SDOH-Homecare Intervention Focus Team (SHIFT) Trial to Improve Stroke Outcomes

Inclusion Criteria: * Ischemic stroke (arterial subtypes) or primary intracerebral hemorrhage (excluding diagnosis of probable cerebral amyloid angiopathy by Boston Criteria) * African American/Black or Hispanic race-ethnicity * Age 18-75 years old * Have at least 3 SDOH barriers from within the 5 SDOH domains (Social and Community, Education, Economic, neighborhood/environment, Health Care) * Have a discharge plan to 1) home with or without home services, or 2) acute rehabilitation with plan to return home after * Pre-stroke Modified Rankin Scale score of ≤3 * Residence in New York City. * English or Spanish speaking. * Can provide informed consent and engage in the initial assessment prior to stroke discharge * Lives in a household with a telephone, and has a caregiver (family member or Home Health Aide) if not fully independent on discharge. If the patient requires a family member to assist with activities of daily living or decision-making, the family member must state a willingness to be present at home visits where their assistance is needed. Exclusion Criteria: * Discharge disposition to a long-term care facility. * Diagnosis of dementia or other neurological diagnosis that affects cognition * Diagnosis of active major depression * Aphasia severe enough to preclude initial examination * Impaired level of consciousness at initial cognitive assessment * Subarachnoid hemorrhage * Diagnosis of probable cerebral amyloid angiopathy by Boston criteria * Life expectancy less than 1 year