Evaluating the Effect of Nurse-Led Stroke Transitional Care in Tanzania

Inclusion criteria * Clinical nurses and physicians with six months of working experience in stroke care * Clinical nurses and physicians with a minimum of diploma in their professions. * Stroke survivors with 18 years old and above * Stroke survivors admitted in the stroke units * Stroke survivors with primary diagnosis of stroke confirmed by brain CT/MRI * Stroke survivors who undergo usual discharge process * Stroke survivors who live with their family caregivers * Stroke survivors who have mobile phones * Stroke survivors who can read and write * Stroke survivors who are able to communicate * Stroke survivors with National Institutes of Health Stroke Scale (NIHSS) \< 6 * Stroke survivors with Modified Barthel Index (MBI) \> 9 * Stroke survivors with Modified Rankin Scale (mRS) \< 5 * Stroke survivors with Montreal Cognitive Assessment Test (MoCA) \> 14 * Stroke survivors who are expected to stay in the ward for 3-5 days, * Stroke survivors who are expected to survive for 3 months * Family caregivers with mobile phones * Family caregivers who can read and write * Family caregivers who are able to communicate * Family caregivers who live with the patient after stroke Exclusion criteria * Healthcare providers who will be on leave during the study period. * Stroke survivors with previous stroke who are not admitted in stroke units * Stroke survivors who are discharged against medical advice * Stroke survivors who have end-stage organ failure * Stroke survivors who have family caregivers * Stroke survivors who can't read/write * Stroke survivors who have no mobile phones. * Family caregivers without mobile phone that is accessible