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.
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.