Fortunately, stroke centers are now reporting initiatives to enhance transitions of care and to provide short-term outpatient follow-up care. Some centers are employing stroke care navigators to help the patient and family navigate post-discharge care and services. MD, APP or stroke coordinator-led stroke outpatient clinics to address short-term post-discharge needs are being developed or considered and outsourcing post-discharge surveillance and care is on the rise. While filling some critically important gaps in care, these short-term surveillance and intervention initiatives are not focused on longer term patient outcomes.

Where is the evidence to guide long-term post-stroke care and outcomes?

Evidence is still limited on how best to support stroke patients as they transition to home and in long-term self-management strategies for optimal outcomes related to secondary stroke prevention and quality of life.³Despite the success of stroke registries in improving acute care, we are well behind in developing a repository of post-discharge outpatient data to help guide evidence-based practice after discharge.

While attempts at intervention studies to address challenges of stroke transitions of care and secondary stroke prevention intervention have been published, the studies were limited to 90-days or less and, in large part, the results did not find significant intervention effect.^3,4 Other, longer, 12-month intervention studies^5,6 did not achieve statistical significance in attempts to  improve in post-discharge long-term outcomes in stroke survivors.

The C3FIT Trial – A new late breaking study presented at ISC 2025  

I have been fortunate to be involved over the last 5 years as the Stakeholder Engagement Coordinator in this 23-hospital post-discharge trial studying a 12-month  intervention after a stroke. C3FIT (Coordinated, Collaborative, Comprehensive, Family-Based, Integrated, and Technology-Enabled Stroke Care) was a PCORI-funded pragmatic, comparative effectiveness trial designed to compare an “integrated stroke practice unit” (ISPU) model of care to usual stroke care over 12-months post-discharge.

Patients in the intervention arm of the study received monthly in-person home, virtual or  telephonic visits by a nurse and lay health educator for 1-year post-discharge. (Note: the original protocol design included monthly in-home, face-to-face visits but was modified to include virtual and telephonic visits when the COVID-19 pandemic prevented in-home visits). Alongside the enhanced follow-up to monitor recovery, manage comorbidities and provide education, clinical decision support technology and real-time collaboration with the inpatient team were leveraged to optimize patient outcomes and close gaps in transitional stroke care. The enhanced follow-up model was implemented at existing Comprehensive Stroke Centers (CSCs) and compared to usual care following discharge at other CSCs. The goal of the intervention was to bring those patients who were in poor risk factor control at discharge, back into control and to maintain good control. For those patients in good control at discharge, it was to maintain good control. The study aim would determine if improved risk factor control would lead to better functional outcomes and improved health-related quality of life.⁷

Although currently unpublished, the initial primary and secondary outcomes were compelling enough to be accepted for presentation in a “Late-breaking Science” main session at the International Stroke Conference in February 2025. In the presentation, the 12-month intervention showed improved post-stroke risk factors with greatest impact on blood pressure, diet, and lipid control (and non-significant improvement in exercise) over usual care. Glucose control and smoking cessation were not addressed due to insufficient data. Although the intervention did not achieve the aims with primary outcomes, if studied for longer time frame, e.g., 2 years or more, it may have provided more useful data. However, some secondary outcomes of the study were significantly improved, indicating significant opportunities remain to enhance long-term risk factor management for stroke survivors, even among those receiving standard care at CSCs.⁸

The Path Forward

The “new frontier” in stroke care we identified two years ago is gradually being explored, but much territory remains uncharted. By building on promising interventions like the C3FIT model and addressing the persistent gaps in longitudinal care, we can continue to improve outcomes and quality of life for stroke survivors and their families.