Compass 3: A Novel Transition Program to Reduce Disability After Stroke

Inclusion Criteria:

* Aged ≥55 years at the time of screening
* Acute stroke diagnosis (IS or ICH) verified by the stroke team or medical record
* Independent in activities of daily living (ADLs) prior to stroke (premorbid Modified Rankin Scale score ≤2)
* Plan to discharge to home from an IR
* Capable of giving informed consent which includes compliance with the requirements and duration of participation as listed in the Informed Consent Form (ICF).

Exclusion Criteria:

* Life expectancy \<6 months
* Cognitive impairment that the participant's stroke team or a research team member believes impairs their ability to provide informed consent or make reasoned choice including the interpretation of the self-rated scales
* Any communication problem that would prevent study completion
* Residence in a congregate living facility
* Not eligible for a therapeutic pass
* Residence outside of the designated catchment area (specific catchment distance to be determined by each site)
* Site investigator's judgment that the participant would not be able to complete research procedures or interventions
* Participation in another research study that in the site investigator's judgment could interfere or conflict with this research study's assessments or interventions