The Delta Stroke Initiative is focused on care transitions to prevent the recurrence of a stroke. Through a collaborative effort with hospitals, community health workers, providers, and certified nurse assistants, we strive to reduce 30-day readmission rates to the hospital. Our patients are enrolled in a 45 day program where they receive home visits from community health workers, personal care from certified nurse assistants, incentives, weekly phone calls, & education about stroke prevention and ways to adopt a healthier lifestyle.