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

Area of Science:

• Neurology
• Healthcare Quality Improvement
• Public Health

Background:

• Post-stroke care lacks standardized protocols in the US, leading to high complication and readmission rates.
• Many stroke survivors are discharged without adequate postacute care services.
• The TRAnsition Coaching for Stroke (TRACS) program provides a foundation for enhanced transitional care.

Purpose of the Study:

• To describe the development, structure, and quality metrics of the COMprehensive Post-Acute Stroke Services (COMPASS) care model.
• To assess the effectiveness of the COMPASS model in a large-scale pragmatic trial.
• To establish measurable best practices for postacute stroke care.

Main Methods:

• Development of the COMPASS model, an extension of the TRACS program, focusing on clinician-led quality improvement.
• A cluster-randomized pragmatic trial across 41 sites in North Carolina, aiming to recruit 6,000 participants.
• COMPASS involves hospital identification/education, telephone follow-up (2, 30, 60 days), and early clinic visits (within 14 days) with functional/social determinant assessments via a web-based application.

Main Results:

• The COMPASS model integrates evidence-based, person-centered, and stakeholder-driven components.
• Individualized care plans are generated immediately using embedded algorithms based on patient assessments.
• The pragmatic design and quality metrics are intended to support measurable improvements in postacute stroke care.

Conclusions:

• The COMPASS model provides a structured, evidence-based approach to postacute stroke care.
• This model has the potential to improve outcomes for stroke survivors discharged home.
• Standardization of postacute stroke care through models like COMPASS is crucial for reducing readmissions and enhancing recovery.