This article describes a 3-year study testing the efficacy of a system of home-based, case-managed care for stroke survivors returning to the community following inpatient poststroke rehabilitation. The Stroke Transition after Inpatient Rehabilitation (STAIR) study was a randomized, controlled trial of a postdischarge management strategy carried out in a group of 55 stroke patients, aged 65 or older, who did not have serious residual cognitive or language impairments and returned to the community following inpatient rehabilitation with the assistance of a primary caregiver. The program was shown to facilitate improvement in the general social activity level of the patients in the experimental group at 6 months compared to the control, and there was a trend for this effect to persist at 1 year. Strong relationships were identified between residual disability, social activity level, patients' perceptions of efficacy, and caregiver stress.
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