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

Inclusion Criteria: * 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 informed consent which includes compliance with the requirements and duration of participation as listed in the Informed Consent Form (ICF). Exclusion Criteria: * Life expectancy \<6 months * Cognitive impairment that the participant's stroke team or a research team member believes impairs their ability to provide informed consent 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