Abstract
BackgroundPatients discharged home after stroke face significant challenges managing residual neurological deficits, secondary prevention, and pre-existing chronic conditions. Post-discharge care is often fragmented leading to increased healthcare costs, readmissions, and sub-optimal utilization of rehabilitation and community services. The COMprehensive Post-Acute Stroke Services (COMPASS) Study is an ongoing cluster-randomized pragmatic trial to assess the effectiveness of a comprehensive, evidence-based, post-acute care model on patient-centered outcomes.MethodsForty-one hospitals in North Carolina were randomized (as 40 units) to either implement the COMPASS care model or continue their usual care. The recruitment goal is 6000 patients (3000 per arm). Hospital staff ascertain and enroll patients discharged home with a clinical diagnosis of stroke or transient ischemic attack. Patients discharged from intervention hospitals receive 2-day telephone follow-up; a comprehensive clinic visit within 2 weeks that includes a neurological evaluation, assessments of social and functional determinants of health, and an individualized COMPASS Care Plan™ integrated with a community-specific resource database; and additional follow-up calls at 30 and 60 days post-stroke discharge. This model is consistent with the Centers for Medicare and Medicaid Services transitional care management services provided by physicians or advanced practice providers with support from a nurse to conduct patient assessments and coordinate follow-up services. Patients discharged from usual care hospitals represent the control group and receive the standard of care in place at that hospital. Patient-centered outcomes are collected from telephone surveys administered at 90 days. The primary endpoint is patient-reported functional status as measured by the Stroke Impact Scale 16. Secondary outcomes are: caregiver strain, all-cause readmissions, mortality, healthcare utilization, and medication adherence. The study engages patients, caregivers, and other stakeholders (including policymakers, advocacy groups, payers, and local community coalitions) to advise and support the design, implementation, and sustainability of the COMPASS care model.DiscussionGiven the high societal and economic burden of stroke, identifying a care model to improve recovery, independence, and quality of life is critical for stroke survivors and their caregivers. The pragmatic trial design provides a real-world assessment of the COMPASS care model effectiveness and will facilitate rapid implementation into clinical practice if successful.Trial registrationClinicaltrials.gov: NCT02588664; October 23, 2015.
Highlights
Patients discharged home after stroke face significant challenges managing residual neurological deficits, secondary prevention, and pre-existing chronic conditions
African Americans comprise over 20% of the North Carolina (NC) population and are more likely to be affected by stroke than their white counterparts, such as having higher post-stroke hospital readmission rates [5, 7, 8]
This study was designed to evaluate whether implementation of a post-acute stroke care model in real-world clinical practice improves functional status of stroke patients discharged home compared with usual care
Summary
Patients discharged home after stroke face significant challenges managing residual neurological deficits, secondary prevention, and pre-existing chronic conditions. Stroke is a major cause of long-term disability and mortality in the United States, exemplifying a complex chronic disease with high co-morbidity, associated healthcare costs, and readmission rates [1,2,3,4,5,6]. Half are discharged directly home from the hospital, where they often realize disabilities not identified during hospitalization and are at risk for complications such as falls, physical deconditioning, aspiration pneumonia, infections, social isolation and depression as well as recurrent stroke [4, 9,10,11,12,13,14,15,16]. Patients with mild post-stroke disability often have undetected physical and cognitive deficits that interfere with function and management of risk factors and medication [17, 18]. Individuals discharged with a clinical diagnosis of transient ischemic attack (TIA) may have residual deficits and are at increased risk for future stroke [19,20,21]
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