Table 1 MISTT Study Patient and Caregiver Inclusion and Exclusion Criteria

i) A final confirmed hospital diagnosis of acute stroke (ischemic or hemorrhagic).

ii) Patient living at home pre-stroke.

iii) Presence of stroke-related deficits at admission (defined as a National Institute of Health Stroke Severity score of > = 1).

iv) Presence of functional limitations at discharge (defined as a modified Rankin score [mRS] score of > = 1 or therapy ordered).

v) Discharged directly home (includes patient’s residence or that of a family member), or discharged to a rehabilitation facility with the expectation of return to home within 4 weeks

i) Any person identified by the stroke patient as the primary caregiver (individual has primary responsibility for assisting with the patient’s care).

ii) Age 18 or over.

i) Patients who live more than 50 miles from the hospital (for reasons related to the home visits).

ii) Patients discharged to hospice care, nursing home for long term care, or long term care hospital (LTCH).

iii) Patients who have clinically documented cognitive deficits or stroke-related impairments including aphasia sufficient to impact the consent process and for whom a proxy respondent is not available.

iv) Patients who fail the 6-item Cognitive Screen for cognitive function (score < =4) and for whom a proxy respondent is not available.

v) Patients enrolled in another acute stroke intervention trial that has a significant impact on the post-acute period (i.e., intensive data collection required of patient during follow-up).

vi) Limited life expectancy (< 6 months) or significant medical comorbidity likely to impact completion of the study (e.g., severe mental illness, drug or alcohol abuse, metastatic cancer).

i. Does not speak English.

i) Does not speak English.