Transitional Care Program to Improve Risk Factors in Stroke Survivors

Inclusion Criteria:

All Cohorts:

• Age 30 or above

• Evidence of ischemic stroke documented on CT or MRI

• Modified Rankin score of 3 or less

Early Enrollment:

• Admission for ischemic stroke at a participating site

• Enrolled during their admission for ischemic stroke or within 24 hours of discharge

Late Enrollment:

• Stroke survivors previously admitted at the participating sites' inpatient strokeunit

• Enrollment date between 1 and 6 months after discharge for inpatient admission forischemic stroke

Exclusion Criteria:

• Participants determined to have hemorrhagic or periprocedural stroke based onhospital EMR review will be excluded.

• Participants determined to have an ischemic stroke due to dissection based onhospital EMR review will be excluded.

• Participants who lack capacity determined by the care team during theirhospitalization (for the early enrollment group) or their most recent clinicalencounter (for the late enrollment group) will be excluded

• Participants with a diagnosis of dementia will be excluded.

• Participants who cannot perform the following will be excluded:

1. offer a consistent choice about participating in the study

2. demonstrate that they can comprehend and recall major features of the studyincluding: participation is voluntary, the major procedures, the primary risk,and the primary benefit.

• Participants who are discharged to Long-term Acute Care Hospitals or Skilled NursingFacilities because they are unable to meet the minimum threshold for dailyrehabilitation therapy for an Acute Rehabilitation Facility will be excluded.

• Participants who are unable to read or communicate fluently in English will beexcluded.

• Participants who do not have reliable internet access to complete telemedicinevisits per self-report will be excluded.