Implementation of a billable transitional care model for stroke patients: the COMPASS study.

Area of Science:

• Stroke recovery and rehabilitation
• Healthcare implementation science
• Transitional care models

Background:

• The COMprehensive Post-Acute Stroke Services (COMPASS) pragmatic trial evaluated comprehensive transitional care (COMPASS-TC) versus usual care for stroke and transient ischemic attack (TIA) patients.
• Implementation of COMPASS-TC was assessed in 20 hospitals using the RE-AIM framework.

Purpose of the Study:

• To evaluate the implementation and effectiveness of COMPASS-TC in North Carolina hospitals.
• To assess hospital-level adoption, patient reach, implementation fidelity, and maintenance of COMPASS-TC.
• To compare 90-day physical function between patients receiving COMPASS-TC and usual care.

Main Methods:

• Hospital-level adoption, patient reach, implementation quality measures (e.g., timely follow-up calls/visits), and maintenance were evaluated.
• Effectiveness was measured by comparing 90-day physical function (Stroke Impact Scale-16) between groups.
• Mixed logistic regression models analyzed associations between hospital/patient characteristics and implementation/reach.

Main Results:

• 19 out of 20 intervention hospitals initiated COMPASS-TC (95% adoption).
• Only 24% of enrolled patients received a billable transitional care intervention, with significant hospital variation (6-66%).
• Patients attending a 14-day visit showed significantly better physical function (adjusted mean difference: 3.84).

Conclusions:

• COMPASS-TC implementation varied, with patient reach being a major challenge due to system and patient preference factors.
• Despite implementation hurdles, receiving COMPASS-TC was associated with improved physical function for stroke survivors.
• Strategies to enhance patient engagement and consistent follow-up are crucial for optimizing transitional care effectiveness.