Hospital to Home Transition for Patients With Stroke Under Bundled Payments

Yucheng Hou, Cheryl D. Bushnell, Pamela W. Duncan, Anna M. Kucharska-Newton, Jacqueline R. Halladay, Janet K. Freburger, Justin G. Trogdon

Research output: Contribution to journalComment/debate

4 Scopus citations


Bundled payments are a promising alternative payment model for reducing costs and improving the coordination of postacute stroke care, yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Centers for Medicare & Medicaid Innovation Bundled Payment for Care Improvement Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.

Original languageEnglish
Pages (from-to)1658-1664
Number of pages7
JournalArchives of Physical Medicine and Rehabilitation
Issue number8
StatePublished - Aug 2021

Bibliographical note

Funding Information:
Supported by the Agency for Healthcare Research and Quality (grant no. AHRQ R01 HS025723 ).

Publisher Copyright:
© 2021 The American Congress of Rehabilitation Medicine


  • Episode of care
  • Rehabilitation
  • Stroke
  • Sub-acute care
  • Transitional care

ASJC Scopus subject areas

  • Physical Therapy, Sports Therapy and Rehabilitation
  • Rehabilitation


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