We have developed a post-acute, home-based stroke care model (“Stroke Mobile”). Each care team consists of an RN and lay educator and patients are managed up to 1 year post-dischage. Metrics include 30-day all cause readmission and mortality, 90-day functional outcome, rates of risk factor control, medication adherence etc. The model was initially supported by a CMS Innovation grant and data indicate significant clinical benefit (e.g., low readmission rates, BP control approaching 90% at 1 year, etc). Now that the grant support has ended, we are struggling to demonstrate financial value of the model despite the clear clinical benefits. Any ideas would be most appreciated.