SDOH-Homecare Intervention Focus Team (SHIFT) Trial to Improve Stroke Outcomes

Inclusion Criteria:

* Ischemic stroke (arterial subtypes) or primary intracerebral hemorrhage (excluding diagnosis of probable cerebral amyloid angiopathy by Boston Criteria)
* African American/Black or Hispanic race-ethnicity
* Age 18-75 years old
* Have at least 3 SDOH barriers from within the 5 SDOH domains (Social and Community, Education, Economic, neighborhood/environment, Health Care)
* Have a discharge plan to 1) home with or without home services, or 2) acute rehabilitation with plan to return home after
* Pre-stroke Modified Rankin Scale score of ≤3
* Residence in New York City.
* English or Spanish speaking.
* Can provide informed consent and engage in the initial assessment prior to stroke discharge
* Lives in a household with a telephone, and has a caregiver (family member or Home Health Aide) if not fully independent on discharge. If the patient requires a family member to assist with activities of daily living or decision-making, the family member must state a willingness to be present at home visits where their assistance is needed.

Exclusion Criteria:

* Discharge disposition to a long-term care facility.
* Diagnosis of dementia or other neurological diagnosis that affects cognition
* Diagnosis of active major depression
* Aphasia severe enough to preclude initial examination
* Impaired level of consciousness at initial cognitive assessment
* Subarachnoid hemorrhage
* Diagnosis of probable cerebral amyloid angiopathy by Boston criteria
* Life expectancy less than 1 year