Table 3 Domains assessed in post-discharge follow-up after stroke
Post-Discharge Follow-Up Call | |
 • Medication reconciliation | • Home Health/Outpatient Services |
 • New/Worsening Symptoms | • Caregiver Assistance |
 • Falls | • PCP follow-up Appointment |
 • Transportation | • Stroke Clinic Follow-up appointment |
Clinic Visit Post-Stroke Functional Assessment | |
 • Medication Management | • Spasticity |
 • Financials to Medication Management | • Social Support |
 • Cognition | • Physical Mobility & Safety |
 • Depression | • General Health |
 • Health Literacy | • Upper Extremity |
 • Access to PCP | • Transportation |
 • ED/Hospital Readmissions | • General health |
 • Status of Advance Directive | • Falls |
 • Stress | • ADL/IADL |
Clinic Visit Caregiver Assessment | |
 • Caregiver Assistance | • Caregiver Stress |
 • Caregiver Health |  |
Clinic Visit Advance Practice Provider Assessment | |
 • Lifestyle Management (alcohol, smoking, drugs, | • Risk factor management (blood pressure, LDL, INR, HgA1c) |
 • Modified Rankin Scale | • Depression |
 • Cognition | • Communication |
 • Physical activity |  |