Transitional Care Program to Improve Risk Factors in Stroke Survivors

Improved Risk Factor Control Through a Transitional Care Program for Stroke Survivors

The goal of this clinical trial is to evaluate whether our transitional care program helps stroke survivors better manage their risk factors for stroke to lower the risk of a repeat stroke. The main question it aims to answer is:

- Does the program help participants meet the targets set by the American Heart Association clinical guidelines for control of risk factors associated with stroke?

Researchers will compare participants enrolled right after being discharged from the hospital to participants enrolled around 3-5 months after being discharged to examine whether timing differences in enrollment affect the efficacy of the program.

Participants will:

• Keep track of their medications, their exercise, and their health information using smart devices provided by the study
• Answer questions about their health and lifestyle
• Meet with our team of healthcare providers

Study Overview

• Status: Recruiting
• Conditions: Stroke, Ischemic
• Intervention / Treatment: Other: Transitional Care Program

• Study Type: Interventional
• Enrollment (Estimated): 224
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Research Coordinator; Phone Number: 434-202-3450; Email: admin@syntrillo.com

Study Locations

• United States
  • Virginia
    • Winchester, Virginia, United States, 22601
      • Recruiting
      • Valley Health System

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

All Cohorts:

• Age 30 or above
• Evidence of ischemic stroke documented on CT or MRI
• Modified Rankin score of 3 or less

Early Enrollment:

• Admission for ischemic stroke at a participating site
• Enrolled during their admission for ischemic stroke or within 24 hours of discharge

Late Enrollment:

• Stroke survivors previously admitted at the participating sites' inpatient stroke unit
• Enrollment date between 1 and 6 months after discharge for inpatient admission for ischemic stroke

Exclusion Criteria:

• Participants determined to have hemorrhagic or periprocedural stroke based on hospital EMR review will be excluded.
• Participants determined to have an ischemic stroke due to dissection based on hospital EMR review will be excluded.
• Participants who lack capacity determined by the care team during their hospitalization (for the early enrollment group) or their most recent clinical encounter (for the late enrollment group) will be excluded.
• Participants with a diagnosis of dementia will be excluded.
• Participants with acute subdural hemorrhage will be excluded.
• Participants with hemorrhagic stroke due to vascular abnormality (aneurysm or AVM) or trauma will be excluded.

• Participants who cannot perform the following will be excluded:

  1. offer a consistent choice about participating in the study
  2. demonstrate that they can comprehend and recall major features of the study including: participation is voluntary, the major procedures, the primary risk, and the primary benefit.
• Participants who are discharged to Long-term Acute Care Hospitals will be excluded.
• Participants who are unable to read or communicate fluently in English will be excluded.
• Participants who do not have reliable internet access to complete telemedicine visits per self-report will be excluded.
• Participants already enrolled in another clinical study which could impact the frequency of monitoring or care that participant receives.
• Participants who do not reside in Virginia, West Virginia, Tennessee, Oklahoma, Illinois, or Michigan will be excluded.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Early Enrollment; Participants enrolled around the time of discharge from the hospital immediately following an ischemic stroke.	Other: Transitional Care Program; Participants will receive personalized risk-factor management stroke care from a multidisciplinary team trained by our neurologists to understand the needs of stroke survivors and the nuances of stroke care. Risk factor data from in-home devices, health records, and self-reports will be collected along with functional status and behavioral data obtained through validated questionnaires and an occupational therapy evaluation. Syntrillo's neurology provider will review this data, assess the participant through a telemedicine encounter, and create a comprehensive secondary prevention plan to supplement the participant's care plan at discharge. Data generated through these clinical encounters will be de-identified and used for subsequent development of Syntrillo's stroke management technology.
Experimental: Late Enrollment; Participants enrolled mainly between 3-5 months after their discharge from the hospital following an ischemic stroke.	Other: Transitional Care Program; Participants will receive personalized risk-factor management stroke care from a multidisciplinary team trained by our neurologists to understand the needs of stroke survivors and the nuances of stroke care. Risk factor data from in-home devices, health records, and self-reports will be collected along with functional status and behavioral data obtained through validated questionnaires and an occupational therapy evaluation. Syntrillo's neurology provider will review this data, assess the participant through a telemedicine encounter, and create a comprehensive secondary prevention plan to supplement the participant's care plan at discharge. Data generated through these clinical encounters will be de-identified and used for subsequent development of Syntrillo's stroke management technology.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
90% of systolic blood pressure (SBP) readings < 130 mmHg AND 90% of diastolic blood pressure (DBP) readings < 80 mmHg in a one week period	Blood pressure will be measured using Tenovi's FDA-cleared, portable home blood pressure monitoring device. Both systolic and diastolic measurements must be below the threshold in order for the condition to be met.	From enrollment to the end of the 6 month monitoring period
Correct prescription of antiplatelet, anticoagulant, and statin medications per guidelines when no contraindications are present	We will verify correct prescriptions and dosing through EHR records, pharmacy records, and/or patient self-report as applicable. Correct prescription and dosing will be determined through expert opinion following AHA therapeutic standards.	From enrollment to the end of the 6 month monitoring period
Adherence of antiplatelet, anticoagulant, and statin medications > 90%	Adherence is determined by percent of missed doses per week. Medication adherence will be monitored through a combination of self-report, device data, and pharmacy records, as applicable. We will administer the 5-Item Medication Adherence Report Scale (MARS-5) and correlate self-reported data with device data from Tenovi's smart pillbox and pharmacy records to estimate percent adherence and assess confidence level in the data.	From enrollment to the end of the 6 month monitoring period
Increased compliance with therapeutic standards of care according to the American Heart Association (AHA) guidelines for secondary stroke prevention in early vs late group	We will measure percent compliance with AHA therapeutic standards in the early enrollment group compared to the anticipated baseline percent compliance in the late enrollment group at equivalent time points post-discharge. Percent compliance is a composite endpoint. Participants will be considered "compliant" to secondary stroke prevention guidelines if all other conditions below (2-5) are met. Participants will be considered "non-compliant" to secondary stroke prevention guidelines if one or more conditions are not met.	From enrollment to the end of the 6 month monitoring period
Moderate intensity activity > 150 minutes per week on average	Physical activity will be assessed through a combination of self-reported and biometric data. We will administer a physical activity questionnaire and correlate self-reported activity with biometric data obtained from the smartwatch to estimate physical activity and assess confidence level in the data.	From enrollment to the end of the 6 month monitoring period

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Average change in compliance percentage at 1, 2, and 3 months following initiation of our transitional care program	Compliance percent is measured based on the data collected from the four primary outcome measures as described in the primary outcomes.	From enrollment to the end of the 6 month monitoring period
Frequency of recurrent stroke in the early enrollment cohort compared to the late enrollment cohort at equivalent time points post-discharge	Highest risk for recurrent stroke is in the initial 6 months following the first stroke. Frequency of recurrent stroke will be measured by aggregating the number of patients readmitted to the hospital within 6 months following enrollment based on EHR records and/or patient self-report.	From enrollment to the end of the 6 month monitoring period
Frequency of readmission in the in the early enrollment cohort compared to the late enrollment cohort at equivalent time points post-discharge	Highest risk for recurrent stroke is in the initial 6 months following the first stroke. Frequency of recurrent stroke will be measured by aggregating the number of patients readmitted to the hospital within 6 months following enrollment based on EHR records and/or patient self-report.	From enrollment to the end of the 6 month monitoring period

Collaborators and Investigators

• Sponsor: Syntrillo, Inc

Study record dates

Study Major Dates

• Study Start (Actual): August 16, 2024
• Primary Completion (Estimated): December 1, 2025
• Study Completion (Estimated): December 1, 2025

Study Registration Dates

• First Submitted: October 15, 2024
• First Submitted That Met QC Criteria: October 22, 2024
• First Posted (Actual): October 24, 2024

Study Record Updates

• Last Update Posted (Actual): June 3, 2025
• Last Update Submitted That Met QC Criteria: May 28, 2025
• Last Verified: May 1, 2025

More Information

Terms related to this study

• Keywords: stroke care; secondary stroke prevention; transitional care program
• Additional Relevant MeSH Terms: Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Vascular Diseases; Cardiovascular Diseases; Ischemic Stroke; Stroke
• Other Study ID Numbers: 2024002

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No