ongoing rehabilitation team at the time of discharge.
- Follow-up assessment and review – a patient who has had a stroke receives a follow-up assessment and review, with appropriate multidisciplinary team input, within six months of their stroke diagnosis. This is arranged before discharge.
The full Stroke Clinical Care Standard is available here.
