A Novel Transition Program to Reduce Disability After Stroke

A gap in care exists at the point of transition from inpatient rehabilitation (IR) to home,
when survivors encounter new environmental barriers due to the cognitive and sensorimotor
sequelae of stroke. Resolving these barriers and improving independence in the community have
potential to significantly improve stroke survivors' long-term morbidity. The proposed study
investigates the efficacy and safety of a novel enhanced rehabilitation-transition program to
reduce environmental barriers and improve daily activity performance and community
participation.

Inclusion Criteria:

- aged ≥50 years

- acute ischemic or hemorrhagic stroke diagnosis

- independent ADLs prior to stroke (premorbid Modified Rankin Scale Score ≤2)

- plan to discharge to home

Exclusion Criteria:

- severe terminal systemic disease that limits life expectancy to < 6 months

- previous disorder (e.g. dementia) that makes interpretation of the self-rated scales
difficult or SBT score of 10 or less (indicating significant cognitive impairment)

- moderate to severe Aphasia as determined by the NIHSS Best Language rating of 2 or
more

- reside in congregate living facility.