Clinical Research Directory

Inclusion Criteria: * Hospital admission with primary ICD-10 discharge diagnosis of Acute Ischemic Stroke (AIS) or Intracerebral Hemorrhage (ICH) o those being referred from the community settings must be within 60 days of post-acute discharge. * Post-stroke functional deficits warranting PASUC rehabilitation * Clinically stable and appropriate for discharge per acute care facility * Completion of a rehabilitation evaluation within the acute setting * Planned discharge to home (with or without Home Health (HH)/Outpatient Rehabilitation (OPR), Inpatient Rehabilitation Facility (IRF), or Skilled Nursing Facility (SNF) * Ability to speak and read English or Spanish * Ability to provide informed consent (patient or LAR) o If LAR is consenting, patient must be able to follow simple commands * Access to a video-capable device and internet Exclusion Criteria: * Clinically unstable medical condition * Poorly controlled severe mental illness * Planned discharge to a long-term care facility (LTACH) * Inability to complete follow-up (psychiatric hospitalization, hospice, incarceration, homelessness) * Discharge against medical advice * Significant language impairment (NIHSS Commands \>1 or Best Language \>2)- Cognitive impairment (Six-Item, PROMIS) -Severe depression (PHQ-8 \>20 or psychiatric hospitalization previous 30 days)- Pre-stroke mRS \>3 * Other neurological or musculoskeletal conditions substantially limiting participation o Patients excluded for one of these criteria may be reassessed at 60-days to see if improvement has occurred.