Compass 3: A Novel Transition Program to Reduce Disability After Stroke

Who May Qualify: - Aged ≥55 years at the time of screening - Acute stroke diagnosis (IS or ICH) verified by the stroke team or medical record - Independent in activities of daily living (ADLs) prior to stroke (premorbid Modified Rankin Scale score ≤2) - Plan to discharge to home from an IR - Capable of giving willing to sign a consent form which includes compliance with the requirements and duration of participation as listed in the willing to sign a consent form Form (ICF). Who Should NOT Join This Trial: - Life expectancy \<6 months - Cognitive impairment that the participant's stroke team or a research team member believes impairs their ability to provide willing to sign a consent form or make reasoned choice including the interpretation of the self-rated scales - Any communication problem that would prevent study completion - Residence in a congregate living facility - Not eligible for a therapeutic pass - Residence outside of the designated catchment area (specific catchment distance to be determined by each site) - Site investigator's judgment that the participant would not be able to complete research procedures or interventions - Participation in another research study that in the site investigator's judgment could interfere or conflict with this research study's assessments or interventions Always talk to your doctor about whether this trial is right for you.