Psychosocial screening
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Core Principles for Psychosocial Screening
Whanaungatanga is foundational and should be prioritised
Psychosocial screening – informal or through validated screening tools – occurs best in the context of a mutual relationship where people feel welcome, known, and have a sense of connection with the person they are working with.
Screening occurs in multiple ways and at multiple time points
Psychosocial screening is not a one-off event.
Screening processes should include a combination of screening approaches; conversations with the person and whānau, observation, structured questions, validated mood screens, and diagnostic assessments where indicated. These all need to be documented.
Mood screens need to be interpreted with caution: combining information from different sources is important for identifying issues and support needs.
Screening needs to be accessible for those with communication differences and impairments.
A number of screening tools have been designed for people with post-stroke communication impairments. Involving speech-language therapists in screening can improve the screening process and outcome.
Whānau, interpreters, and/or cultural advisors should be included for people from culturally and linguistically diverse backgrounds.
Screening should consider people’s holistic well-being needs
Within screening, it is important to attend to the different ways psychosocial well- being can be impacted. Formal screening tools commonly focus on depression and anxiety, but other aspects such as adjustment and identity are important to consider as are cultural aspects of well-being.
Appropriate action plans should be developed and implemented
Observations and results should be shared with the person with stroke, other team members, and with their whānau, if appropriate. These should be documented in discharge documentation.
Action plans need to be developed and implemented in a timely manner and need to be monitored over time.
All stroke services should have a process for screening for psychosocial needs. Screening helps ensure psychosocial needs are identified early; this can facilitate well-being and improve people’s engagement and motivation in rehabilitation. Psychosocial well-being should be considered within the initial assessments of all disciplines and monitored in the weeks and months after stroke.
Psychosocial screening can occur through multiple means: conversation and observation, semi-structured interviews, validated screening tools, and diagnostic assessments. All members of the stroke team can screen for psychosocial needs with appropriate training and support. Diagnostic assessments need to be completed by appropriately qualified healthcare professionals (e.g. medical or mental health providers).
Ensuring screening processes are culturally responsive, culturally safe, and engaging is critical to improving equity and better health outcomes. This helps create positive and empowering interactions with the healthcare team, and can help achieve equity for whānau Māori.
Every person with stroke should have a validated mood screen in the first few weeks after stroke – although formal screening is not recommended in the first week after stroke. If there are any concerns about mood after this time, a validated screen should be completed. Key timepoints when screening may be particularly important are:
At point of transfer to, or during, inpatient rehabilitation
Before discharge to the community, or before discharge from community
services
During routine follow-up in primary care or stroke review clinics [14, 15].
People who require further assessment or intervention should be identified early, provided with supports appropriate to their level of need, and referred for specialist support (if required) as soon as possible.
“All stroke services should have a process for screening for psychosocial needs.
Screening helps ensure psychosocial needs are identified early; this can facilitate well-being and improve people’s engagement and motivation in rehabilitation.”
Informal screening: Supportive conversations and observations
Psychosocial well-being should be considered at all times throughout stroke care. Well-being can be reviewed through conversations with the person with stroke, their whānau and friends, and via observation.
Supportive conversations or observations might be brief check-ins, short chats or extensive discussions. It might simply be a 30 second check in at the beginning of a nursing shift or medical review, a few questions during an initial assessment, an informal five-minute discussion before or after a rehab session, or a longer chat with them or whānau if it appears their mood and motivation is causing them difficulties. These should be two-way conversations, going beyond asking questions to having a conversation about how things are going.
It helps to be down-to-earth, demonstrating care for the person, and being non- judgemental of how they are adjusting to their stroke. You don’t need to ‘fix’ their mood; simply create an accepting and supportive space for them to share, ask questions, and reflect if they wish. Creating an environment where people feel safe to talk and to ask questions is invaluable.
Be mindful about how questions are framed. This may be particularly important for Māori, Pacific peoples, and those from non-English speaking backgrounds. Use interpreters if needed. Minimise technical words and use more everyday, informal language. More questions may need to be asked both to clients and whānau. When providing information, ensure this is shared in ways, and at times, that facilitate understanding and are responsive to the needs and priorities of the person and their whānau.
Pay attention to changes in mood and behaviour over time. The sooner that difficulties are noticed, or the sooner that improvements are noticed, the more proactive and supportive providers can be.
You don’t need to ‘fix’ their mood; simply create an accepting and supportive space for them to share, ask questions, and reflect if they wish.
The sooner that difficulties are noticed, or the sooner that improvements are noticed, the more proactive and supportive providers can be.
Checking in about well-being through conversation
Simple check-ins with whānau and friends
This has been a big change for you and whānau – how are you coping?
How do you feel [Person] is coping? Do you have any concerns about them?
• Is this mood or behaviour (e.g, quiet, tearful, aggressive) normal for them or new since the stroke?
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How are you feeling today? How’s your mood or spirits? Is anything bothering you? How are you feeling in yourself?
If integrating Te Whare Tapa Whā into practice, consider questions that address the different elements of hauora:
Tinana: How are you feeling physically?
Hinengaro: How are you feeling emotionally - your mood and energy? Is there anything weighing on your mind?
Whānau: How are you and your whānau coping or navigating things currently? Is there anything you are worried about for your whānau? What role do your whānau play in your well-being?
Wairua: How are you feeling spiritually? How would you describe your overall feeling or energy? Is there anything standing out strongly?
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You look more (refreshed, motivated, tense, down, restless) than last time – how are you feeling? Is there a reason for this?
Simple 0-10 scales can be helpful. Ask them to comment on the intensity of their mood. 10 reflecting most intense and 1 reflecting least intense.
Yesterday you said you were feeling 9/10 in depressed mood and really fed up with life; are you feeling similar today or different?
Before we started this transfer to your wheelchair you were feeling really anxious – 9/10. How about now that we are finished?
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Pay attention to the words they use to describe their mood: e.g., “whakamā” “down in the dumps”, “tired”, “pissed off”, “amped”. Explore the reasons for this, and what people think might help. Sometimes, ‘simply’ acknowledging that these feelings are there is enough, but come back and revisit this at later times.
Screening with structured interviews
Initial assessments completed by any discipline or by an interdisciplinary team should include brief screening questions about client and whānau psychosocial well-being. This ideally includes questions on adjustment, mood changes, emotional lability, behavioural/personality changes and carer stress, all of which are common post-stroke. These should be documented in the patient’s clinical notes.
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Mood and behaviour changes: Are they tearful, tense, glum or agitated OR responsive, motivated, with a sense of humour?
Motivation: Are they motivated and engaged in their own cares and rehabilitation activities? Are they interacting with others?
Sleep, appetite and energy: These can all be affected by a stroke but can also be a sign of mood changes.
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Acknowledge and normalise concerns, be empathetic, and provide a sense of hope
Discuss with team and with whānau if consenting. Consider structured mood screens or risk assessments (see guidelines below)
Consider referrals to mental health clinicians and/or cultural or spiritual support.
Document any concerns and actions
For practical strategies and examples see below sections on Communication following psychosocial screening and Action Plans to Support Well-being.
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How do you feel your stroke/situation has affected your life and well-being (hauora)?
Have you been feeling down, depressed or hopeless over the last week?
Yes / No
If Yes;
Does this feeling come and go or does it stay with you for most of the day?Have you been feeling anxious or having difficulty stopping your worries over the last week or so?
Yes / No
If Yes;
Does this feeling come and go or does it stay with you for most of the day?
What is your biggest worry?Do you find yourself crying or laughing more than you would normally do?
Yes / NoHave you or anyone else noticed any changes in your behaviour or personality since the stroke?
Yes / No
If Yes;
What have you or others noticed?How do you think your whānau are adjusting after your stroke?
What do you think might be most important for you and your whānau’s well-being/hauora for the next few weeks?
If any concerns raised from above questions, consider formal mood screen and further discussion about current stressors and goals.
Screening using validated screening tools
All stroke patients should be screened for depression and anxiety with a simple, brief, validated measure at least one time point after stroke. These measures cannot be used to diagnose mood disorders, but they provide a measure of symptoms and severity that can help guide further assessment and intervention.
Some validated screening tools require staff to be trained to administer them.
Things to consider when using validated screening tools
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Screening tools are ideally administered with the person face-to-face (rather than simply asking them to complete the form) and in a private space. This has several benefits: greater reliability, confidentiality of responses, reducing distractions and cognitive load, and it allows the provider to explore further if appropriate. If completing the screen in the presence of other patients or whānau, obtain consent before proceeding
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Screening may need to take place via telephone or other telehealth mediums. As part of the conversation, it can be helpful to check who else is in the room (who might not be visible to you). Check
if they are happy having others involved in the connection. If they want whānau involved, encourage them to be visible on the screen. Screening can feel more impersonal, particularly if the person is upset. ‘Normal’ actions such as passing
a tissue or putting a hand on their arm aren’t possible. Facial expression, tone of voice, and body positioning can still show empathy and concern.
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Within the context of screening, it is important to create the space where the person with stroke has choice and control over how screening occurs. One example of this is that people should have choice over who is there when screening occurs. Many will want whānau to be present and this should be supported [13]. If whānau cannot be physically present, technology may be useful in enabling whānau to provide support.
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Ensure the person has their assistive devices present, e.g., hearing aids, glasses, microphone and/or communication prompts (see section below on supporting people with cognitive and communication impairments). Where speech and/or language impairments exist, assessments could be carried out in conjunction with the speech-language therapist.
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When someone is from a different linguistic background screening must be conducted in the person’s primary language with the support of an interpreter. If a person was multi-lingual pre-stroke and is experiencing aphasia, this may impact each language differently. The speech-language therapist will be able to provide advice about screening. It
is not appropriate to use whānau as interpreters. However, whānau can provide valuable collateral information to help understand the person’s usual mood, their observations of changes in mood and well-being post-stroke, and insight into cultural understandings of illness and of well-being.
Mood screens should be interpreted with caution and guided by clinical judgement. Several symptoms included in mood screens are not specific to mood disorders – they are also common following a stroke and other medical conditions. For example, reduced energy, sleep, appetite and concentration may be symptoms of the stroke itself, or they may be a sign of a mood disorder. Furthermore, people with cognitive or communication difficulties may provide less reliable responses – for example if they have difficulty remembering or monitoring their symptoms, or understanding and expressing how they feel. Take care to use the most appropriate mood screen, identify the best timing of screening, and use clinical judgement to interpret results.
Introducing the screening process
Before screening, explain why screening is happening. Mood and well-being screens are more reliable and therapeutic when clients understand the rationale and feel they can trust their clinicians.
A possible script is: “As you know, a medical event like a stroke can impact not only our brain and body, but also our sense of self and our confidence. As well as monitoring how your body is adjusting to the stroke, we find it helpful to check how you are adjusting to your stroke to make sure we are supporting you as best we can. I would like to ask some questions about how you have been feeling lately – is this ok? Do you have any questions before we start?”
It is helpful to talk about how screening and supporting psychosocial well-being can support people’s goals and priorities.
Example of screening approaches
Te Whatu Ora Counties Manukau’s Community Rehabilitation Service uses multiple approaches to screening and supporting well-being that is embedded within car processes.
Early Discharge and Rehabilitation Service (EDARS) at Te Whatu Ora Waitematā screens well-being at multiple points during a person’s six week rehabilitation programme, requiring information on the referral form, and holistic screening by alied health and nurses.
Te Whatu Ora Southern’s community rehabilitation service, REACH embed psychosocial screening in their initial interdisciplinary screening form.
Recommended screening tools
All screening tools have pros and cons. The following mood screens are recommended because they have been validated for people following a stroke, are relatively easy and quick to use, are familiar to providers and GPs within the NZ health system, and they are freely available.
For people without a significant cognitive or communication difficulty
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Can be administered as a single page form to provide a measure of both depressive (PHQ-9) and anxiety (GAD-7) symptoms. In addition to providing a checklist of mood symptoms, the total score can provide a general indication of the severity of these symptoms, from normal to mild, moderate and severe.
PHQ-9 : Patient health screening tool for depression symptoms with 9 questions, addressing the symptom criteria for major depression, including 1 question about suicidal ideation. View PHQ-9 here
GAD-7 : Generalised anxiety screening tool for anxiety symptoms with 7 questions relating to anxiety disorders and panic. View GAD-7 here
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An alternative to the above. Users may be required to pay for it. It provides a measure of both depressive and anxiety symptoms, is validated for people with stroke, and is less confounded by somatic symptoms than the PHQ-9 and GAD-7.
For people with communication difficulties
People with aphasia have higher rates of anxiety and depression post-stroke. Screening processes need to be modified to ensure people can fully participate. Some measures have been developed for people who experience cognitive and communication issues, although some people will be able to complete the PHQ-9 and GAD-7 if supported conversation strategies are used (see below). The speech-language therapist plays an important role in decision-making about how screening should occur.
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The Stroke Aphasic Depression Questionnaire (SADQ-10) is a tool for screening for depression in people with cognitive and/or communication issues after stroke. There is a hospital version and a community version. It is an observational screening, completed by a carer or someone close to the person with stroke.
The Depression Intensity Severity Circles (DISCs) can be a useful tool for people with more severe aphasia or cognitive impairments. The DISCs is a pictoral scale rating the intensity of depression from the perspective of the person with stroke. It does not provide information on different depressive symptoms but can provide a simple screen for monitoring severity of their self-reported mood state.
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The Behavioural Observation of Anxiety (BOA) is a rating scale completed by a significant other, rating for symptoms of anxiety and may be useful when someone has significant aphasia.
Strategies for supported conversations
Simplify the language you use
Use short sentences and pause in between so people have time to process what you are saying.
Supplement your question with visual supports: write key words and use gesture to convey meaning
Write down possible responses (or use pictures) so the person can give their response by pointing. Having some laminated response sheets with possible answers may be helpful.
Ensure the environment supports communication: quiet with no distractions, good lighting, each person is able to see the other.
Example of validated screening tools in integrated stroke care.
Taiao Ora, the integrated stroke service at Te Toka Tumai completes the PHQ-9 and GAD-7 with every patient, and uses the SADQ-10 or DISCs for people with significant communication issues.
Screening for psychological risks
It is important to note:
Suicide risk will not be increased by a professional asking about the possibility of suicide.
Suicide attempts are twice as likely for those with a stroke and are highest in the first 2-5 years post-stroke.
Suicide risk factors post-stroke include younger age, post-stroke depression, previous mood disorder or self-harm, higher stroke severity, cognitive impairment, persistent and poorly controlled pain, substance use or withdrawal, and lower education or income [17].
Distress and thoughts of death & suicide are common as people process the reality of their stroke and consider how to resolve challenging situations. They may think or openly talk of death or suicide: ‘I’d rather be dead’, ‘I should’ve died’, ‘I’ve had enough’, ‘there’s no point’.
The risk of self-harm is on a continuum from low risk to imminent risk. Many people will have passive and fleeting thoughts post-stroke such as ‘I can’t cope’ and ‘I wouldn’t mind if I didn’t wake up’. Others can develop more serious considerations of self-harm – with active intent and plan of self-harm. Self-harm attempts
can occur with preparation (e.g. stockpiling medications) but can also occur impulsively during a time of distress or helplessness.
Teams should have contact information for local mental health and crisis teams easily available, both for consultation and to provide to clients and their whānau.
If a clinician is worried about someone’s safety, they must inform the appropriate clinicians involved in the person’s care even if the person requests that they do not do this. This process should be discussed in a transparent and supportive manner. Information that is shared to others should be only on a ‘need-to-know’ basis, unless permission is given from the person.
It is important to note: Suicide risk will not be increased by a professional asking about the possibility of suicide.
Healthcare professionals should:
Be aware of self-harm risk factors
Take expressions of self-harm seriously
Be familiar with simple risk questions
Follow protocol on managing self-harm
Ensure clear communication with team and senior/expert clinicians
How and when to ask about suicide
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It sounds like you are feeling really down. Have you been having thoughts of death or dying? Have you been thinking of ending your life?
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This has been a really tough time. It sounds like you have been really upset.
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Have you had thoughts about what you might do to hurt yourself?
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How likely do you think it is that you would go through with it today / this week? What would stop you from doing it?
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I may need to let our doctor / psychologist / senior staff / whānau know what we have been talking about. Anything else you think would be helpful?
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Inform senior team member to develop support plan.
A decision about risk and risk management needs to be made by someone with expertise.
Document concerns and plan in notes.
If immediate risk concerns, consider:
Ensure safe environment and remove means of self-harm
Contact psychology/psychiatry or mental health crisis line
Observation and monitoring of self-harm expressions or behaviours, agitation, depressed mood, anxiety, and refusal of drink, food, cares or socialising.
Informing whānau or carers and discuss support plan
Screening tools for Māori
The screening tools mentioned are all based on Western constructs of well-being and many are focused on symptoms and diagnoses. A number of Māori measures have been developed which are informed by Māori models of health and well- being, and which are commonly strengths-based. It might be appropriate to discuss screening approaches with the Māori health team, or other Māori advisors to determine what is appropriate for your service .
These tools include:
Hua Oranga. Hua Oranga is based on Te Whare Tapu Whā. It asks about the different domains of well-being (tinana, wairua, whānau, hinengaro) and has tools to support action planning after completing the measure.
Te Waka Kuaka explores the cultural needs of whānau experiencing brain impairment. Whilst it has been developed for people with traumatic brain injury, it is relevant for whānau impacted by stroke. Te Waka Kuaka has been developed alongside Te Waka Oranga which is a tool for whānau and health workers to share knowledge and priorities, and develop shared purpose and plans that see them work in partnership on the person’s recovery journey.
Screening for broader well-being
Conversations about holistic well-being
Having conversations with patients and whānau about the wider domains of well-being may help normalise the psychosocial impacts for people and may help identify issues earlier. This means support can be offered in a timely manner. This section touches on four areas that people identify as important in well-being: adjustment, relationships, hope, and identity. The questions suggested here are not intended to be asked as part of a formal screening process. Instead, they may be interwoven into conversation at different times throughout care.
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The process of adjustment is on-going after stroke as people make sense of what has happened, as they continue to experience changes in themselves, and as they engage in different activities. It does not have a specific endpoint.
Through conversation, providers might explore how people are adjusting to the stroke – their journey so far, the emotional impacts of stroke, challenges they are having, and what might help them in their post-stroke journey. This may help explore people’s insight and adjustment and help you identify areas where further support is beneficial. It is also invaluable to provide reassurance about adjustment being an on-going process where people might feel a mix of emotions – some positive and some negative.
Questions include:
How have things changed for you since you had your stroke (think: emotions, roles, identity, relationships, roles)? How do you feel about those changes?
How do you feel you’re adjusting to what’s happened?
Is there anything we can do to help you as you adjust to a new life after stroke?
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Having a sense of connection with others and a feeling of belonging within their social networks is important in well-being. Relationships often change after the stroke; this is particularly common when the person has a communication impairment.
Through conversation, providers might explore if different relationships (with whānau, with friends) have been impacted by the stroke, and if so, how. This may help identify how services can support relationships, through involving friends and whānau, providing information to friends and whānau, and working on areas important to sustaining relationships (e.g. communication, hobbies).
Questions include:
How has your relationship been affected by the stroke? What is most important to your relationship?
Has the stroke impacted on your intimacy or sexual relationship?
Who else do you enjoy spending time with?
Do you have some relationships that have improved since the stroke? Are there some relationships that you worry might be lost, or negatively impacted by the stroke?
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The sense of well-being is enhanced when people feel hope and have a positive view of what their future may look like. Low hope can come from multiple areas including low mood, a sense of loss, changes in identity, and a loss of confidence in themselves and in the future. Hope can be built through re-establishing a view of a possible and desired future, positive relationships, and a sense of progress toward things that matter [19]. Processes such as goal-setting can help but it best supports hope when clinicians acknowledge people's hopes and connect short- term goals to people's broader aspirations. This also supports engagement [20].
Through conversation, providers might explore people’s sense of hope for the future, what they hope for, and what they would like life to look like. Try not to focus just on what people hope for (specific hopes) but also explore people’s broader sense of hope for the future [21]. Through this, providers might identify areas where rehabilitation can support hope and well-being, or where other supports might be useful.
Questions include:
What is most important to you right now? Do you feel hopeful about the future? Why is this?
When you think of yourself in (specified amount of time), what would you hope to be doing? What do you hope to be like? What might help build your hope for the future?
What might help you feel more confident that the things will be okay in the future?
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People’s identities are ever-changing, but these changes can be particularly disruptive or unwelcome after a stroke. Many strands of what makes a person who they are are disrupted – a loss of roles or activities, a sense of disconnection to their body or to their pre-stroke self, a loss of connection to others. A loss of identity is particularly common for people with aphasia. One Māori stroke patient described stroke as impacting on their “’whole āhua’... one’s presence, being or identity.”. For many Māori, their cultural identity is crucial in supporting well-being – through reo, whānau and communities – and this needs to be acknowledged and supported. It is important for services to respond to who the person is and tailor rehabilitation to their personalities, interests and their identity, acknowledging their personhood and mana in interactions and care, and seek to build people’s confidence and sense of self. Supporting people to engage with others, and in activities that support their identity, is important.
Through conversation, providers might explore what helps people’s sense of self. This might be through questions around what they enjoy doing, what makes them ‘them’, where they feel most contented and have a sense of belonging. It is important to delve beneath simply what people do and explore why they do it and why they enjoy it. It is also important to not assume that someone’s pre-stroke identity is their desired identity. Following stroke, many work through a process of adaptation and change, and their identity is ever-evolving. Exploring what matters, what brings meaning and purpose, and what they want to be and be doing in the future is important.
Questions include:
Tell me about yourself. How would people who knew you before the stroke describe you? What are the things you enjoy doing?
Tell me about the situations where you feel you are most able to ‘be yourself’? Why is this? Is there anything about you that you would like to change?
If you think of yourself in six months time, what do you want to be like?
What helps you feel good?
Validated screens for holistic well-being
The measures above have been used extensively to screen for mood disorders in people with stroke. However, broader measures of quality of life can provide understandings into other areas of well-being that are commonly impacted by stroke.
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Stroke Impact Scale is a holistic self-report tool of multi-dimensional stroke outcomes, including physical, communicative and cognitive function, mood and role functions. It also asks people to rate their recovery from stroke.
Stroke Specific Quality of Life Scale is a patient-centred outcome measure intended to provide an assessment of health-related quality of life for people with stroke. Like the Stroke Impact Scale, it is a multi-dimensional measure of stroke impacts across physical and cognitive function, communication, mood, personality, roles, and self-care.
The Stroke and Aphasia Quality of Life Scale (SAQOL-39) has been developed specifically for people with aphasia . This is based on the Stroke Specific Quality of Life but has been adapted to make it easier for people with aphasia to understand and provide their answers using a range of communicative modalities.
The Warwick-Edinburgh Mental Well-being Scale is not a stroke specific scale but provides insights into positive mental health.
Communication following psychosocial screening
After screening, findings need to be discussed with the person with stroke, their whānau (if appropriate and consenting), and with other members in the team.
Communicate with the person with stroke, whānau and team
It is important to share your observations and screening results with both the person and those involved in the persons’ care. Consider their confidentiality: only share information that is relevant to their care and goals.
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Summarise simply: e.g., “It sounds like you have been feeling really down recently and you feel this is impacting on your daily life and relationships.”
Empathise: “This must be hard for you”
Normalise: “Adjusting to this change in life and building our confidence and sense of self can take time. It is common to feel up and down after a stroke”.
Educate and provide hope:
“We know our mindset is important when recovering from a stroke. When we feel down or anxious, this can impact on our energy and motivation, our enjoyment of life and our relationships. It can also start to impact on our rehabilitation and recovery. It can even impact on our symptoms, because our brain focusses more on what is not working – pain, discomforts, weakness, speech difficulties etc. Have you noticed this?”
“There are things that you and we can do to help. If ok with you I want to check in regularly with you (and whānau) about this. In the meantime, is there anything you think would help?
Check with whānau: Any concerns or recommendations for the client’s well-being (if relevant and client consenting).
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Document: Place copy of mood screen in notes; make brief comment in notes to inform team that screen is completed and general results. e.g:
Mood screens PHQ-9 and GAD-7 completed: Scores fell in normal range for depressive symptoms but severe range for anxiety symptoms. Reports not sleeping well and particularly worried about stress on partner. Plan: Discuss in IDT meeting today and develop shared goals for addressing stress and sleep.
Team meetings (MDT meetings, Rapid Round meetings, Nursing handovers).
Provide brief update on screening and check other providers’ perspectives. Team can reflect on any concerns with motivation, engagement, safety, sleep, appetite etc.
Team can also discuss any strengths or positives so that all of the team can build on these (e.g., James really appreciates having a plan on his calendar for the day and an afternoon siesta and seems happiest when friends drop in).
Discuss action plan (see next section).
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Creating an environment that supports well-being
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Development of psychosocial pathways in stroke services
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Psychosocial screening
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Action plans to support well-being
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Whānau well-being