Michigan Stroke Transitions Trial (MISTT)
Acute Stroke

About this trial
This is an interventional supportive care trial for Acute Stroke focused on measuring acute stroke, care transitions, patient engagement, patient education, caregivers, social workers
Eligibility Criteria
Patient Inclusion Criteria:
- A final confirmed hospital diagnosis of acute stroke (ischemic or hemorrhagic).
- Patient living at home pre-stroke.
- Presence of stroke-related deficits at admission (defined as a National Institute of Health Stroke Severity score of >=1).
- Presence of at least mild functional limitations at discharge (defined as a modified Rankin score [mRS] score of >=1), or therapy ordered.
- Discharged directly home (includes patient's residence or that of a family member).
- Discharged to a rehabilitation facility (IRF or SNF) with the expectation of return to home within 4 weeks.
Patient Exclusion Criteria:
- Patients who live more than 50 miles from the hospital (for reasons related to the home visits).
- Patients discharged to nursing home, hospice care or LTCH (Long term care hospital).
- Patients who have clinically documented cognitive deficits or stroke-related impairments including aphasia sufficient to impact the consent process and for whom a proxy respondent is not available.
- Patients who fail the 6-item cognitive screening (SIS-6) for cognitive impairment (score <=4) and for whom a proxy respondent is not available
- Patients enrolled in another acute stroke intervention trial that has a significant impact on the post-acute period (i.e., intensive data collection required of patient during follow-up).
- Limited life expectancy (< 6 months) or significant medical comorbidity likely to impact completion of the study (e.g., severe mental illness, drug or alcohol use or dependence, metastatic cancer).
- Neither the patient nor caregiver speaks English.
Caregiver Inclusion Criteria:
- Age 18 or over.
- Are identified by the stroke patient as the primary caregiver (individual who has primary responsibility for assisting with the patient's care).
- Speaks English.
Sites / Locations
- University of Michigan
- Sparrow Health System
- Saint Joseph Mercy Health System
Arms of the Study
Arm 1
Arm 2
Arm 3
No Intervention
Experimental
Experimental
Usual Care
SCM
SCM and VSSP
Patients in this group will receive the hospitals' usual transitional care approach.
One intervention is provided: 1. SCM (Stroke Case manager): a trained social worker who provides in-home case management services.
Two interventions are provided: SCM (Stroke Case manager): a trained social worker who provides in-home case management services. Plus: VSSP (Virtual Stroke Support Portal): Access and training in the use of the VSSP: a purpose-built, online, patient-centered information and support resource.