By Melinda Young


Investigators developed a comprehensive transitional care program for people who are discharged home after a stroke.

  • The Comprehensive Post-Acute Stroke Services (COMPASS) program was studied at 20 different hospitals in North Carolina.
  • Care coordinators called patients to ensure they filled their medication, bought healthy food, and were prepared for their clinic and provider visits.
  • COMPASS helped patients and care coordinators find solutions to the most urgent needs.

Vulnerable stroke patients often are transitioned home, which can create challenges and the continued need for case management or follow-up care.

Researchers studied these transitions in a pragmatic trial to see if health systems would implement transitional care for certain stroke patients, says Pamela W. Duncan, PhD, PT, professor of neurology at Wake Forest School of Medicine in Winston-Salem, NC.

“We randomized hospitals. Some were the [12-month] intervention hospitals, and others were usual care,” Duncan says. “We enrolled 40 hospitals across the state of North Carolina.”

The Comprehensive Post-Acute Stroke Services (COMPASS) study authors collected information about 6,000 patients and included meetings with post-acute care coordinators and the collection of quantitative data, says Barbara J. Lutz, PhD, RN, CRRN, FAAN, McNeill distinguished professor at the University of North Carolina Wilmington.

The authors of one paper studied the effectiveness of the intervention. A parallel analysis of the program’s implementation helped COMPASS investigators understand the findings. The pragmatic trial did not require intervention hospitals to enroll all eligible patients. Fifty-eight percent of intervention hospitals experienced uninterrupted delivery of the COMPASS transitional care program. Thirty-five percent of patients enrolled at intervention hospitals completed the COMPASS protocol.1

“There was this wide variability of implementing the study at different sites,” Lutz says. There was a wide variability, across sites, in the protocol implementation, Lutz says. For example, the intervention hospitals that enrolled eligible stroke patients saw a range from a hospital that enrolled 6% of patients to one that enrolled 69% of eligible patients.

“Other hospitals fell within that range, and the average was somewhere around one-third,” Lutz says. “A low number of patients that were eligible received the intervention.”

Perform a Thorough Assessment

The study analysis included the outcomes of all eligible patients and whether they received the intervention at an appropriate hospital. This diluted the findings, but was necessary, she adds. (See story on lessons learned about making transitional care work in this issue.)

The COMPASS program focused on assessing patients carefully and ensuring they received enough information to know their own risk factors. The intervention included post-acute care coordinators, mostly nurses, serving as case managers for patients. They teamed up with advanced practice providers, such as nurse practitioners, Lutz says.

Care coordinators met with patients in the hospital to talk about the program. They made follow-up calls to patients to ensure they filled their medication, bought healthy food, and knew about their provider appointments. “The post-acute care coordinator or case manager would try to get resources to them to fill those needs,” Lutz says.

When patients visited the clinic, the same coordinator would meet the patient to perform a comprehensive assessment. The nurse practitioner talked with patients about their stroke, showing them CT scans to explain where the stroke occurred. Their goal was to provide specific information to help patients understand. Patients were screened for cognitive issues, as well as medical conditions and social determinants of health.

“We did a quick cognitive screen to see if they had the skills necessary to manage their medicine,” Duncan says. “We found that 39% of the patients who were going directly home may have some cognitive challenges that would be a problem in their managing five or more medications.” More than 75% of the stroke patients were taking more than five medications.

When screening showed a cognitive challenge, the team brought in a caregiver as a resource to help the patient with medication. “One of the most valued aspects of this that all the clinicians loved was that we linked them to community-based resources,” Duncan says. “Patients would go home and not be able to afford their medicine, so we had community resources to help.”

Community-Based Resources

Connecting patients to community resources required some prioritization. The patients often had an overwhelming list of needs. “We targeted community-based resources on their most urgent needs,” Duncan explains. “The nurse practitioner would say, ‘We can’t deal with all of these problems, so what is the most important?’”

Medical issues like high blood pressure remained at the top of the list. Falls prevention also was a top priority, as was helping patients afford and manage their medication.

Case managers meet patients in the hospital, review the program, and answer questions. They make sure patients fill all their medications, set appointments, and know to inform the case manager of any issues after returning home. Case managers follow up by phone within two days to prevent gaps in care.

For example, the post-acute care coordinator at one site met with a patient in the hospital and helped set up everything for the patient’s safe transition home. Then, the coordinator called back in two days and learned the patient did not have medication, food, and possibly not even transportation to get to the clinic appointment, Lutz recalls.

“The care coordinator had a relationship with the community paramedic program, and had a paramedic go out and do a home visit to make sure the gentleman had everything he needed before coming back to the clinic,” she explains.

True case management and care coordination is to not just hand the patient a sheet of paper with phone numbers of 10 organizations. “This coordinator made those connections for people because that is really hard for patients and families to do,” Lutz says. “Patients don’t know who to call.”

The team’s nurse practitioners also help solve problems. If a patient is not taking medication, the nurse practitioner can write a referral for therapy, if needed. “If the patient has been falling and doesn’t have physical mobility, then [the team] can refer the patient to physical therapy,” Duncan says. “If the patient is screened for depression, then they could further evaluate for depression and make a change medications or refer them to a support group.”

Look for Practical Solutions

COMPASS administrators look for practical solutions to patients’ obstacles to self-care and disease management. For instance, blood pressure is the chief risk factor for stroke. Most patients do not have their blood pressure controlled after their hospital discharge. “We know that only 49% of patients recognize blood pressure as a risk factor for stroke,” Duncan says. “We’re telling them all of this information in the hospital, but it’s not embraced, or when they get home they have so many problems.”

A potential solution encouraged by COMPASS was to provide stroke patients with blood pressure cuffs and logs before they were discharged. “The people who got our intervention self-reported they monitored their blood pressure more often,” Duncan adds.2

When care coordination teams saw the value in implementing the intervention and went above and beyond after a patient’s discharge, their efforts were more likely to succeed.

“Our healthcare system is so siloed and fragmented that when someone gets out of the hospital, for years and years, it was [the attitude of] ‘our part is done,’” Lutz says. “We wanted to go beyond that and have patients thrive when they get out of the hospital.”

Stroke care coordinators actively help patients manage their blood pressure and symptoms. The COMPASS program is a bridge from the hospital back to the community, she adds.


  1. Lutz BJ, Reimold AE, Coleman SW, et al. Implementation of a transitional care model for stroke: Perspectives from frontline clinicians, administrators, and COMPASS-TC implementation staff. Gerontologist 2020;60:1071-1084.
  2. Duncan PW, Bushnell CD, Jones SB, et al. Randomized pragmatic trial of stroke transitional care: The COMPASS study. Circ Cardiovasc Qual Outcomes 2020;13:e006285.