Michigan Stroke Transitions Trial

"One intervention (SCM) is provided. Stroke Case Managers (SCMs) will conduct 2 home visits; the first within 72-96 hours and the other after 30-days of returning home. SCMs will conduct weekly follow-up phone calls. Additional home visits are permitted if needed. Home visit activities include:~1. Biopsychosocial assessment of patient and caregiver needs.~2. Set up appointments.~3. Assist scheduling appointments with primary care physician and other medical providers.~4. Promote medication adherence through medication tool kits, pill organizers and other aids.~5. Facilitate patient and caregiver engagement and activation.~6. Facilitate access to social and community services."

"SCM: Stroke Case Managers (SCMs) will conduct home visits at 72-96 hours and after 30-days. SCMs will conduct weekly follow-up phone calls. Additional home visits are permitted as needed. Activities include:~1. Biopsychosocial assessment of patient and caregiver needs.~2. Set up appointments.~3. Assist scheduling appointments with primary care physician and other medical providers.~4. Promote medication adherence through medication tool kits, pill organizers and other aids.~5. Facilitate patient and caregiver engagement and activation.~6. Facilitate access to social and community services.~VSSP: Access and training on the Virtual Stroke Support Portal, an online information and support website which includes:~1. Contact list of care team members.~2. Access to hospital patient portal.~3. Stroke education materials, resources, and guidelines.~4. Access to Michigan 2-1-1 services.~5. Medication information and adherence tools.~6. Patient and Caregiver support networks."