Compass: A Novel Transition Program to Reduce Disability After a Stroke

Washington University, Saint Louis MO

Investigators

Linked publications, trials & patents

Abstract

PROJECT SUMMARY ABSTRACT Stroke is a leading cause of death and disability, with dismal 1-year outcomes for survivors. Many are rehospitalized, fall, are admitted to skilled nursing facilities (SNFs), or die. Stroke is fundamentally a chronic condition that is currently managed as an acute event. Acute inpatient rehabilitation (IR), focused on resolving impairments, does not typically address the environmental barriers stroke survivors face when they return home (e.g., stairs without railings). As a result, they leave IR without the skills to successfully reintegrate into the community. There is a critical gap in post-acute care as chronic needs of survivors are not being met during their transition from a medical to a community model of care. To address this gap, we developed a novel rehabilitation transition program, Community Participation Transition after Stroke (COMPASS), a behavioral intervention delivered in the home during the transition from IR that resolves barriers to independence using home modifications (e.g., grab bars by the toilet) and self-management (learning to resolve barriers independently). Feasibility and phase IIb trial results showed that COMPASS can reduce environmental barriers in the home and may impact health outcomes such as SNF admission and death. We now propose a hybrid type 1 randomized effectiveness-implementation trial to establish COMPASS as the missing link between IR and home. Our central hypothesis is that COMPASS will be superior to usual care for key outcomes and implementable in practice. The specific aims are: (1) conduct a multicenter randomized controlled trial to evaluate the impact of COMPASS on SNF admission, death, rehospitalization, and falls compared to enhanced usual care; (2) evaluate the quality, cost, and efficiency of COMPASS during transition from IR to home relative to enhanced usual care; and (3) conduct a mixed-methods study informed by the Practical Robust Implementation and Sustainability Model (PRISM) and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the sustainability and implementation potential of COMPASS. Hypotheses are: (1) COMPASS participants will have significantly lower incidence of 12-month SNF admissions and mortality, lower incidence of 30-day rehospitalization, and lower fall rates compared to enhanced usual care; (2) the incremental cost-effectiveness ratio will be cost-effective by World Health Organization standards, and return on investment will be positive; and (3) COMPASS will have high reach, adoption, implementation (fidelity), and maintenance (12-month adherence) and a high potential for implementation and sustainability. COMPASS is innovative because it augments current practice by resolving barriers in the environment as stroke survivors transition home. This proposal is significant as it fills critical gaps in rehabilitation evidence by investigating the therapeutic efficacy, cost-effectiveness, and implementation potential of a novel behavioral intervention during the transition from IR. COMPASS could effectively bridge the gap between acute and community care, reducing stroke survivors' morbidity and mortality.