A need exists for effective and cost-efficient approaches to the management of stroke survivors, not only to prevent recurrent stroke but also to prevent and manage other post-stroke complications. Currently, it is assumed that by the time of discharge from an acute care or rehabilitation setting the patient, family, primary care physician, physiatrist, and neurologist have negotiated a shared responsibility to assure compliance with prescribed treatments. Often, this assumption is not met, resulting in fragmented care and negative patient outcomes that could have been prevented. As has been shown to be effective for the management of other chronic diseases, effective post-discharge stroke care management must not only address the physical needs of the stroke survivor, but also psychosocial issues which are known to impact on stroke outcomes. Previous post-stroke care research has found little improvement in patient outcomes due, in part, to the lack of a truly comprehensive care model. Many studies have been narrowly focused on medical management of targeted stroke-related conditions, for example hypertension or diabetes, with little or no consideration of the effect of the interplay between psychosocial and other variables. Other studies focused more on psychosocial, rather than physical, interventions. No previous studies have measured the patient's global well being as a study outcome. We propose a randomized controlled trial of 380 post-discharge ischemic stroke patients. The primary aim of this study is to determine the effectiveness of an integrated post-discharge interdisciplinary stroke care model in improving stroke survivor's global well being (a composite of neuromotor function, severe complications, management of risk for common post-stroke complications, quality of life, and stroke knowledge) by six months as compared to stroke patients who receive usual post- discharge care. Our model, tested and refined in a pilot study at this community teaching hospital, overcomes many of the weaknesses of previous trials of post-stroke care management. The pilot results showed that this intervention had a significant positive overall impact on stroke survivors' well being. This study will advance the field's knowledge of the effectiveness of truly comprehensive post-discharge stroke care management. The standardized assessments and intervention protocols can be used as a template that is easily adapted to a variety of health care settings. Such information will allow more effective and efficient management of stroke survivors
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