Center for Stroke Disparities Solution - Community Transitions Intervention (CSDS)
Hypertension, Stroke, Transient Ischemic Attack
About this trial
This is an interventional treatment trial for Hypertension focused on measuring stroke, transient ischemic attack, High blood pressure, Hypertension
Eligibility Criteria
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
Sites / Locations
- Visiting Nurse Service of New York
Arms of the Study
Arm 1
Arm 2
Arm 3
No Intervention
Experimental
Experimental
Usual Home Care
Nurse Practitioner + Health Coach
Nurse Practitioner Only
Regardless of study arm, all patients will receive usual home health services: a physician-ordered plan of care; skilled nursing and/or therapy services as prescribed by the MD; patient education, monitoring and hands-on care; and home health aide services depending on functional deficits and availability of unpaid caregivers.
The NP + HC arm will include the same protocol as the NP only arm plus 30 additional days of support. The HC will pick up the case after the initial 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.
The NP only program will provide a 30 day intervention via in-home and telephone encounters for patients randomized to this group. 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.