ROCC Member Spotlight: Pamela W. Duncan PhD, FAPTA, FAHA

Pamela W. Duncan PhD, FAPTA, FAHA is a nationally and internationally renowned expert in health policy, outcomes research and clinical epidemiology. Her expertise is in post acute management of the elderly and individuals with stroke and falls management and prevention. In this Spotlight, Dr. Duncan details her recently PCORI-funded study COMPASS (COMprehensive Post Acute Stroke Services). See also the study's technical abstract and associated publications, and download Dr. Duncan’s ROCC Star profile.

Please describe the recently PCORI-funded study COMPASS (COMprehensive Post Acute Stroke Services). What is the research question? What is the study design, sample size, priority population?

Cluster Randomized Trial of 50 hospitals across North Carolina which have significant diversity (racial and geographic, urban and rural, comprehensive stroke centers and non-comprehensive stroke centers). Fifty North Carolina Stroke Care Collaborative participating hospitals will be randomized (stratified by stroke volume and primary stroke center status) to receive COMPASS or usual care (control group) in Phase 1. In Phase 2, usual care hospitals will cross over to COMPASS, while the early intervention hospitals sustain the intervention using hospital-based resources.

Patient population Patients over age 18 admitted to a NCSCC hospital with a diagnosis of ischemic or hemorrhagic stroke or transient ischemic attack and discharged from acute care hospitalization to home will be included (about 6,000 patients/year).

Research Question

This PCORI pragmatic trial will implement and compare the effectiveness of COMprehensive Post-Acute Stroke Services (COMPASS) to usual care. The COMPASS model of care combines CMS transitional care services provided by advanced practice providers (APP) and early supported discharge services coordinated by the APPs to develop with patients and families actionable care plans. Care plans will be individualized to manage blood pressure and diabetes, manage medications, increase physical activity, reduce falls risk, optimize functional recovery and optimize access to primary care and community-based services.

The trial has three integrated components: 1) COMPASS, which combines transitional care services provided by advanced practice providers (APPs) and early supported discharge services coordinated by the APPs; 2) COMPASS-funded post-acute care coordinators who will engage patient and stakeholder communities to improve post-acute stroke comprehensive stroke services; and 3) development of a stroke metrics scorecard for NCSCC hospitals and primary care providers. Well-trained APPs and coordinators will have access to online learning and ongoing support/consultation from WFBH personnel and board-certified vascular neurologists. 

What outcomes will be measured during the course of the study? Potential impact?

The primary outcome will be patient-reported functional status (SIS-16). Secondary outcomes at 90 days include caregiver stress (MCSI); unadjusted 30- and 90-day all-cause readmissions captured via claims data; cognitive status, medication adherence, blood pressure management, depression, continuity of care, and use of community resources. One year post-stroke outcomes ascertained via claims data will include: mortality, recurrent stroke, use of transitional care management billing codes, proportion of patients with 7- and 14-day post-stroke hospitalization, physician follow-up, and health care use (emergency department visits, number of hospital admissions and inpatient days, and admissions to skilled nursing and inpatient rehabilitation facilities).

These functional and patient-centered outcomes could be adopted in the future as metrics for value-based health care. Value-based outcomes could be expanded to include the metric - did the patient get better (improve function) and the caregiver have less stress.

What other health systems and stakeholders will join Wake Forest Baptist Medical Center in the project? Please share any lessons learned from collaborating across system. 

The COMPASS trial was developed and will be implemented in collaboration with North Carolina Justus Warren Task Force, the NC Stroke Care Collaborative (NCSCC), Wake Forest Baptist Medical Center Comprehensive Stroke Program, UNC School of Public Health, East Carolina Centers for Health Disparities, and the Duke University School of Nursing. North Carolina Stroke Care Collaborative includes over 80 hospitals. Other Stakeholders; American Heart/American Stroke Association, North Carolina Area Agency on Aging,  North Carolina Area Agency on Aging, Home Health Agencies.

Lessons Learned: For successful collaboration must have mutual vision and goals, value a culture of collaboration and multidisciplinary goals, all individuals and organizations driven by purpose and a desire to make a meaningful impact, supported by open and transparent communication and a strong and experienced leadership teams.

Please describe the process used to solicit feedback from stroke survivors on ways to improve post discharge stroke care.

Patients, family caregivers regional stakeholder organizations designed a patient-centered intervention. We interviewed patients statewide for their experience during discharge and recovery. Themes that emerged were used to define the intervention goals and components. We incorporated their “voice “and needs throughout the proposal design and writing.  We also identified a diverse, highly engaged cross-section of relevant stakeholders (AHA/ASA, NC Stroke Associations, Leaders of Post- Acute Stroke Coordinators, Area Agency on Aging, Area Health Education Centers, Eastern NC Stroke Network, NC Stroke Care Collaborative, Jusus Warren Task Force for Stroke) to form working groups and jointly establish the objectives, prepare the proposal, and informs plans for implementation.