ESD was initially developed and tested in randomized controlled trials in Europe and Canada, summarized in a Cochrane Review [54], and is now part of the standard of care in the UK and Canada. In the European model, mild to moderate stroke patients (about 37 % of the stroke population) [55] are discharged home early, and are treated by a team that integrates stroke specialty care and rehabilitation in the home. In addition to efficacy, ESD reduces cost and improves function. The Canadians have projected that optimal stroke care in Canada avoids $307 million direct costs and that access to ESD generates $132.9 million of the direct cost savings [55]. In addition to the cost savings patients spend less time in hospital-based rehabilitation programs, and have better community engagement, improved patient satisfaction and self-management strategies for recovery, and reduced death and dependency at 6 months.

ESD has not been implemented in the USA, perhaps because of the traditional gaps between acute care and post-acute care. Home health services are generally not equipped or staffed to provide care for patients with significant disabilities, and therefore before ESD could be implemented in the USA, there will need to be a reengineering of home health agencies to provide more intensive services early after discharge, along with extended support from a hospital stroke specialty team and primary care with stroke expertise. Current payer models and CMS regulatory issues do not support this level of care in the home; therefore ESD would require a new payer model.

As illustrated above, the major contributions to the wide variation, high cost, and poor quality in stroke post-acute care are the fragmentation of care amongst the many possible sites where care is delivered. As patients move through these post-acute care silos, in most cases they have different providers at each location, each associated with handoffs of care, often with little or no integration or careful coordination of care and services in between. The Medicare Post-acute Care Advisory Committee (MedPAC) has thus suggested bundled payments for post-acute services as a method to incentivize providers to work together throughout the post-acute continuum to integrate services and thus improve care by reducing readmissions and improving quality [45]. Although the interdisciplinary nature of post-acute care is emphasized in the latest policy recommendations for integration of stroke systems of care, the integration of post-acute care services for stroke was not even mentioned [15]. Given the success of ESD in Canada and the UK, models of post-acute stroke care do not necessarily need to be reinvented, but focused efforts towards integration of post-acute services are clearly needed in the USA.