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| ID | Type | Description | Link |
|---|---|---|---|
| HIS-1310-07420-01 | Other Grant/Funding Number | Patient-Centered Outcomes Research Institute (PCORI) |
Not provided
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Not provided
Not provided
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| Name | Class |
|---|---|
| University of Michigan | OTHER |
| Trinity Health Michigan | OTHER |
| Sparrow Health System | OTHER |
| Massachusetts General Hospital |
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The Michigan Stroke Transitions Trial (MISTT) is a patient-centered randomized control trial that aims to improve the experience of stroke patients after they return home. The MISTT study will test the effect of two complementary interventions against usual care. The two interventions include: a) Stroke Case Managers (SCMs) who are trained social workers, and b) an online informational website or portal. The 12 week intervention period begins when the stroke patient returns home from the hospital or rehab facility. The SCMs will conduct at least 2 home visits with the patient (one within 3-4 days and one around 30 days) along with weekly follow-up telephone calls. Supplemental home visits will be used as necessary over the 12 week period. At the first home visit the social workers will conduct a comprehensive in-home assessment and link patients and caregivers to local resources as necessary. Patients also assigned to the website will have access to a patient-centered online information and support resource called the Virtual Stroke Support Portal (VSSP). The investigators hypothesize that this personalized case management program will reduce patient and caregiver needs, improve quality of life, and decrease caregiver stress. The MISTT study will enroll 315 acute stroke patients discharged from 3 Michigan hospitals and will be completed by the end of 2017.
To improve care transitions for acute stroke patients this pragmatic, community-based, randomized, open clinical trial will test the efficacy of two separate but complementary interventions against usual care. The parallel group design will compare the following 3 groups:
This patient-level randomized trial will be conducted at 3 Michigan hospitals and will enroll a total of 315 acute stroke patients (105 per intervention group). Each hospital will enroll cases over an 18 month period. Randomization will be balanced within each hospital to ensure that an equal number of patients are assigned to the 3 groups. If the patient identifies a primary caregivers they will be contacted and enrollment accordingly.
The trial interventions begin once the patient returns home (= Day 1) and end 3 months later (= Day 90). Outcomes data will be collected by telephone at baseline (= Day 7) and at Day 90. Subjects who are enrolled but do not go home within 1 month (because they remain in a rehabilitation or Skilled Nursing Facility) will be dropped and replaced by new patients. Two primary patient-level outcome measures include the Patient Activation Measure (PAM), a measure of self-efficacy, and the PROMIS-10, a global quality of life scale. Two primary caregiver-level outcome measures include the Bakas Caregiving Outcomes Scale (BCOS) and depression (PHQ-9).
By adhering to the principles of pragmatic trials, this trial is designed to inform typical U.S. clinical practice, with outcomes that are directly relevant to patients and caregivers. Specifically, this trial is designed to answer the practical question of whether the transitional care experience of stroke patients and caregivers can be improved by social workers who visit the home, and whether their effectiveness can be enhanced by a comprehensive patient-centered online resource.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Usual Care | No Intervention | Patients in this group will receive the hospitals' usual transitional care approach. | |
| SCM | Experimental | One intervention is provided: 1. SCM (Stroke Case manager): a trained social worker who provides in-home case management services. |
|
| SCM and VSSP | Experimental | Two interventions are provided:
|
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| SCM | Other | 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:
|
| Measure | Description | Time Frame |
|---|---|---|
| Change From Baseline (7-days Post Discharge) to 90-days in the PROMIS-10 Global Quality of Life, Physical Health T-scores (Patient) | Patient-centered questionnaire of 10 self-reported items addressing the 2 main quality-of-life domains of physical and mental health which include physical health, physical function, pain, fatigue, quality of life, mental health, satisfaction with social activities, and emotional problems. PROMIS Global-10 Physical Health Quality-of-Life is a 4-item subscale measuring general aspects of physical health using a five-point Likert scale with higher scores reflecting better quality-of-life. Raw scores are summed and converted to a T-score which has a population mean score of 50 with standard deviation of 10; higher scores indicate better QOL (0-100). | 7 days and 90 days post discharge |
| Change From Baseline (7-days Post Discharge) to 90-days in the PROMIS-10 Global Quality of Life, Mental Health T-scores (Patient) | Patient-centered questionnaire of 10 self-reported items addressing the 2 main quality-of-life domains of physical and mental health which include physical health, physical function, pain, fatigue, quality of life, mental health, satisfaction with social activities, and emotional problems. PROMIS Global-10 Mental Health Quality-of-Life is a 4-item subscale measuring general aspects of physical health using a five-point Likert scale with higher scores reflecting better quality-of-life. Raw scores are summed and converted to a T-score which has a population mean score of 50 with standard deviation of 10; higher scores indicate better QOL (0-100). | 7 days and 90 days post discharge |
| Change From Baseline (7-days Post Discharge) to 90-days in the Bakas Caregiving Outcomes Scale Scores (Caregiver) | Instrument designed to measure perceived caregiver life changes in response to providing care to stroke survivors. Bakas is a 15-item measure using a rating scale with 7 points ranging from -3 (changed for the worse) to +3 (changed for the best); responses are converted to a 1-7 scale and summed (range 15-105). Higher scores indicate more positive changes resulting from caregiving experience whereas lower scores indicate negative changes. | 7 days and 90 days post discharge |
| Measure | Description | Time Frame |
|---|---|---|
| Change From Baseline (7-days Post Discharge) to 90-days in the Patient Activation Measure Scores (Patient) | Patient questionnaire to assess knowledge, skills, and self-efficacy for managing one's own healthcare. Patient Activation Measure is a 13-item survey using a five-point Likert scale (strongly disagree, disagree, agree, strongly agree, NA) whose response items are summed and converted to an activation score ranging from 0-100. Higher scores indicate a higher level of activation. |
| Measure | Description | Time Frame |
|---|---|---|
| NeuroQOL Anxiety Scale (Patient) | Validated QOL scale measuring patient anxiety (administered by computer adaptive testing). | 90 day post discharge |
| Depression Symptoms (PHQ-9) (Patient) | Validated 9-item questionnaire to identify depressive symptoms. |
Patient Inclusion Criteria:
Patient Exclusion Criteria:
Caregiver Inclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Mathew J Reeves, BVSc, PhD | Professor, Department of Epidemiology and Biostatistics, College of Human Medicine | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University of Michigan | Ann Arbor | Michigan | 48109 | United States | ||
| Sparrow Health System |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 28623892 | Background | Reeves MJ, Hughes AK, Woodward AT, Freddolino PP, Coursaris CK, Swierenga SJ, Schwamm LH, Fritz MC. Improving transitions in acute stroke patients discharged to home: the Michigan stroke transitions trial (MISTT) protocol. BMC Neurol. 2017 Jun 17;17(1):115. doi: 10.1186/s12883-017-0895-1. | |
| 31296043 | Derived |
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Of 320 enrolled patients, 55 were excluded prior to randomization due to extended rehab stays lasting >4 weeks (n=36), health reasons preventing participation (n=7), and other reasons that contributed to ineligibility (n=12).
Of 210 enrolled caregivers, 41 were excluded prior to randomization due to exclusion of their patient.
Patients and their caregivers were recruited from three mid-Michigan hospital stroke units. MISTT recruitment started in January 2016 and concluded in July 2017.
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| ID | Title | Description |
|---|---|---|
| FG000 | Usual Care | Patients in this group will receive the hospitals' usual transitional care approach along with mailings of stroke and health-related brochures to help promote study retention. |
| FG001 | SWSCM | One intervention is provided: 1. SWSCM (Social Work Case Management) program: a trained social worker provides in-home case management services. SWSCM: Stroke Case Managers (SWSCMs) will conduct 2 home visits; one within 72-96 hours and another after 30-days of returning home. SWSCMs will conduct weekly follow-up phone calls. Additional home visits are permitted as needed. Home visit activities include:
|
| FG002 | SWSCM and VSSP Website | Two interventions are provided:
SWSCM and VSSP: SWSCM activities as described in the SWSCM group. VSSP website: Access and training on the Virtual Stroke Support Portal, an online information and support website which includes:
|
| Title | Milestones | Reasons Not Completed | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
|
Not provided
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| ID | Title | Description |
|---|---|---|
| BG000 | Usual Care | Patients in this group will receive the hospitals' usual transitional care approach along with mailings of stroke and health-related brochures to help promote study retention. |
| BG001 | SWSCM |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Change From Baseline (7-days Post Discharge) to 90-days in the PROMIS-10 Global Quality of Life, Physical Health T-scores (Patient) | Patient-centered questionnaire of 10 self-reported items addressing the 2 main quality-of-life domains of physical and mental health which include physical health, physical function, pain, fatigue, quality of life, mental health, satisfaction with social activities, and emotional problems. PROMIS Global-10 Physical Health Quality-of-Life is a 4-item subscale measuring general aspects of physical health using a five-point Likert scale with higher scores reflecting better quality-of-life. Raw scores are summed and converted to a T-score which has a population mean score of 50 with standard deviation of 10; higher scores indicate better QOL (0-100). | Number of observations used in the analysis are larger than indicated above since both available 7-day and 90-day values were utilized (n=434) | Posted | Least Squares Mean | Standard Error | change in T-score | 7 days and 90 days post discharge |
|
90-day study participation period
Serious Adverse Event: reported if admitted to Hospice Care or a Nursing Home/Long-term Care Facility Other Adverse Event: not collected
NOTE: hospital readmissions were collected as a secondary outcome measure and were not included in the Adverse Event reporting.
Not provided
| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Usual Care | Patients in this group will receive the hospitals' usual transitional care approach along with mailings of stroke and health-related brochures to help promote study retention. |
| Term | Organ System | Source Vocabulary | Assessment Type | Notes | Statistical Information |
|---|---|---|---|---|---|
| Admitted to Nursing Home or Long-term Care Facility | General disorders | Non-systematic Assessment | Admitted to nursing home or long-term care facility |
Not provided
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. Mathew Reeves | Michigan State University | 517-353-8623 | reevesm@msu.edu |
Not provided
| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot | Yes | No | No | Study Protocol | Aug 19, 2016 | Jul 9, 2019 | Prot_000.pdf |
| SAP | No | Yes | No | Statistical Analysis Plan | Jun 17, 2019 | Jul 9, 2019 | SAP_001.pdf |
Not provided
| ID | Term |
|---|---|
| D020521 | Stroke |
| D010358 | Patient Participation |
| ID | Term |
|---|---|
| D002561 | Cerebrovascular Disorders |
| D001927 | Brain Diseases |
| D002493 | Central Nervous System Diseases |
| D009422 | Nervous System Diseases |
Not provided
Not provided
| ID | Term |
|---|---|
| D000198 | Spectinomycin |
| ID | Term |
|---|---|
| D004146 | Dioxanes |
| D006573 | Heterocyclic Compounds, 1-Ring |
| D006571 | Heterocyclic Compounds |
| D006575 | Heterocyclic Compounds, 3-Ring |
Not provided
Not provided
| OTHER |
Not provided
Not provided
Not provided
Not provided
Not provided
|
| SCM and VSSP | Other | 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:
VSSP: Access and training on the Virtual Stroke Support Portal, an online information and support website which includes:
|
|
| 7 days and 90 days post discharge |
| Change From Baseline (7-days Post Discharge) to 90-days in Depression Symptoms (PHQ-9) (Caregiver) | The Patient Health Questionnaire (PHQ-9) measures severity of depression symptoms. PHQ-9 is a 9-item measure using a four-point Likert scale (not at all, several days, more than half the days, nearly every day). Response items are summed (range 0-27) with higher scores indicating the respondent is experiencing more symptoms of depression. | 7 days and 90 days post discharge |
| 90 day post discharge |
| Hospital Readmission (Patient) | Unscheduled hospital admissions | 90 day post discharge |
| Stroke Recurrence (Patient) | New onset acute stroke events requiring hospital admission | 90 day post discharge |
| Home Time (Patient) | Total number of days spent at home since discharge back to home. | 90 day post discharge |
| Oberst Caregiver Burden Scale (OCBS) (Caregiver) | Validated 15-item questionnaire measuring caregiver burden in response to providing care to stroke survivors. | 90 day post discharge |
| Unhealthy Days (Caregiver) | Number of days in the past 30 days that the caregiver reported that their own physical or mental health had not been good. | 90-days post discharge |
| PROMIS Emotional Support Scale (Caregiver). | A validated 4-item questionnaire measuring emotional support. Emotional support is defined as the perceived feeling of being cared for and valued as a person. | 90-days post discharge |
| PROMIS Informational Support Scale (Caregiver). | A validated 4-item questionnaire measuring informational support. Informational support is defined as the perceived availability of helpful information or advice. | 90-days post discharge |
| Lansing |
| Michigan |
| 48912 |
| United States |
| Saint Joseph Mercy Health System | Ypsilanti | Michigan | 48197 | United States |
| Reeves MJ, Fritz MC, Woodward AT, Hughes AK, Coursaris CK, Swierenga SJ, Nasiri M, Freddolino PP. Michigan Stroke Transitions Trial. Circ Cardiovasc Qual Outcomes. 2019 Jul;12(7):e005493. doi: 10.1161/CIRCOUTCOMES.119.005493. Epub 2019 Jul 12. |
| Lost to Follow-up |
|
One intervention is provided:
1. SWSCM (Social Work Case Management) program: a trained social worker provides in-home case management services.
SWSCM program: Stroke Case Managers (SWSCMs) will conduct 2 home visits; one within 72-96 hours and another after 30-days of returning home. SWSCMs will conduct weekly follow-up phone calls. Additional home visits are permitted if as needed.
| BG002 | SWSCM and VSSP Website | Two interventions are provided:
SWSCM and VSSP: SWSCM activities as described in the SWSCM group. VSSP website: Access and training on the Virtual Stroke Support Portal, an online information and support website which includes:
|
| BG003 | Total | Total of all reporting groups |
| years |
|
| Age, Customized | Count of Participants | Participants |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Race/Ethnicity, Customized | Count of Participants | Participants |
|
| Race/Ethnicity, Customized | Count of Participants | Participants |
|
| Recruitment Site | Count of Participants | Participants |
|
| Required Proxy Consent | Proxy consent was required if patients failed the Six-Item Cognitive Screen (score of <=4) or had clinically documented cognitive deficits or stroke-related impairments sufficient to impact the consent process: | Count of Participants | Participants |
|
| Stroke type | Count of Participants | Participants |
|
| Stroke Severity | Stroke severity was documented at admission using the NIH-Stroke Scale (NIHSSS) or Glasgow Coma Scale (GCS). Severity was categorized as mild (NIHSS=1-5 and GCS=13-15), moderate (NIHSS=6-13 and GCS=5-12), or severe (NIHSS=14-42, GCS=3-4). | Count of Participants | Participants |
|
| Modified Rankin Score (mRS) | Modified Rankin Score documented at acute hospital discharge. Scores were categorized into mild (<=2) or moderate/severe (>2). | Count of Participants | Participants |
|
| Days Between Stroke Admission and Discharge to Home | Duration of time from stroke admission until discharge to home. This includes acute hospital length of stay in addition to rehabilitation length of stay, if applicable. | Mean | Standard Deviation | days |
|
| Discharge Destination | Discharge destination immediately following discharge from acute stroke hospitalization. | Count of Participants | Participants |
|
| History of Prior Stroke | Count of Participants | Participants |
|
| History of Prior Transient Ischemic Attack (TIA) | Count of Participants | Participants |
|
| History of Myocardial Infarction | Count of Participants | Participants |
|
| Coronary Artery Disease | Count of Participants | Participants |
|
| Atrial Fibrillation | Count of Participants | Participants |
|
| Diabetes | Count of Participants | Participants |
|
| Hypertension | Count of Participants | Participants |
|
| Hyperlipidemia | Count of Participants | Participants |
|
| Living Alone Pre-Stroke | Count of Participants | Participants |
|
| Caregiver consented to MISTT | Count of Participants | Participants |
|
| Relationship to Consented Caregiver | Count of Participants | Participants |
|
| Living with Consented Caregiver | Count of Participants | Participants |
|
| Usual Care |
Patients in this group will receive the hospitals' usual transitional care approach along with mailings of stroke and health-related brochures to help promote study retention. |
| OG001 | SWSCM | One intervention is provided: 1. SWSCM (Social Work Case Management) program: a trained social worker provides in-home case management services. SWSCM: Stroke Case Managers (SWSCMs) will conduct 2 home visits; one within 72-96 hours and another after 30-days of returning home. SWSCMs will conduct weekly follow-up phone calls. Additional home visits are permitted as needed. Home visit activities include:
|
| OG002 | SWSCM and VSSP Website | Two interventions are provided:
SWSCM and VSSP: SWSCM activities as described in the SWSCM group. VSSP website: Access and training on the Virtual Stroke Support Portal, an online information and support website which includes:
|
|
|
|
| Primary | Change From Baseline (7-days Post Discharge) to 90-days in the PROMIS-10 Global Quality of Life, Mental Health T-scores (Patient) | Patient-centered questionnaire of 10 self-reported items addressing the 2 main quality-of-life domains of physical and mental health which include physical health, physical function, pain, fatigue, quality of life, mental health, satisfaction with social activities, and emotional problems. PROMIS Global-10 Mental Health Quality-of-Life is a 4-item subscale measuring general aspects of physical health using a five-point Likert scale with higher scores reflecting better quality-of-life. Raw scores are summed and converted to a T-score which has a population mean score of 50 with standard deviation of 10; higher scores indicate better QOL (0-100). | Number of observations used in the analysis are larger than indicated above since all available 7-day and 90-day data were utilized (n=434) | Posted | Least Squares Mean | Standard Error | change in T-score | 7 days and 90 days post discharge |
|
|
|
|
| Primary | Change From Baseline (7-days Post Discharge) to 90-days in the Bakas Caregiving Outcomes Scale Scores (Caregiver) | Instrument designed to measure perceived caregiver life changes in response to providing care to stroke survivors. Bakas is a 15-item measure using a rating scale with 7 points ranging from -3 (changed for the worse) to +3 (changed for the best); responses are converted to a 1-7 scale and summed (range 15-105). Higher scores indicate more positive changes resulting from caregiving experience whereas lower scores indicate negative changes. | Number of observations used in the analysis are larger than indicated above since all available 7-day and 90-day data were utilized (n=263) | Posted | Least Squares Mean | Standard Error | change in score | 7 days and 90 days post discharge |
|
|
|
|
| Secondary | Change From Baseline (7-days Post Discharge) to 90-days in the Patient Activation Measure Scores (Patient) | Patient questionnaire to assess knowledge, skills, and self-efficacy for managing one's own healthcare. Patient Activation Measure is a 13-item survey using a five-point Likert scale (strongly disagree, disagree, agree, strongly agree, NA) whose response items are summed and converted to an activation score ranging from 0-100. Higher scores indicate a higher level of activation. | Number of observations used in the analysis are larger than indicated above since all available 7-day and 90-day data were utilized (n=413) | Posted | Least Squares Mean | Standard Error | change in PAM score | 7 days and 90 days post discharge |
|
|
|
|
| Secondary | Change From Baseline (7-days Post Discharge) to 90-days in Depression Symptoms (PHQ-9) (Caregiver) | The Patient Health Questionnaire (PHQ-9) measures severity of depression symptoms. PHQ-9 is a 9-item measure using a four-point Likert scale (not at all, several days, more than half the days, nearly every day). Response items are summed (range 0-27) with higher scores indicating the respondent is experiencing more symptoms of depression. | Number of observations used in the analysis are larger than indicated above since all available 7-day and 90-day data were utilized (n=265) | Posted | Least Squares Mean | Standard Error | change in PHQ-9 score | 7 days and 90 days post discharge |
|
|
|
|
| Other Pre-specified | NeuroQOL Anxiety Scale (Patient) | Validated QOL scale measuring patient anxiety (administered by computer adaptive testing). | Not Posted | 90 day post discharge | Participants |
| Other Pre-specified | Depression Symptoms (PHQ-9) (Patient) | Validated 9-item questionnaire to identify depressive symptoms. | Not Posted | 90 day post discharge | Participants |
| Other Pre-specified | Hospital Readmission (Patient) | Unscheduled hospital admissions | Not Posted | 90 day post discharge | Participants |
| Other Pre-specified | Stroke Recurrence (Patient) | New onset acute stroke events requiring hospital admission | Not Posted | 90 day post discharge | Participants |
| Other Pre-specified | Home Time (Patient) | Total number of days spent at home since discharge back to home. | Not Posted | 90 day post discharge | Participants |
| Other Pre-specified | Oberst Caregiver Burden Scale (OCBS) (Caregiver) | Validated 15-item questionnaire measuring caregiver burden in response to providing care to stroke survivors. | Not Posted | 90 day post discharge | Participants |
| Other Pre-specified | Unhealthy Days (Caregiver) | Number of days in the past 30 days that the caregiver reported that their own physical or mental health had not been good. | Not Posted | 90-days post discharge | Participants |
| Other Pre-specified | PROMIS Emotional Support Scale (Caregiver). | A validated 4-item questionnaire measuring emotional support. Emotional support is defined as the perceived feeling of being cared for and valued as a person. | Not Posted | 90-days post discharge | Participants |
| Other Pre-specified | PROMIS Informational Support Scale (Caregiver). | A validated 4-item questionnaire measuring informational support. Informational support is defined as the perceived availability of helpful information or advice. | Not Posted | 90-days post discharge | Participants |
| 0 |
| 87 |
| 1 |
| 87 |
| 0 |
| 87 |
| EG001 | SWSCM | One intervention is provided: 1. SWSCM (Social Work Case Management) program: a trained social worker provides in-home case management services. SWSCM: Stroke Case Managers (SWSCMs) will conduct 2 home visits; one within 72-96 hours and another after 30-days of returning home. SWSCMs will conduct weekly follow-up phone calls. Additional home visits are permitted as needed. Home visit activities include:
| 2 | 88 | 2 | 88 | 0 | 88 |
| EG002 | SWSCM and VSSP Website | Two interventions are provided:
SWSCM and VSSP: SWSCM activities as described in the SWSCM group. VSSP website: Access and training on the Virtual Stroke Support Portal, an online information and support website which includes:
| 0 | 90 | 5 | 90 | 0 | 90 |
|
| Admitted to Hospice Care | General disorders | Non-systematic Assessment | Admitted to Hospice Care |
|
Not provided
Not provided
| D014652 | Vascular Diseases |
| D002318 | Cardiovascular Diseases |
| D010342 | Patient Acceptance of Health Care |
| D000074822 | Treatment Adherence and Compliance |
| D015438 | Health Behavior |
| D001519 | Behavior |
| D000072471 | Heterocyclic Compounds, Fused-Ring |
| D000617 | Aminoglycosides |
| D006027 | Glycosides |
| D002241 | Carbohydrates |
| Superiority |
| Superiority |