Enhancing Resilience Among Patients With Stroke: Implementation of High Intensity Home-based Rehabilitation

The goal of this observational study is to test whether a model of high-intensity home-based rehabilitation (HIHR) helps patients get good outcomes after treatment for a stroke at Duke University Hospital. The main question it aims to answer is: Do patients who receive HIHR services after their stroke recover their function at least as well as patients who discharge to an inpatient rehabilitation facility? Participants will not be assigned to any group. Rather, patients who choose to discharge from the hospital to their home and receive HIHR services after their stroke will be enrolled in the study so that researchers can compare their outcomes to those for other patients who instead discharged to an inpatient rehabilitation facility.

Inclusion Criteria: * Ability to read and understand English. * Admitted to Duke University Hospital stroke medical service * Confirmed diagnosis of stroke (per documentation in medical record) * At time of hospital discharge: 1. Home adress in the followng zipcodes: 27713, 27704, 27511, 27513, 27518, 27519, 27560, 27703, 27712, 27707, 27705 and 27701. 2. NIH Stroke Scale Score = 4-13 3. AM-PAC 6-Clicks basic mobility score \>/=13 4. Documented need for rehabilitation from 2 disciplines in post-acute or for a Skilled Nursing Facility (SNF). 5. No contraindications to safe medical management at home (ongoing cancer treatment, dialysis-dependent ESRD, complex wounds, others as determined by the attending medical team) g) Clinically judged to have adequate caregiver support at home Exclusion Criteria: * Those with acute psychosis or an inability to provide legal and effective consent will be excluded from participation. * Those with medical contraindications as determined by the hospital attending neurology team