Post-Acute Stroke Services Research Articles

Meeting Medicare requirements for transitional care: Do stroke care and policy align?

This study (1) describes transitional care for stroke patients discharged home from hospitals, (2) compares hospitals' standards of transitional care with core transitional care management (TCM) components recognized by Medicare, and (3) examines the association of policy and hospital specialty designations with TCM implementation. Hospitals participating in the Comprehensive Post-Acute Stroke Services (COMPASS) Study provided data on their hospital, stroke patient population, and standards of transitional care. Hospital-reported transitional care strategies were compared with the federal TCM definition (2-day follow-up, 14-day visit, non-face-to-face services). We examined the associations of TCM billing, stroke center certification, and Magnet nursing excellence designation with TCM implementation. Transitional care varied widely among 41 hospitals in North Carolina and no one strategy was universally applied or provided across hospitals. One third of hospitals met the TCM definition (37% provided telephone follow-up, 76% provided face-to-face provider follow-up, all provided a type of non-face-to-face support). There were no differences between groups (TCM met/not met) in hospital characteristics or transitional care resources and processes. Stroke center certification, Magnet designation, and use of TCM billing codes were not different for hospitals that did and did not meet the TCM definition. There was substantial variation in the provision of strategies supporting stroke patients' transition home from the hospital. Supportive stroke care transitions are essential when more than 50% of stroke patients are discharged home and more than half experience moderate to severe strokes. More research is needed to identify drivers of TCM uptake. NCT02588664.

COMPASS-CP: An Electronic Application to Capture Patient-Reported Outcomes to Develop Actionable Stroke and Transient Ischemic Attack Care Plans.

Background Patient-reported outcomes (PROs) are clinical tools that measure patients' goals of care and assess patient-reported physical, mental, and social well-being. Despite their value in advancing patient-centered care, routine use of PROs in stroke management has lagged. As part of the pragmatic COMPASS (Comprehensive Post-Acute Stroke Services) trial, we developed COMPASS-Care Plan (CP), a clinician-facing application that captures and analyzes PROs for stroke and transient ischemic attack patients discharged home and immediately generates individualized electronic CP. In this report, we (1) present our methods for developing and implementing COMPASS-CP PROs, (2) provide examples of CP generated from COMPASS-CP, (3) describe key functional, social, and behavioral determinants of health captured by COMPASS-CP, and (4) report on clinician experience with using COMPASS-CP in routine clinical practice for care planning and engagement of stroke and transient ischemic attack patients discharged home. Methods and Results We report on the first 871 patients enrolled in 20 North Carolina hospitals randomized to the intervention arm of COMPASS between July 2016 and February 2018; these patients completed a COMPASS follow-up visit within 14 days of hospital discharge. We also report user satisfaction results from 56 clinicians who used COMPASS-CP during these visits. COMPASS-CP identified more cognitive and depression deficits than physical deficits. Within 14-day posthospitalization, less than half of patients could list the major risk factors for stroke, 36% did not recognize blood pressure as a stroke risk factor, and 19% of patients were nonadherent with prescribed medications. Three-fourths of clinicians reported that COMPASS-CP identifies important factors impacting patients' recovery that they otherwise may have missed, and two-thirds were highly satisfied with COMPASS-CP. Conclusions The COMPASS-CP application meets an immediate need to incorporate PROs into the clinical workflow to develop patient-centered CP for stroke patients and has high user satisfaction. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02588664.

A Person‐Centered Approach to Poststroke Care: The COMprehensive Post‐Acute Stroke Services Model

Many individuals who have had a stroke leave the hospital without postacute care services in place. Despite high risks of complications and readmission, there is no standard in the United States for postacute stroke care after discharge home. We describe the rationale and methods for the development of the COMprehensive Post-Acute Stroke Services (COMPASS) care model and the structure and quality metrics used for implementation. COMPASS, an innovative, comprehensive extension of the TRAnsition Coaching for Stroke (TRACS) program, is a clinician-led quality improvement model providing early supported discharge and transitional care for individuals who have had a stroke and have been discharged home. The effectiveness of the COMPASS model is being assessed in a cluster-randomized pragmatic trial in 41 sites across North Carolina, with a recruitment goal of 6,000 participants. The COMPASS model is evidence based, person centered, and stakeholder driven. It involves identification and education of eligible individuals in the hospital; telephone follow-up 2, 30, and 60 days after discharge; and a clinic visit within 14 days conducted by a nurse and advanced practice provider. Patient and caregiver self-reported assessments of functional and social determinants of health are captured during the clinic visit using a web-based application. Embedded algorithms immediately construct an individualized care plan. The COMPASS model's pragmatic design and quality metrics may support measurable best practices for postacute stroke care.

Hospital recruitment for a pragmatic cluster-randomized clinical trial: Lessons learned from the COMPASS study

BackgroundPragmatic randomized clinical trials are essential to determine the effectiveness of interventions in “real-world” clinical practice. These trials frequently use a cluster-randomized methodology, with randomization at the site level. Despite policymakers’ increased interest in supporting pragmatic randomized clinical trials, no studies to date have reported on the unique recruitment challenges faced by cluster-randomized pragmatic trials. We investigated key challenges and successful strategies for hospital recruitment in the Comprehensive Post-Acute Stroke Services (COMPASS) study.MethodsThe COMPASS study is designed to compare the effectiveness of the COMPASS model versus usual care in improving functional outcomes, reducing the numbers of hospital readmissions, and reducing caregiver strain for patients discharged home after stroke or transient ischemic attack. This model integrates early supported discharge planning with transitional care management, including nurse-led follow-up phone calls after 2, 30, and 60 days and an in-person clinic visit at 7–14 days involving a functional assessment and neurological examination. We present descriptive statistics of the characteristics of successfully recruited hospitals compared with all eligible hospitals, reasons for non-participation, and effective recruitment strategies.ResultsWe successfully recruited 41 (43%) of 95 eligible North Carolina hospitals. Leading, non-exclusive reasons for non-participation included: insufficient staff or financial resources (n = 33, 61%), lack of health system support (n = 16, 30%), and lack of support of individual decision-makers (n = 11, 20%). Successful recruitment strategies included: building and nurturing relationships, engaging team members and community partners with a diverse skill mix, identifying gatekeepers, finding mutually beneficial solutions, having a central institutional review board, sharing published pilot data, and integrating contracts and review board administrators.ConclusionsAlthough we incorporated strategies based on the best available evidence at the outset of the study, hospital recruitment required three times as much time and considerably more staff than anticipated. To reach our goal, we tailored strategies to individuals, hospitals, and health systems. Successful recruitment of a sufficient number and representative mix of hospitals requires considerable preparation, planning, and flexibility. Strategies presented here may assist future trial organizers in implementing cluster-randomized pragmatic trials.Trial registrationClinicaltrials.gov, NCT02588664. Registered on 23 October 2015.

Abstract WP304: Clinician-User Satisfaction With Compass-cp for Stroke

Introduction: COMPASS-CP is a patient-centered electronic application that includes real-time, patient-reported measures of functional and social determinants of health (PROMs). Algorithms assess PROMS and immediately generate actionable, individualized care plans. Algorithms may also trigger a caregiver assessment. COMPASS-CP identifies relevant local community resources tailored to the needs identified on the care plan. COMPASS-CP is administered by a nurse during a 7 to 14 day post-stroke transitional care clinic visit which meets CMS requirements for transitional care management codes. COMPASS-CP is being evaluated in a PCORI-funded pragmatic trial of COMprehensive Post-Acute Stroke Services (COMPASS). Scalability and sustainability of COMPASS-CP will require high user satisfaction. The purpose of this study was to evaluate clinician/user satisfaction with the COMPASS-CP application. Methods: We surveyed 56 clinicians (nurses, NPs or PAs) from 20 hospitals utilizing COMPASS-CP to assess satisfaction with the application in (1) efficiency in care plan development, (2) identifying factors impacting patient self-management and caregiver needs, (3) patient/provider communication, (4) patient/caregiver engagement, and (5) patient satisfaction with care. Clinicians rated their satisfaction on a 5-point Likert scale as either Strongly Agree , Agree , Neither Agree Nor Disagree , Disagree , Strongly Disagree . Results: Forty-four clinicians (79%) from 19 hospitals (95%) responded. Thirty-nine responders (89%) had used COMPASS-CP for 3 months or more. Conclusions: Successful implementation of electronic applications requires high levels of clinician/user satisfaction. The majority (66 %) of users agreed that they were satisfied with the COMPASS-CP application and 58% reported it made their job easier. Future analyses will determine if individualized care plans improve patient satisfaction and outcomes.

Abstract TP169: Knowledge of Hypertension as a Stroke Risk Factor and Use of Home Blood Pressure Monitoring. A Preliminary Report From Comprehensive Post-Acute Stroke Services (COMPASS) Study

Background: Self-monitoring blood pressure (BP) among persons with hypertension is associated with lower BP. The prevalence of BP self-monitoring and factors that may predict this behavior in the early post-acute stroke setting are unknown. Our aim was to identify whether knowledge of high BP as a stroke risk factor, social support, or primary care visits would be independently associated with BP self-monitoring 30 days after discharge in stroke patients. Methods: We utilized data from consenting intervention participants in the Comprehensive Post-Acute Stroke Services (COMPASS) Study, who attended the post-discharge clinic visit, and had a 30-day follow-up call (N=528). The primary outcome was self-reported BP monitoring assessed at the 30-day call. The clinic visit included assessment of risk factor knowledge, social support and other clinical and neurological factors. Odds ratios were obtained using logistic mixed models that adjusted for confounders classified as demographic characteristics and clinical factors. Results: Among 528 patients (mean age 67 (SD=14), 50.9% female, 80.1% white), 435 (82%) reported self-monitored BP at 30 days. Fifty-seven percent of those who noted high BP as a stroke risk factor monitored BP vs 43% of those who did not acknowledge this risk factor. Knowledge of BP as risk factor was significantly associated with monitoring after adjustment for demographic, but not after adjustment for clinical factors (Table). Those with social support and recent PCP visits also had higher odds of self-monitoring than those without support or PCP visits, respectively, though estimates were highly imprecise. Conclusions: Among participants, acknowledging high BP is a stroke risk factor may lead to greater use of self-home BP monitoring at 30 days, although the magnitude of this effect is diminished when adjusted for having a history of hypertension. The COMPASS Study will determine whether BP self-monitoring leads to improved BP control at 90 days.

Abstract WMP110: Building Successful Hospital-Community Networks for Stroke Survivors and Their Family Caregivers

Introduction: Stroke patients, caregivers and providers are often frustrated by a lack of knowledge about community resources to optimize post-acute stroke care and recovery. To address this gap, an innovative model of care is being tested in the COMprehensive Post-Acute Stroke Services (COMPASS) Study, a PCORI-funded cluster-randomized pragmatic trial in North Carolina (NC). Hospital-based post-acute nurse care coordinators (PAC) and advanced practice providers partnered with community organizations to build 20 community resource networks (CRNs) providing transitional care to stroke survivors and caregivers. Community organizations include Area Agencies on Aging, Community Care of NC Community Pharmacy Enhanced Services Network, and NC Department of Health and Human Services. Methods: In May 2017, 337 members from 19 CRNs were surveyed to assess the utility of the CRNs and their impact on connecting survivors to community-based services. COMPASS team members, including PACs from all intervention hospitals and 36 community representatives from 17 CRNs responded (N=85, 25% response rate). Results: 80% of the PACs had contacted CRN members for help connecting patients to community-based services; 65% found the CRN very useful or useful. By working together hospital and community members felt their CRN was able to respond to stroke / TIA patients’ needs and problems: 30% to a great extent, 41% mostly, 9% sometimes, 11% a little, 10% not at all. In open-ended comments, streamlined referrals and partnerships with community pharmacists were identified as beneficial. Lack of transportation services in rural areas was a barrier. Some community service providers reported not being contacted again after the initial convening with the hospital. Conclusion: PACs were able to build local CRNs to integrate medical services with community-based services as a strategy for addressing functional and social determinants of health. The majority reported that working with their CRN helped them optimize patients’ recovery after stroke. Future analyses will assess patient utilization of recommended community services. A quality metric assessing hospital-community partnerships may help solidify significance of this important and often overlooked part of care.

Abstract 26: Disparities in Post-Acute Stroke Rehabilitation Services Delivery: Preliminary Findings From the COMprehensive Post-Acute Stroke Services (COMPASS) Study

Background: Timely rehabilitation after stroke is essential for optimizing recovery. Patients discharged home can experience unnecessary service delays and gaps in care. Our aim was to examine sociodemographic characteristics associated with receipt of rehabilitation services within 30 days after discharge home in stroke or transient ischemic attack (TIA) patients. Methods: COMPASS is a cluster-randomized pragmatic trial measuring the effectiveness of the COMPASS model of care vs. usual care on functional status 90 days after stroke or TIA for patients discharged home. We analyzed data from 369 participants who enrolled in the intervention arm of the COMPASS trial, completed the post-acute clinic visit within 14 days, and the 30-day call between July 2016 and May 15, 2017. For those who were referred to rehabilitation services at hospital discharge or at the clinic visit, receipt of home health (HH) and outpatient (OP) rehabilitation services was reported by the participant during the 30-day call. Sociodemographic differences between those who did and did not receive these services were evaluated. We computed adjusted odds ratios with 95% confidence intervals using logistic regression to identify factors associated with receipt of rehabilitation services. Results: Of the 369 patients, 176 (47.7%) had ascertainment of receipt of services. Of the 115 patients referred to HH, 50 (43.5%) received it, and of 85 patients referred to OP therapy, 29 (34.1%) received it. There were no statistically significant differences in sociodemographic characteristics related to receipt of HH, but non-whites were less likely (3 of 20, or 15%) than whites (25 of 64, 34.9%) to receive OP therapy. After adjustment for NIHSS, ambulatory status at hospital admission, and age, non-white participants had a 78% decreased odds (OR 0.22; 95% CI 0.05, 0.95; p=0.04) of receiving OP therapy. Conclusion: These findings indicate that a significant gap exists between referral to and receipt of recommended post-acute stroke rehabilitation services. In addition, despite the small sample size, our results suggest that there may be a disparity in receipt of OP therapy for non-white patients relative to white patients.

The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial

The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial

The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial

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.

Methods guiding stakeholder engagement in planning a pragmatic study on changing stroke systems of care.

The Comprehensive Post-Acute Stroke Services (COMPASS) Study is one of the first large pragmatic randomized-controlled clinical trials using comparative effectiveness research methods, funded by the Patient-Centered Outcomes Research Institute. In the COMPASS Study, we compare the effectiveness of a patient-centered, transitional care intervention versus usual care for stroke patients discharged home from acute care. Outcomes include stroke patient post-discharge functional status and caregiver strain 90 days after discharge, and hospital readmissions. A central tenet of Patient-Centered Outcomes Research Institute-funded research is stakeholder engagement throughout the research process. However, evidence on how to successfully implement a pragmatic trial that changes systems of care in combination with robust stakeholder engagement is limited. This combination is not without challenges. We present our approach for broad-based stakeholder engagement in the context of a pragmatic trial with the participation of patients, caregivers, community stakeholders, including the North Carolina Stroke Care Collaborative hospital network, and policy makers. To maximize stakeholder engagement throughout the COMPASS Study, we employed a conceptual model with the following components: (1) Patient and Other Stakeholder Identification and Selection; (2) Patient and Other Stakeholder Involvement Across the Spectrum of Research Activities; (3) Dedicated Resources for Patient and Other Stakeholder Involvement; (4) Support for Patient and Other Stakeholder Engagement Through Organizational Processes; (5) Communication with Patients and Other Stakeholders; (6) Transparent Involvement Processes; (7) Tracking of Engagement; and (8) Evaluation of Engagement. In this paper, we describe how each component of the model is being implemented and how this approach addresses existing gaps in the literature on strategies for engaging stakeholders in meaningful and useful ways when conducting pragmatic trials.

Abstract TP308: Transitional Care in Stroke Certified and Non-certified Hospitals: The Comprehensive Post-Acute Stroke Services (COMPASS) Study

Background: Greater than 50% of stroke patients are discharged home from the hospital, most with continuing care needs. In the absence of evidence-based transitional care interventions for stroke patients, procedures likely vary by hospital even among stroke-certified hospitals with requirements for transitional care protocols. We examined the standard of transitional care among NC hospitals enrolled in the COMPASS study comparing stroke-certified and non-certified hospitals. Methods: Hospitals completed an online, self-administered, web-based questionnaire to assess usual care related to hospitals’ transitional care strategy, stroke program structural components, discharge planning processes, and post-discharge patient management and follow-up. Response frequencies were compared between stroke certified versus non-certified hospitals using chi-squared statistics and Fisher’s exact test. Results: As of July 2016, the first 27 hospitals enrolled (of 40 expected) completed the survey (67% certified as a primary or comprehensive stroke center). On average, 54% of stroke patients were discharged home. Processes supporting hospital-to-home care transitions, such as timely follow-up calls and follow-up with neurology, were infrequent and overall less common for non-certified hospitals (Table). Assessment of post-discharge outcomes was particularly infrequent among non-certified sites (11%) compared with certified sites (56%). Uptake of transitional care management billing codes and quality metrics was low for both certified and non-certified hospitals. Conclusion: Significant variation exists in the infrastructure and processes supporting care transitions for stroke patients among COMPASS hospitals in NC. COMPASS as a pragmatic cluster-randomized trial will compare outcomes among hospitals that implement a CMS-directed model of transitional care with those hospitals that provide highly variable transitional care services.

Lack of post-acute stroke services hindering some patients’ recovery

An audit of post-acute stroke services across England, Wales and Northern Ireland has found wide variations in standards - with 'too many areas failing to commission comprehensive care', according to the authors.

Perceived value of stroke outcome measures across the post-acute care continuum: A qualitative case study

Connecting the continuum of post-acute care stroke services may be important for easing patients' transition between settings and facilitating recovery and community reintegration. The use of outcome measures is suggested as one means of connecting the continuum. The purpose of this qualitative case study is to describe administrators' and physiotherapists' perceived value of an outcomes program across the post-acute care stroke continuum at a rehabilitation hospital. Data were collected through individual interviews and focus groups with 18 participants. Three themes emerged on the value of the outcomes program: 1) enhanced communication; 2) supports clinical decision-making; and 3) value of objective data. These findings lend support for the use of standardized outcome measures by physiotherapists in stroke rehabilitation. Findings from this study may be useful for organizations and physiotherapists who wish to integrate outcome measures into practice.

Stroke Rehab Down Under: Can Rupert Murdoch, Crocodile Dundee, and an Aboriginal Elder Expect the Same Services and Care?

Australia is the world’s sixth largest country, has a relatively small population of 21.5 million, and a blended (public and private) health system. In this article, we explain the stroke rehabilitation infrastructure including consumer organisations, research networks, data collection systems, and registries. This represents a complex but fledgling set of organisations showing great promise for coordination of care and research. The article goes on to expose the inequalities in service provision by describing the paths of stroke survivors in three settings – in the city, in the country, and in remote settings. The complexities and difficulties in treating indigenous stroke survivors are described in a culturally sensitive narrative. The article then discusses the outcomes of the first Australian audit of post acute stroke services completed in December 2008, which describes the journeys of 2,119 stroke survivors at 68 rehabilitation units throughout Australia’s 6 states and 2 territories. It demonstrates an average length of stay of 26 days, with 18% of survivors requiring nursing home or other supported accommodation. The article concludes with future directions for stroke rehabilitation in Australia, which include hyperacute rehabilitation trials, studies in 7-days-a-week rehabilitation, and the potential use of robotics.

Stroke Rehab Down Under: Can Rupert Murdoch, Crocodile Dundee, and an Aboriginal Elder Expect the Same Services and Care?

Australia is the world's sixth largest country, has a relatively small population of 21.5 million, and a blended (public and private) health system. In this article, we explain the stroke rehabilitation infrastructure including consumer organisations, research networks, data collection systems, and registries. This represents a complex but fledgling set of organisations showing great promise for coordination of care and research. The article goes on to expose the inequalities in service provision by describing the paths of stroke survivors in three settings - in the city, in the country, and in remote settings. The complexities and difficulties in treating indigenous stroke survivors are described in a culturally sensitive narrative. The article then discusses the outcomes of the first Australian audit of post acute stroke services completed in December 2008, which describes the journeys of 2,119 stroke survivors at 68 rehabilitation units throughout Australia's 6 states and 2 territories. It demonstrates an average length of stay of 26 days, with 18% of survivors requiring nursing home or other supported accommodation. The article concludes with future directions for stroke rehabilitation in Australia, which include hyperacute rehabilitation trials, studies in 7-days-a-week rehabilitation, and the potential use of robotics.