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

Abstract

BackgroundThe COMprehensive Post-Acute Stroke Services (COMPASS) pragmatic trial compared the effectiveness of comprehensive transitional care (COMPASS-TC) versus usual care among stroke and transient ischemic attack (TIA) patients discharged home from North Carolina hospitals. We evaluated implementation of COMPASS-TC in 20 hospitals randomized to the intervention using the RE-AIM framework.MethodsWe evaluated hospital-level Adoption of COMPASS-TC; patient Reach (meeting transitional care management requirements of timely telephone and face-to-face follow-up); Implementation using hospital quality measures (concurrent enrollment, two-day telephone follow-up, 14-day clinic visit scheduling); and hospital-level sustainability (Maintenance). Effectiveness compared 90-day physical function (Stroke Impact Scale-16), between patients receiving COMPASS-TC versus not. Associations between hospital and patient characteristics with Implementation and Reach measures were estimated with mixed logistic regression models.ResultsAdoption: Of 95 eligible hospitals, 41 (43%) participated in the trial. Of the 20 hospitals randomized to the intervention, 19 (95%) initiated COMPASS-TC.Reach: A total of 24% (656/2751) of patients enrolled received a billable TC intervention, ranging from 6 to 66% across hospitals.Implementation: Of eligible patients enrolled, 75.9% received two-day calls (or two attempts) and 77.5% were scheduled/offered clinic visits. Most completed visits (78% of 975) occurred within 14 days.Effectiveness: Physical function was better among patients who attended a 14-day visit versus those who did not (adjusted mean difference: 3.84, 95% CI 1.42–6.27, p = 0.002).Maintenance: Of the 19 adopting hospitals, 14 (74%) sustained COMPASS-TC.ConclusionsCOMPASS-TC implementation varied widely. The greatest challenge was reaching patients because of system difficulties maintaining consistent delivery of follow-up visits and patient preferences to pursue alternate post-acute care. Receiving COMPASS-TC was associated with better functional status.Trial registrationClinicalTrials.gov number: NCT02588664. Registered 28 October 2015.

Methodological Challenges and Statistical Approaches in the COMprehensive Post-Acute Stroke Services Study

“…We have previously reported on the substantial efforts required to recruit hospitals and to implement COMPASS-TC. 16 , 29 Critical to successful TC delivery is a commitment to implementing the care model as new standard practice and having sufficient capacity to do so. 39 In the COMPASS study, research staff provided ongoing, extensive support for training and implementation.…”

“…Incentives may be particularly important to engage hospitals with limited capacity and to generate high-quality data that achieve the best return on investment in pragmatic trials. 14 , 29 , 39 …”

“…Others never achieved true buy-in by those implementing the intervention. 29 Patients also experienced barriers to receipt of treatment including costs, transportation challenges, and difficulty balancing multiple follow-up visits. As a result, only 35% of patients assigned to treatment received the core elements of the COMPASS-TC intervention (ie, an eCare plan within 30 d of hospital discharge).…”

“… 32 Second, a key reason for noncompliance to COMPASS-TC was preference for alternative follow-up, for example, primary care, consistent with that offered in UC. 29 …”

Transitional Care for Patients with Portal Hypertension:A multicenter study of intervention for patients post-TIPS

“…6 Transitional care intervention programs have been targeted at patients with speci c diagnoses 7,8 or focused on general medical patients with an average risk of readmission. 9,10 A new model of specialized caregiving that is based on a series of diagnostic imaging procedures performed in real time and on the integrated activity of consultant hepatologists in outpatient departments, dedicated nurses, physicians in training, and primary physicians has reduced the rates of 30-day readmission and 12-month mortality in patients with cirrhosis and ascites. 11 There have been few well-designed studies supporting the effectiveness of transitional care for patients with portal hypertension post-TIPS, primarily due to the multifaceted nature of portal hypertension complications and the di culty of performing randomized controlled studies (RCTs) on transitional care interventions.…”