Project 2: Stroke Community Transitions Project

Project Leader: Penny Feldman, PhD, Visiting Nurse Service of New York

Purpose: This project will evaluate the effectiveness of a culturally-tailored transition care program delivered by nurse practitioners and community health workers in improving blood pressure control, quality of life and functional outcomes among Black and Hispanic post-stroke home care patients.  The transition care program will have a three-fold focus: 1) linking patients to continuous, rapidly responsive preventive and primary care, 2) increasing patients’/caregivers’ ability to manage a culturally and individually tailored blood pressure reduction plan, and 3) facilitating the patient’s reintegration into the community after home health care discharge.

Design: Three-arm randomized controlled trial

Participants: 495 Black and Hispanic post-stroke home care patients with uncontrolled hypertension

Interventions: Participants will be randomly assigned to one of three groups:

  • Usual home care
  • Usual home care plus a 3-month nurse practitioner community transitions intervention
  • Usual home care plus a 3-month nurse practitioner and health coach community transitions intervention

Outcomes: The primary outcome is systolic blood pressure from baseline to 3 and 12 months.  The secondary outcomes are cost-effectiveness of the interventions, patient quality of life, and patient functional status at 12 months.

Click here to view this project’s information on NIH RePORT