Virtually Assisted Home Rehabilitation After Stroke for Underserved Texas Communities

Virtually Assisted Home Rehabilitation After Stroke for Underserved Texas Communities

The purpose of this study is to evaluate the clinical effectiveness of Virtually Assisted Home Rehabilitation After Acute STroke (VAST) + post-acute stroke usual care (PASUC) compared to PASUC alone and examine how social determinants of health (SDOH) influence access to and utilization of PASUC rehabilitation.

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.