MSU UARC is shutting down effective June 30, 2021. We are no longer taking on new projects.

Patient-Centered Case Management Program

The majority of the 1 million stroke patients discharged from U.S. hospitals every year return back to their homes. For many stroke patients and caregivers, navigating the transition between hospital discharge and home is associated with substantial psychosocial and health-related challenges. Stroke transitions are often characterized by hospital readmission, slow recovery, poor quality of life, dissatisfaction with care, and high caregiver burden.

The Michigan Stroke Transitions Trial (MISTT) was a randomized clinical trial designed to help stroke patients and their caregivers after returning home from the hospital. The study compared 3 groups: usual care (group 1), social work case management (group 2), and a combination of social work case management plus access to an online information and support resource (MISTT website) (group 3), and involved 265 patients and 169 caregivers, to find out which approach works best for the hospital-to-home transition. Primary results indicated that combining access to a social work case manager with access to online stroke-related information produced greater gains in patient-reported physical health and activation compared with usual care or case management alone.

Press Releases

Project-Related Research Publications

  • Hughes, A. K., Woodward, A. T., Freddolino, P. P., Fritz, M. C., Coursaris, C. K., Swierenga, S. J., & Reeves, M. J. (2019). Transitioning home after stroke: Improving physical health and patient activation. Presented at the Gerontological Society of America’s 71st Annual Scientific Meeting, November 13-17, Austin, TX.
  • Woodward, A. T., Hughes, A. K., Freddolino, P. P., Fritz, M. C., Coursaris, C. K., Swierenga, S. J., & Reeves, M. J. (2019). Patterns of unmet needs and strengths among stroke patients and their influence on outcomes. Presented at the Gerontological Society of America’s 71st Annual Scientific Meeting, November 13-17, Austin, TX.
  • Hughes, A. K., Woodward, A. T., Fritz, M. C., Swierenga, S. J., Freddolino, P. P. , & Reeves, M. J. (2019). Unmet needs of US acute stroke survivors enrolled in a transitional care intervention trial. Journal of Stroke and Cerebrovascular Diseases, 29(2), 104462, 1-8.
  • Reeves, M. J., Fritz, M. C., Woodward, A. T., Hughes, A. K., Coursaris, C. K., Swierenga, S. J., Nasiri, M., & Freddolino, P. P. (2019). The Michigan Stroke Transitions Trial (MISTT): A Clinical Trial to Improve Stroke Transitions. Journal of Circulation: Cardiovascular Quality and Outcomes, 12(7):e005493. DOI: 10.1161/CIRCOUTCOMES.119.005493
  • Reeves, M. J., Hughes, A. K., Woodward, A. T., Freddolino, P. P., Coursaris, C. K., Swierenga, S. J., Lee, H. Schwamm, L. H., & Fritz, M. C. (2017). Improving transitions in acute stroke patients discharged to home: The Michigan Stroke Transitions Trial (MISTT) Protocol. BMC Neurology, 17:115. DOI: 10.1186/s12883-017-0895-1. http://rdcu.be/txwn
  • Hughes, A. K., Woodward, A. T., Freddolino, P. P., Fritz, M. C., Coursaris, C. K., Swierenga, S. J., & Reeves, M. J. (2019). Transitioning home after stroke: Improving physical health and patient activation. Paper presentation at the Gerontological Society of America’s 71st Annual Scientific Meeting, Austin, TX, November 13-17, 2019.
  • Woodward, A. T., Hughes, A. K., Freddolino, P. P., Fritz, M. C., Coursaris, C. K., Swierenga, S. J., & Reeves, M. J. (2019). Patterns of unmet needs and strengths among stroke patients and their influence on outcomes. Paper presented at the Gerontological Society of America's 71st Annual Scientific Meeting, Austin, TX, November 13-17, 2019.
  • Fritz, M. C., Woodward, A. T., Hughes, A. K., Coursaris, C. K., Swierenga, S. J., Mojdeh, M., Freddolino, P. P. (2019, February 6). Final patient-level results from the Michigan Stroke Transitions Trial (MISTT): A randomized clinical trial to improve stroke transitions. Presented at the International Stroke Conference, February 6-8, Honolulu, HI.
  • Freddolino, P., & Swierenga, S., Woodward, A., Lounds, N., Fitzgerald, J., Coursaris, C. K., Hughes, A., Fritz, M., & Reeves, M. (2018). Defining the limits of technology-based tools for stroke patients and caregivers. Presentation at Social Work, Education and Social Development Conference, July 4-7, Dublin, Ireland.
  • Reeves, M., Woodward, A., Fritz, M., Freddolino, P., Coursaris, C., Swierenga, S., Nassiri, M, & Hughes, A. (2019, May 16). A randomized trial of social worker led home-based case management to improve outcomes for caregivers of acute stroke patients during the transition period. Presentation at the 4th European Stroke Organization Conference, May 16-18, 2018, Gothenburg, Sweden.
  • Reeves, M. J., Fritz, M. C., Woodward, A. T., Freddolino, P. P., Coursaris, C. K., Swierenga, S., Nasiri, J., & Hughes, A. K. (2018). Improving transitions in acute stroke patients after they return home: Results of the Michigan Stroke Transitions Trial (MISTT). Presentation at International Stroke Conference (ICS), January 24-26, Los Angeles.
  • Freddolino, P., Swierenga, S., Woodward, A., Lounds, N., Fitzgerald, J., Coursaris, C. K., Hughes, A., Fritz, M., & Reeves, M. (2018). Defining the limits of technology-based tools for stroke patients and caregivers. Poster presentation at International Stroke Conference (ICS), January 24-26, Los Angeles.
  • Woodward, A., Freddolino, P. P., Nelsen, M., Swierenga, S., Coursaris, C. K., Fritz, M. C., & Reeves, M. J. (2018). Integrating web-based resources and social work case management: Preliminary results on website utilization from the Michigan Stroke Transitions Trial. Poster presentation at the 22nd Annual Conference of the Society for Social Work and Research (SSWR), January 10-14, 2018, Washington, DC.
  • Freddolino, P., Swierenga, S. J., Coursaris, C. K., Woodward, A. T., & Reeves, M. J. (2017, May 23). Implementation Challenges in an RCT for Stroke Patients and Caregivers. International conference on practice research (ICPR), May 22-24, Hong Kong, China.

Grant Team and Funding

  • Research Team: Reeves, M. (PI), Freddolino, P. (Co-I), Hughes, A. (Co-I), Woodward, A. (Co-I), Coursaris, C. (Co-I), Swierenga, S. J. (Co-I), Chen, J. (Co-I), Lounds, N. (Co-I), Fitzgerald, J. (Co-I), Jones, N., Babbage, J. (Co-I)
  • Grant Funder: Patient-Centered Outcomes Research Institute (PCORI), 8/16/2014–3/31/2018