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Early supported discharge for improving functional outcomes after stroke
Investigator (PI): Duncan, Pamela W
Performing Organization (PO): (Current): Wake Forest University, School of Medicine, Department of Neurology / (336) 716-3545
Supporting Agency (SA): Patient-Centered Outcomes Research Institute (PCORI)
Initial Year: 2015
Final Year: 2022
Record Source/Award ID: PCORI/PCS-1403-14532
Funding: Total Award Amount: $14,524,920
Award Type: Contract
Award Information: PCORI: More information and project results (when completed)
Abstract: We are implementing a cluster randomized trial of 41 North Carolina hospitals to compare approaches to post-acute care for stroke patients. We are asking whether Comprehensive Post-Acute Stroke Services (COMPASS), improves patients' daily function compared with usual care. Comprehensive Post-Acute Stroke Services (COMPASS), combines transitional care and early-supported discharge for stroke patients who go home directly from the hospital. Participating hospitals will be assigned randomly to receive COMPASS or usual care in the first phase of the study. Phase 1 compares COMPASS with usual care. In phase 2, the usual-care hospitals will also receive COMPASS, while the other hospitals continue the intervention. Patients discharged from the COMPASS intervention hospitals receive a 2-day telephone follow-up, a comprehensive clinic visit within 2 weeks that includes standardized neurological evaluation, assessments of social and functional determinants of health, delivery of an individualized care plan, and additional follow-up telephone calls at 30 and 60 days post stroke discharge. COMPASS uses Medicare-approved transitional care services from advanced practice providers (APPs; nurse practitioners, physician assistants, or physicians) and early-supported discharge services coordinated by post-acute care coordinators (PACs). Our intervention also includes the creation of a community resource network trained on the COMPASS model and brings together leaders from the hospital and local organizations to partner in supporting stroke survivors and their caregivers. COMPASS provides ongoing training to hospitals and quality metrics so they can see how they are doing in improving care for patients after a stroke. We assess outcomes at 90 days and 1 year post stroke. The primary outcome of our study is function as reported by the patients. Secondary outcomes at 90 days include caregiver stress, all-cause readmissions 30 and 90 days after discharge (assessed via insurance data), cognitive status, taking medicines as needed, blood pressure control, depression, continuity of care, and use of community resources. One year after stroke, outcomes will include death, recurrent stroke, utilization of transitional care management billing codes, proportion of patients re-hospitalized within 7 or 14 days after their first stroke hospitalization, physician follow-up, and use of health care. Our Engagement Committee works with our community resource networks to advise and support the implementation of COMPASS, provide feedback to the researchers, and recommend ways to continue COMPASS in the future. These networks will help us tell others about the COMPASS results and (if merited) how to begin similar programs across the United States to improve life for stroke survivors and their caregivers. Stakeholder partners: American Stroke Association, North Carolina Stoke Care Collaborative, North Carolina Area Agency on Aging, North Carolina Center for Health Disparities.
Abstract Archived: We are planning a randomized trial of 50 North Carolina hospitals, in partnership with the North Carolina Stroke Care Collaborative (NCSCC) registry, to compare approaches to care for stroke patients. We are asking whether Comprehensive Post-Acute Stroke Services (COMPASS), which combines transitional care and early supported discharge for stroke patients who go home directly from the hospital, improves patients' daily function compared with usual care. We will also consider caregiver strain, hospital readmission rates, and mortality, use of health care, consistency of physician care, use of transitional care services, and death. We will also compare outcomes in some subgroups (race, sex, age, stroke severity, and insured versus uninsured). Participating hospitals will be assigned randomly to receive COMPASS or usual care. Phase 1 compares COMPASS with usual care. In phase 2, the usual-care hospitals will also receive COMPASS, while the other hospitals continue the intervention. In addition to COMPASS, which combines Medicare-approved transitional care services from advanced practice providers (APPs; nurse practitioners or physician assistants) and early supported discharge services coordinated by the APPs, our intervention includes a community coordinator, who will work with local organizations to improve services for stroke survivors and their caregivers, and a stroke scorecard report, so hospital and primary care providers can see how they are doing in improving care for patients after a stroke. Together with the patient and caregiver, the APPs will develop an individualized care plan for each patient. Trained post-acute-care coordinators will help organize community groups to improve and continue care for recovering stroke patients. We will assess 90-day and one-year health outcomes. The primary outcome of our study is function as reported by the patients. Secondary outcomes at 90 days include caregiver stress, all-cause readmissions 30 and 90 days after discharge (assessed via insurance data), cognitive status, taking medicines as needed, blood pressure control, depression, continuity of care, and use of community resources. One year after stroke, outcomes will include death, recurrent stroke, utilization of transitional care management billing codes, proportion of patients re-hospitalized within 7 or 14 days after their first stroke hospitalization, physician follow-up, and use of health care. Our Patient and Stakeholder Engagement Committee will work with our community coalitions to advise and support the implementation of COMPASS, provide feedback to the researchers, and recommend ways to continue COMPASS in the future. These coalitions will help us tell others about the COMPASS results and (if merited) how to begin similar programs across the United States to improve life for stroke survivors and their caregivers.

MeSH Terms:
  • Caregivers
  • Cognition
  • Continuity of Patient Care
  • Female
  • Humans
  • Insurance, Health
  • Male
  • Medicare
  • North Carolina
  • Outcome Assessment, Health Care
  • * Patient Discharge
  • Patient Readmission
  • Primary Health Care /organization & administration
  • Randomized Controlled Trials as Topic
  • Stroke
  • Time Factors
  • Treatment Outcome
  • United States
Country: United States
State: North Carolina
Zip Code: 27157
UI: 20153603
CTgovId: NCT02588664
Project Status: Ongoing
Record History: ('2021: Project extended to 2022. 2020: Project extended to 2021. Alternate Title: Comparing ways to improve daily functioning for stroke survivors after they leave the hospital--The COMPASS Study. 2018: Archived abstract to Abstract Archived 1 field and added new abstract.',)