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

Sabina B. Gesell, Cheryl D. Bushnell, Sara B. Jones, Sylvia W. Coleman, Samantha M. Levy, James G. Xenakis, Barbara J. Lutz, Janet Prvu Bettger, Janet Freburger, Jacqueline R. Halladay, Anna M. Johnson, Anna M. Kucharska-Newton, Laurie H. Mettam, Amy M. Pastva, Matthew A. Psioda, Meghan D. Radman, Wayne D. Rosamond, Mysha E. Sissine, Joanne Halls, Pamela W. Duncan

Research output: Contribution to journalArticlepeer-review

20 Scopus citations


Background: The 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. Methods: We 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. Results: Adoption: 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. Conclusions: COMPASS-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 registration: number: NCT02588664. Registered 28 October 2015.

Original languageEnglish
Article number978
JournalBMC Health Services Research
Issue number1
StatePublished - Dec 19 2019

Bibliographical note

Funding Information:
This project received funding from the Wake Forest CTSA through National Center for Advancing Translational Sciences (NCATS) National Institutes of Health (NIH) Grant Award UL1TR001420 and through PCORI Contract Award PCS-1403-14532.

Publisher Copyright:
© 2019 The Author(s).


  • Implementation Science
  • Ischemic Attack, Transient
  • Reimbursement Mechanisms
  • Stroke
  • Transitional Care

ASJC Scopus subject areas

  • Health Policy


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