About the COMPASS Study

About the COMPASS Study

The COMPASS Study was a pragmatic trial to investigate post-acute stroke care models in North Carolina hospitals. The pragmatic nature of the study emphasizes ease of implementation and sustainability given real-world practice and reimbursement models as well as the importance of meaningful patient outcomes. 

Study Aims

Primary Aim

• Determine the comparative effectiveness of COMPASS model vs usual care on stroke survivor functional status at 90 days post-stroke

Secondary Aims

• Assess caregiver strain at 90 days
• Assess self-rated general health, medication adherence, self-monitoring of blood pressure, global disability, physical activity, depression, cognition, falls, fatigue, and satisfaction with care at 90 days
• Using claims data, we determined all-cause readmissions at 30 days and 90 days and at 1 year
• Using claims data, we determined mortality, visits to the emergency department, skilled nursing facility or inpatient rehabilitation facility, and use of the Transitional Care Management (TCM) billing code at 1 year

Exploratory Aims

• We conducted a number of analyses to explore our Phase 2 data to better understand Sustainability of the COMPASS intervention for patients and hospitals

Why Conduct the Study

This study was motivated by the high stroke burden and the needs of stroke patients for post-acute care management.

• Post-acute care after stroke is currently fragmented and holistic approaches to prevention, recovery, self-management and support do not exist
• 2 out of 5 stroke patients who are discharged home are not referred to any post-acute care
• 1 in 4 stroke patients who are discharged home are re-admitted within 4 months of discharge
• North Carolina has the 8th-highest stroke mortality rate in the country
• NC patients have identified the critical need for post-acute care management

Here is what stroke survivors and other stakeholders shared about their experiences:

“So what is in place for the patient? Nothing. Seriously, nothing. No visiting nurse, no one to answer questions, or help them to get what they need. That is why people end up back in the hospital.”
60-year-old, female, living in urban NC (stroke at 45)

“If there is one thing I advocate for, it is for a navigator or ombudsman for stroke patients. A follow-up phone call has got to be the prime piece that has to happen in stroke recovery.”
60-year-old, male, living in urban NC

“Stroke is just as hard on family members. They carry a large portion of the weight of recovery.”
31-year-old female, living in rural NC (stroke at 22)

“Preparing the arrangements at home was left to the family. There was no home visit, and no directions were given to help with getting other services.”
62-year-old male, living in urban NC