BACKGROUND Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group. METHODS A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months. RESULTS Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9–10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC. CONCLUSION The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally. CLINICAL TRIALS REGISTRATION Trial Number NCT01918891.

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Activity-limiting pain is common among older home care patients and pain management is complicated by the high prevalence of physical frailty and multimorbidity in the home care population. A comparative effectiveness study was undertaken at a large urban home care agency to examine an evidence-based pain self-management program delivered by physical therapists (PTs). This article focuses on PT training, methods implemented to reinforce content after training and to encourage uptake of the program with appropriate patients, and therapists’ fidelity to the program. Seventeen physical therapy teams were included in the cluster randomized controlled trial, with 8 teams (155 PTs) assigned to a control and 9 teams (165 PTs) assigned to a treatment arm. Treatment therapists received interactive training over two sessions, with a follow-up session 6 months later. Additional support was provided via emails, e-learning materials including videos, and a therapist manual. Program fidelity was assessed by examining PT pain documentation in the agency’s electronic health record. PT feedback on the program was obtained via semistructured surveys. There were no between-group differences in the number of PTs documenting program elements with the exception of instruction in the use of imagery, which was documented by a higher percentage of intervention therapists (p = 0.002). PTs felt comfortable teaching the program elements, but cited time as the biggest barrier to implementing the protocol. Possible explanations for study results suggesting limited adherence to the program protocol by intervention-group PTs include the top-down implementation strategy, competing organizational priorities, program complexity, competing patient priorities, and inadequate patient buy-in. Implications for the implementation of complex new programs in the home healthcare setting are discussed.