Secondary Stroke prevention by Uniting Community and

Control of stroke risk factors is suboptimal, especially in minority populations. Los Angeles County is the largest county in the country, and its safety net hospitals serve a predominantly indigent, minority population, so it can serve as a setting for testing new care interventions to close racial and ethnic disparities. We are currently testing a care intervention focusing on system delivery redesign, and we have successfully enrolled over 300 subjects in a randomized-controlled trial, of whom 90% of subjects are nonwhite. We are proposing to enhance this intervention by emphasizing a community-centered component of a Chronic Care Model-based intervention called Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED). It consists of community health workers (CHWs) visiting patients at home and leading self-management classes in the community. CHWs will also use mobile health technology to foster communication between themselves and physician extenders serving as care managers. Finally, subjects will be given blood pressure monitors to collect measurements at home. A steering committee, composed of community leaders, researchers, lay persons, and academic collaborators will ensure that the intervention is culturally tailored. We will then evaluate this enhanced chronic care model-based intervention by conducting a randomized-controlled trial of 500 patients who speak English, Spanish, Korean, Mandarin, or Cantonese, and who have suffered a recent stroke or transient ischemic attack. The study is powered to detect an 8 mm Hg difference in the primary outcome of systolic blood pressure. Secondary outcomes consist of controling other stroke risk factors and improving lifestyle habits. We will also collect a set of mediators and moderators to understand robustness of intervention impacts across levels of individual and health system characteristics. We will also conduct a cost analysis of SUCCEED from the perspective of the Los Angeles County Department of Health Services, and develop a sustainability plan for the Los Angeles County Department of Health Services to maintain SUCCEED after the funding period.