Center for Stroke Disparities Solution - Community Transitions Intervention

Targeted study participants are Black and Hispanic patients with a history of stroke and a current systolic blood pressure (BP) above JNC7 recommended range (>=140 mmHg) who recently entered home care service. The NP only program will provide a 30 day intervention while the NP/HC team will provide 3 months of support via in-home and telephone encounters for patients randomized to one of these groups. In the first 30 days post-enrollment the NP will focus on medical case management and coordination with primary care providers and specialists, provide self-management coaching, and intervene if gaps in care are identified - all with a focus on BP reduction and preparing the patient for ongoing BP maintenance. As applicable, the HC will pick up the case after 30 days and follow up with the plan of care jointly established by the patient, NP and HC. The focus will be on ongoing self-management coaching, providing preparation support for physician visits, and linking patient to additional community resources, as needed.

Inclusion criteria

• Newly admitted to the VNSNY post acute care program
• 21 years of age or older
• Black and/or Hispanic
• Speaks English or Spanish
• History of stroke or transient ischemic attack (TIA)
• Hypertension diagnosis
• Average screening systolic BP >= 140 mmHg
• Is available to participate in intervention activities during the study timeframe if randomized to treatment group

Exclusion criteria

• Dialysis
• End stage renal disease
• Kidney transplant
• Severe heart failure
• Significant cognitive impairment. Unable to provide informed consent, accurate self-report, and/or unable to participate effectively in intervention
• Significant verbal speech impairment. Unable to participate in intervention telephone sessions
• Patients with upper arm circumference outside of valid use parameters for the automated device used for eligibility screening