Table 3 Information to be collected and used in analysis

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