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

Adverse Social Determinants of Health (SDOH) have been shown increase stroke risk in a dose dependent manner. The SDOH-Homecare Intervention Focus Team (SHIFT) trial is a Phase 3, randomized, blinded outcome trial that tests the hypothesis that a homecare intervention shortly after discharge from an acute stroke unit by a team comprising a community health worker (CHW), a community social worker (CSW) and a community nurse (CN) can improve health outcomes among stroke patients with three or more SDOH compared with UC.

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