Table 3.
Information to be collected and used in analysis
| Baseline | 3 Months | 12 Months | |
|---|---|---|---|
| Patient Characteristics | |||
| Basic sociodemographics: age, sex, race, ethnicity, preferred language to use, living situation, education, health literacy | X | ||
| Marital status, employment status, income | X | X | X |
| Acculturation: place of birth, parent and grandparent place of birth, length of time in US | X | ||
| Executive Cognitive Function (FAB) | X | ||
| Stroke, HTN and hospitalization history; co-morbidities (modified Charlson) | X | X | X |
| Clinical and functional outcomes | |||
| Primary outcome | |||
| Blood pressure measurement | X | X | X |
| Secondary outcomes | |||
| Cost-effectiveness | X | X | X |
| Health-related quality of life (EuroQol) | X | X | X |
| ADL/Functional Status (modified Barthel/Rankin for patient self-report) | X | X | X |
| Physical function (PROMIS®) | X | X | X |
| New cardiovascular events | X | X | |
| Exploratory outcome mediators | |||
| Knowledge of HTN management | X | X | X |
| Stroke literacy questions (Willey) | X | X | X |
| Adherence to regimen (Morisky) | X | X | X |
| Beliefs about medications (BMQ) | X | X | X |
| Linkage to PCP | X | X | X |
| Chronic condition management (PACIC) | X | X | X |
| General self-efficacy scale (Lorig) | X | X | X |
| Lifestyle management: diet/sodium intake (modified CATCH), physical activity (IPAQ), tobacco, alcohol and drug use, body mass index | X | X | X |
| Depression (PROMIS®) | X | X | X |
| Medication profile | X | X | X |
| Organizational and system costs | |||
| Intervention costs: nurse practitioner and health coach time, patient educational material | X | X | |
| Home care-related costs: nurse, therapy, social work, and aide home care visits | X | X | |
| Overall medical costs: nights in hospital, ED visits, physician visits, medications | X | X |
Notes: Barthel/Rankin [37,53]; FAB = Frontal Assessment Battery [54]; Charlson, modified self-report [55,56]; EuroQol [38]; PROMIS® [57]; Willey [58]; Morisky, 8-item version [59]; BMQ [60], PACIC = Patient Assessment of Chronic Illness Care, modified subscales [61]; Lorig [62]; CATCH [63]; IPAQ = International Physical Activity Questionnaire [64,65]; PROMIS® depression [66]; ED = emergency department; ADL = activities of daily living; PCP = primary care provider; HTN = hypertension.