In this episode, Ian reviews a 2016 paper in Stroke by Condon et al. describing a prospective RN/NP-led transitional stroke care program including follow-up calls and clinic visits after patients were discharged to home from a single-center hospital system. This program intended to review two phases of the TSC program to assess any potentially significant improvements across the phases of implementation from phase 1 to phase 2 in terms of reducing 30- or 90-day readmission rates.