SDOH-Homecare Intervention Focus Team (SHIFT) Trial to Improve Stroke Outcomes

Inclusion Criteria

• •Ischemic stroke (arterial subtypes) or primary intracerebral hemorrhage (excluding diagnosis of probable cerebral amyloid angiopathy by Boston Criteria)
• •African American/Black or Hispanic race-ethnicity
• •Age 18-75 years old
• •Have at least 3 SDOH barriers from within the 5 SDOH domains (Social and Community, Education, Economic, neighborhood/environment, Health Care)
• •Have a discharge plan to 1) home with or without home services, or 2) acute rehabilitation with plan to return home after
• •Pre-stroke Modified Rankin Scale score of ≤3
• •Residence in New York City.
• •English or Spanish speaking.
• •Can provide informed consent and engage in the initial assessment prior to stroke discharge
• •Lives in a household with a telephone, and has a caregiver (family member or Home Health Aide) if not fully independent on discharge. If the patient requires a family member to assist with activities of daily living or decision-making, the family member must state a willingness to be present at home visits where their assistance is needed.