Table 3.

Domains assessed in post-discharge follow-up after stroke

Post-Discharge Follow-Up Call
• Medication reconciliation	• Home Health/Outpatient Services
• New/Worsening Symptoms	• Caregiver Assistance
• Falls	• PCP follow-up Appointment
• Transportation	• Stroke Clinic Follow-up appointment
Clinic Visit Post-Stroke Functional Assessment
• Medication Management	• Spasticity
• Financials to Medication Management	• Social Support
• Cognition	• Physical Mobility & Safety
• Depression	• General Health
• Health Literacy	• Upper Extremity
• Access to PCP	• Transportation
• ED/Hospital Readmissions	• General health
• Status of Advance Directive	• Falls
• Stress	• ADL/IADL
Clinic Visit Caregiver Assessment
• Caregiver Assistance	• Caregiver Stress
• Caregiver Health
Clinic Visit Advance Practice Provider Assessment
• Lifestyle Management (alcohol, smoking, drugs,	• Risk factor management (blood pressure, LDL, INR, HgA1c)
• Modified Rankin Scale	• Depression
• Cognition	• Communication
• Physical activity