COMPASS - Start With Your Heart

A Pragmatic Trial for COMprehensive
Post-Acute StrokeN
Services
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(COMPASS)
Pamela Duncan, PhD, PT
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Cheryl Bushnell, MD, MHS
Wayne Rosamond, PhD
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Acknowledgement
Funding
• This research was supported through a Patient-Centered
Outcomes Research Institute (PCORI) Project Program
Award (PCS-1403-14532)
Disclaimer
• All statements in this presentation, including its findings
and conclusions, are solely those of the authors and do
not necessarily represent the views of the PatientCentered Outcomes Research Institute (PCORI), its Board
of Governors or Methodology Committee
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THANK YOU for NC State Legislative
Funding
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Thanks to AHA/ASA
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Introduction: The Team
• PI: Pamela Duncan, PhD, PT, FAPTA, FAHA
– Professor of Neurology,
Wake Forest Baptist Health
• Co-PI: Cheryl Bushnell, MD, MHS, FAHA
– Professor of Neurology and Director,
Wake Forest Baptist Comprehensive Stroke Center
• Co-PI: Wayne Rosamond, PhD, MS, FAHA
– Professor of Epidemiology,
UNC Gillings School of Global Public Health
Director,
North Carolina Stroke Care Collaborative
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Introduction: The Team
• Co-I: Sabina Gesell, PhD
– Assistant Professor, Social Sciences and Health
Policy
Public Health Sciences, Wake Forest School of
Medicine
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COMPASS Investigators & Study Team
Rica Abbott
Robert Agans
Walter Ambrosius
Martinson Arnan
Vicki Bartinkowski
Blair Barton-Percival
Dawn Becker
Janet Bettger
Cathy Black
Natasha Bourne
Allison Brashear
Nancy Buchheimer
Cheryl Bushnell
Josie Caves
Frank Celestino
Joan Celestino
Sylvia Coleman
Christina Condon
Remy Coyteaux
Skip Doyle Cummings
Ralph D’Agostino
Jim Daunais
April Davenport
Pamela Duncan
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Jennifer Ellis
Shannon Emmanuel
Janet Freburger
Sabina Gesell
Jacqueline Halladay
Bryan Hatcher
Richard Hopson
Anna Johnson
Rayetta Johnson
Robin Jones
Sara Jones
Linda King
Anna Kucharska-Newton
Hope Landrine
Gladys Lundy
Barbara Lutz
Sarah Lycan
Jamie McGlaughon
Laurie Mettam
Nicole Miller
Jeremy Moseley
Joy Murphy
Meagan O’Brien
Maria Orsini
Amy Pastva
Rudeemart Prajongtat
Harshada Rajani
Susan Reeves
Wayne Rosamond
Margaret Rudisill
Scott Rushing
Hannah Segal
Mysha Sissine
Bill Smith
Sharon "Anne" Stafford
Lynette Staplefoote-Boynton
Karen Taylor
Cathy Thomas
Mary Van de Kamp
Betsy Vetter
Brian Wells
Ken Wilson
David Yoshikawa
Rachel Zimmer
PCORI:
Lauren Azar
Steve Clauser
Michelle Johnston-Fleece
Carly Parry
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WHY A TRIAL OF COMPREHENSIVE
POST-ACUTE STROKE SERVICES?
Cheryl Bushnell, MD, MHS
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Stroke Death Rates N.C. vs. U.S., 1979-2010
140
Healthy People Target 2020 (33.8)
North Carolina
United States
Healthy People 2010 Target (50.0)
Age-adjusted Death Rate
120
100
80
60
40
20
'79
'81
'83
'85
'87
'89
'91
'93
'95
Year
'97
'99
'01
'03
'05
'07
Stroke: 1999-2010: ICD-10 codes I60-I69; 1979-1998: ICD-9 codes 430-434, 436-438 multiplied by comparability ratio of 1.0588.
Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population.
Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File,
1979-1998 and 1999-2010. CDC WONDER Online Database. http://wonder.cdc.gov/mortSQL.html. Accessed 05/2013.
'09
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Stroke Death Rates by County of Residence, N.C.,
2008-2012
Stroke Mortality (2008-2012)
US rate: 42.2/100,000
NC rate: 45.1/100,000
Stroke: ICD-10 codes I60-I69.
Rates per 100,000 population, age-adjusted to the 2000 U.S. standard population. N.C. Data Source: North Carolina Division of Public Health, State Center
for Health Statistics. Accessed April 9, 2014.
Volume 2: Leading Causes of Death in North Carolina 2012, SCHS Online Database 2014. http://www.schs.state.nc.us/schs/deaths/lcd/2012/.
Map Source: NC DPH – Community and Clinical Connections for Prevention and Health Branch
NC Rank: 6th
highest in the US
Stroke Hospital Discharge Rates by County of Residence, NC, 2012
Stroke: ICD-9 codes 430-438.
Discharge rates per 100,000 population, age-adjusted to the 2000 U.S. standard population.
Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, 2012.
Produced by the State Center for Health Statistics, 04/16/2014.
Stroke Health Disparities in NC
• 40% of stroke deaths in African American men occur
before age 65 vs 17% of white men
• 24% of stroke deaths in African American women
before age 65 vs 8% of white women
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BUILDING
ON PARTNERSHIPS AND
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COLLABORATIONS TO IMPROVE STROKE CARE
COVERDELL REGISTRY IN NORTH CAROLINA
(NC STROKE CARE COLLABORATIVE)
Wayne D. Rosamond, PhD
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History of Partnerships for Improving
Stroke Care in NC
Justus-Warren Heart
Disease & Stroke Prevention
Task Force
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Senator Paul Coverdell –
Georgia (R) 1939-2000
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Died of stroke while in Congress
Congress funds Paul Coverdell National
Acute Stroke Registry
Mandates CDC to create registry
Mission
• Measure, track, improve acute stroke care
• Decrease rate of premature death and disability
• Eliminate disparities in care
• Support development of systems of care that emphasize
quality of care across the spectrum of care
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NCSCC Hospital Network & COMPASS
Supporting Sites
Dark blue color indicates metropolitan areas, medium blue indicates micropolitan,
and light blue indicates small town and rural areas
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NCSCC Activities
• Custom made, interactive, web-based data
management tool
• Network and sharing of best practices
• Quality improvement working group
• Regional quality improvement workshops
• Quality improvement monthly webinars
• Linkage with EMS database
• Grant program for hospital specific QI innovations
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NCSCC: Receipt of Defect-Free Care,
2005-2015
% of patients receiving defect-free care
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Rosamond W, et al. Monitoring and improving acute stroke care: The North Carolina Stroke
Care Collaborative. NC Med J 2012; 73(6):494-496.
Stroke Care: Many gaps remain
Stroke
Hyper
acute
Acute
Rehab
Community
• 42% of stroke patients were not referred to any
post-acute care (Gage, et al. U.S. DHHS 2009)
• 65% of patients under age 65 discharged without
post-acute services (Bettger, et al. J Am Heart Assoc
2015)
• No performance indicators for processes of care
after discharge
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Patient’s Discharged-HOME
• 24% readmission rates in 90 days
• 75% Fall in 6 months and if Fall 4 times as likely to break a hip
• Less than 30% of Stroke Survivors Have Their BP controlled
• Acute Deficit Free Care- 76% but Post Acute Only 44%• Poor Medication – Adherence
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Stroke patient voices
“With my brain not working
properly, it was important to
“Stroke
is just slower,
as
have things
explained
hard on family
and in non-medical
terms. It
They for
carry
was members.
also important
the
31 year old, white
a large
portion
of the to
doctors
and the
therapists
female, living in rural NC, explainweight
of recovery.”
it multiple
times—not
high school graduate,
to assume I knew why I needed
associate’s degree (stroke
this.”
at 22)
Stroke Patient Voices
60 year old, white
male, living in urban
NC, member of the
business community
“A follow-up phone call
has got to be the prime
piece that has to happen
in stroke recovery.”
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“After the stroke I had new
prescriptions…I couldn’t
dispense my medications into
daily doses. This math
deficit was not recognized
until I got home. I lived
alone and I had to take care
of myself and I was unable to
cope.”
Stroke: One of the most costly conditions for
post acute care management
• 85% of Medicare beneficiaries with stroke having
4 or more other chronic health conditions
• Stroke patients with congestive heart failure
have per capita costs that are about 5 times
higher than the average spending for Medicare
fee-for-service beneficiaries.
• Stroke patients are frequently readmitted to the
hospital
Wake Forest Baptist Medical Center
Stroke Costs IN North Carolina
• Direct costs due to stroke in N.C. are
estimated be at least $1.05 billion each year.
2012 Samuel N. Tchwenko, MD, MPH ,Heart Disease & Stroke Prevention Branch Chronic
Disease & Injury Section Division of Public Health North Carolina Department of Health and
Human Services
Wake Forest Baptist Medical Center
Cost of Stroke Post Acute Services Compared
to Acute Care- Medicaid in Forsyth County
• Service Category
• Acute Inpatient
$8,014
• Skilled Nursing
$41,029
• Inpatient Rehab
$15,695
• Home Health
$6,207
• Long-Term NH
$62,000
Wake Forest Baptist Health
Evidence for Interventions that Improve
Post-acute Care
• Transitional care management
– Only covers the first 30 days
– Naylor, et al. Health Affairs 2011;30:45-54
• Early supported discharge
– Hospital-based stroke team provides coordinated
care (rehab, prevention, support) in the home
– Standard of care in U.K. and Canada
– Never been implemented in the U.S.
– Fearon, et al Cochrane Database Syst Rev 2012
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The Challenges
• Can an intervention to improve care for stroke
patients regardless of the settings and providers
be adapted to the U.S. health care system?
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Stroke
Recovery
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Secondary
Prevention
Comprehensive Coordinated Services
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COMPASS Objectives
• Address the needs of stroke survivors and
their caregivers for optimal outcomes
• Connect hospitals, community providers, and
community agencies for improved chronic
disease management
• Develop an individualized care plan for each
patient
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THE CARE MODEL
Cheryl Bushnell, MD, MHS
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Pragmatic = Implementable & Sustainable
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Real World
Real Practice
Current Reimbursement
Real Partners Across the Continuum
Meaningful Patient Outcomes
How Many Patients How Many Hospitals
• 6000 patients in phase 1
• 3000 patients in phase 2
• 50 hospitals from the mountains to the sea
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Finding The Way Forward
NUMBERS
Know your numbers: BP; A1C;
Cholesterol etc.
NUMBERS
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ENGAGE
WILLINGNESS
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SUPPORT
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ENGAGE
Be active: Engage your mind,
your hands, your arms and your
feet
SUPPORT
Take advantage of Support
systems/resources: Community,
Family and caregivers
WILLINGNESS
What medication are you on?
Why are you on them?
When do you take them?
COMPASS Team Intervention
• Post-acute Coordinator (RN)
– Perform the 2-day follow-up phone call
– Prior to discharge introduce the hospitals comprehensive
post acute stroke services and establish that the PAC will
call in 2 days
– Coordinate appointments with NP and PCP
– Review the patient’s individualized care plan with patient ,
establish priorities and provide appropriate community
referrals (e.g. stroke survivor support group, area agency
on aging, chronic self-management , community falls
prevention and other support during the intervention
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COMPASS Team Intervention
• Nurse Practitioner/Physician Assistant
– See patients within 7 to 14 days in clinic for TCM billing
– Establish an individualized care plan with the patients and
the families
– Provide referrals to home health, outpatient therapy, falls
prevention, neurological assessment, cognitive and
depression screen, medication management, secondary
prevention, community services
– Support PCP, provide notes and communications related to
post-acute care to PCP and Home Health Agencies ,
Outpatient Therapies
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MY PLAN FOR RECOVERY, INDEPENDENCE AND HEALTH
Quality Improvement and Web-based
Feedback
• Candidate measures are:
– Percent of patients called within 2 days
– Percent of patients seen by NP/PA within 7 to 14
days
– Percent of eligible patients referred to
rehabilitation or community services
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COMPASS DESIGN
Cheryl Bushnell, MD, MHS
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COMPASS: Target Population
• Inclusion criteria
– Patients who are discharged home from
participating hospitals
• Exclusion criteria
– Patients discharged to skilled nursing or
inpatient rehab facility
– Patients that do not speak English or Spanish
– Age < 18 years
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COMPASS Design
• Cluster-randomized pragmatic trial
• Stratification by hospital characteristics: stroke
volume (<100, 100-299, and >300) and primary
stroke center status (6 strata)
• Primary outcome: Stroke Impact Scale-16 at 90
days (patient-reported outcome)
• Secondary outcomes: Modified Caregiver Strain
index at 90 days
‒ All-cause readmissions at 30 and 90 days
‒ Mortality, health care utilization, use of TCM
billing codes using claims data
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Study Design
Hospitals Assessed for Eligibility & Interest
Randomization
COMPASS Intervention
Phase 1 Allocation
Usual Care
1 Year
1 Year
Sustain COMPASS
Intervention
Phase 2 Allocation
COMPASS Intervention
1 Year
1 Year
Sustain COMPASS Intervention
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What is Engagement?
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Active incorporation of perspectives
beyond those of the researchers across all
phases of the research project
Study design
Measures
used
Recruitment
Implementation
Data
collection
Data
interpretation
Dissemination
of results
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What is the purpose of Engagement?
Engagement is one way to make research
• patient-centered
• findings matter to patients and healthcare providers
• lead to greater use and uptake of research results
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Who are our stakeholders?
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Stakeholders
involved in intervention design and implementation to maximize effectiveness and uptake
Stroke
Survivors
Family
Caregivers
Hospital
Stroke
Team
Primary
Care
AHEC
Community
Outpatient
-based
Pharmacy
Rehab
services
Influential Leaders
involved in high level advising to support dissemination and sustainability
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Justus Warren Heart Disease and
Stroke Prevention Taskforce
Stroke Advisory Council
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AHA / ASA
NC DHHS
Home
Health
Benefits of Participation
• Post-discharge follow-up of acute stroke
patients
– Potential for improved functional status and
patient outcomes, patient satisfaction with care,
and reduced readmission rates
– Use of a new care plan that will accompany the
patient across various post-acute providers
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Benefits of Participation For Health
Systems
• Prepare for Population Health Management
– Facilitation of health systems to implement CMS
Transitional and Chronic Management Payments
– Facilitation of community-clinical connections for
sustainable chronic disease management
• Enhance existing QI efforts
– Grant-supported post-acute coordinator for duration of
intervention
– Systematic framework for coordination and integration of
post-acute care services
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What is needed- reinstatement of
funds for a statewide registry ?
1) Establish a state-wide stroke registry
and links to mortality records
2) Require hospitals to participate in
registry and financial support to
participate ( e.g $2500 per hospital)
3) Support for Stroke Advisory Council
over site
Thank You to Our Partners in
Improving Stroke Care For the Citizens
of NC!
Justus-Warren Heart Disease &
Stroke Prevention Task Force
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For more information you may also visit our website
https://www.nccompass-study.org
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