By Melinda Young

For case management and transitional care services to produce positive results in patient and economic outcomes, they need to be consistent, researchers suggest.1

The Comprehensive Post-Acute Stroke Services (COMPASS) transitional care study used a pragmatic approach. The investigators did not hire transitional care coordinators to ensure all eligible patients were enrolled and all intervention solutions were consistently applied. Then, investigators studied the results. They found a wide variability in how the program was implemented across 20 hospitals. Some barely enrolled any patients, and others enrolled at least two-thirds of patients eligible for the intervention.1

The result was that some sites, particularly those with poor communication and low staff availability, were not as successful at consistently implementing the program.

Overall, little more than one-third of eligible stroke patients received the intervention, says Pamela W. Duncan, PhD, PT, professor of neurology at Wake Forest School of Medicine in Winston-Salem, NC.

“There were a lot of system barriers to that,” Duncan says. “We had five or six sites that reached out to a lot their patients, but in a pragmatic trial, we were not allowed to pay research coordinators to provide the intervention.”

Hospitals had to provide the intervention. Only half of the intervention hospitals sustained the intervention without interruption. “Many of them treated it as a PRN service — ‘We got it if we have the staff,’” Duncan explains. “If the nurse was out on leave, they didn’t have services available.”

Researchers studied the variability among implementation of the program and have tried to explain what the variation was about, says Barbara J. Lutz, PhD, RN, CRRN, FAAN, McNeill distinguished professor at the University of North Carolina Wilmington.

“We found organizations really had to be ready to implement,” she says. “They had to have the commitment of the organization — not just at the highest level or staff level, but also horizontally and vertically.”

Buy-in from staff is needed for the transitional care program to succeed. “That was a big ‘ah-ha’ moment for us,” Lutz says. “Even if you have commitment from staff, if the hospital couldn’t dedicate the resources necessary to implement this, it wouldn’t succeed. Hospitals had to use their own resources because that’s what the way the funding works.”

Hospitals also needed a program champion. “They needed someone well-connected throughout the organization and who could have the ear of the administration,” Lutz explains. “They needed someone who could navigate the system and talk to the people they needed to talk to.”

For example, one eastern North Carolina hospital employed a post-acute coordinator and stroke coordinator who would visit the hospital’s board and top leader to tell them what she needed to make the program work. She provided a case for it, and they listened to her, Lutz says. “She had [the attention of] a wide range of decision-makers, and they were very successful.”

By contrast, upper-level administrators at some larger hospitals were unaware of the program. When the care coordinators attempted to implement the intervention, they found the leaders were not involved in reducing obstacles.

The most successful sites for the intervention involved administrators who believed in the COMPASS transitional care program and who recognized it as an important part of stroke care, Lutz says. “They wanted to see it work.”

Health systems have reduced readmissions and invested in case management services in recent years, but the bigger question is if these efforts have improved the health of patients. “Right now, all the [available] studies have had mixed results, but that doesn’t mean we have to stop,” Duncan says.

Duncan’s own experience after a bike accident and skull fracture taught her that everyone recovering from a traumatic injury or severe illness could benefit from some immediate follow-up or transitional care.

After spending a couple of days in a coma in the neuro intensive care unit, Duncan awoke and was told she would be discharged. Her only discharge plan was to see her primary care provider within two weeks. As soon as she went home, she experienced severe leg cramping. It turned out her potassium level was dangerously low, a problem that might not have been discovered if she had not suggested this when her husband took her to a local healthcare facility.

“We can all be the victim of poor transitional care,” Duncan says.

Organizational readiness also was a key factor in implementation. Successful sites included both clinical champions and institutional commitment to implementing the intervention in the way it was designed. They made the program a priority, and communicated that commitment to frontline staff. “They provided dedicated and sufficient resources for implementation, including hiring staff with appropriate skills and experience,” Lutz says. “You have to hire the right people. These are folks who have to have the right kind of problem-solving skills, and feel OK in an autonomous role.”

Implementation challenges included the length of the clinic visit, the clinic’s location, and patients’ access to transportation and copay funds. “Those kinds of logistical and tangible issues also made implementation more difficult,” Lutz says.

Transitional care programs based on COMPASS can succeed for other chronic conditions and medical problems as well, she notes.


  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.