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Improving Care Transitions for Acute Stroke Patients Through a Patient-Centered Home Based Case Management Program

The majority of the one million stroke patients discharged from U.S. hospitals every year return back to their homes. For many stroke patients and caregivers, navigating the transition between hospital discharge and home is associated with substantial psychosocial and health-related challenges. Stroke transitions are often characterized by hospital readmission, slow recovery, poor quality of life, dissatisfaction with care, and high caregiver burden.  Our proposed research program aims to improve the transition experience of stroke patients and caregivers through the development of a patient- and caregiver-centered case management program delivered by Social Work Bridge Coordinators (SWBC). We will conduct a comprehensive assessment of the informational needs of stroke patients and caregivers regarding their transition experiences and then develop a patient-centered online communication, information, and support resource–termed a Virtual Stroke Support Portal (VSSP). We anticipate that this personalized case management program will reduce patient and caregiver needs, improve quality of life, and decrease caregiver burden.


  • Massachusetts General Hospital
  • MSU Department of Epidemiology and Biostatistics
  • MSU Department of Media and Information
  • MSU IT Services
  • MSU School of Social Work
  • Saint Joseph Mercy Health System
  • University of Michigan


  • Patient-Centered Outcomes Research Institute