| Primary | Stroke Impact Scale (SIS-16) | 16-item survey to assess the difficulty level of performing basic physical activities; scores range from 0-100; higher scores correspond to more favorable outcomes | Of the 5,882 that were enrolled in the study, 3476 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure | Posted | | Mean | Standard Deviation | score on a scale | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
| | | Title | Denominators | Categories |
|---|
| | | Title | Measurements |
|---|
| - OG00079.9± 21.4
- OG00180.6± 21.1
|
|
| |
| Secondary | Modified Caregiver Strain Index | 13-item survey to measure strain that caregivers may experience; scores range from 0-100; higher scores indicate more caregiver burden | Each enrolled patient was asked to identify a caregiver. A total of 4208 caregivers were identified and asked to complete the Caregiver Questionnaire. A total of 1228 caregivers completed the Caregiver Survey. However, to account for missing data, we utilized inverse probability weight to perform the analysis so the final analysis included was 4208 for this outcome. | Posted | | Mean | Standard Deviation | score on a scale | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Self-reported General Health | Self-reported general health is a single question to rate their general health. Responses on a 5-point Likert Scale (Excellent, Very Good, Good, Fair, or Poor) will be analyzed as a continuous variable. Scores range from 95-15 with a higher score indicating better health. | Of the 5,882 that were enrolled in the study, 3169 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure. | Posted | | Mean | Standard Deviation | score on a scale | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Modified Rankin Score | to measure the degree of disability or dependence; scores range from 0-6; higher scores correspond to less favorable outcomes | Of the 5,882 that were enrolled in the study, 3209 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure. | Posted | | Median | Inter-Quartile Range | score on a scale | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Number of Participants Physically Active and Not Physically Active | Participants are asked whether they walked continuously for at least 10 minutes on any of the last seven days, how many of those days they walked continuously for at least 10 minutes and how many minutes they walked, on average, each day. The physical activity endpoint will be self-reported total number of minutes walked during the past seven days. | Of the 5,882 that were enrolled in the study, 2968 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure. | Posted | | Count of Participants | | Participants | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Number of Participants With or Without Depression | Based on answers to Patient Health Questionnaire 2-Item (PHQ-2) which is a 2-item questionnaire to determine the frequency of depressed mood; scores range from 0-6; higher scores correspond to less favorable outcomes | Of the 5,882 that were enrolled in the study, 2,774 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure. | Posted | | Count of Participants | | Participants | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Cognition (MoCA 5-min Protocol) | 4-item questionnaire to determine vascular cognitive impairment; scores range from 0-30; higher scores are more favorable | Of the 5,882 that were enrolled in the study, 2,728 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure. | Posted | | Mean | Standard Deviation | score on a scale | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Medication Adherence (Morisky Green Levine Scale-4) | 4 items with yes/no response options; scores range from 0-4; higher scores correspond to less medication adherence | Of the 5,882 that were enrolled in the study, 2,730 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure. | Posted | | Median | Inter-Quartile Range | score on a scale | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Number of Participants With or Without Falls | Participants are asked 4 questions to determine whether they have fallen (yes versus no) since hospital discharge, whether or not the fall resulted in a doctor/emergency room visit, whether they have fallen multiple times since discharge, and how many times they have fallen since discharge. Analysis of falls will be based on incidence of any fall since hospital discharge (no falls versus at least one fall). | Of the 5,882 that were enrolled in the study, 3,055 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure. | Posted | | Count of Participants | | Participants | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Self-reported Fatigue (PROMIS Fatigue Instrument) | 4-question instrument to determine level of fatigue; higher scores correspond to less favorable outcomes; The total raw score is obtained by summing individual question scores and has a range of 4-20. For analysis, raw scores are translated into T-scores which range from 33.7 - 75.8. The T-score rescales the raw score into a standardized score with a mean of 50 and a SD of 10. | Of the 5,882 that were enrolled in the study, 2,721 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure. | Posted | | Mean | Standard Deviation | score on a scale | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Satisfaction With Care | 6 questions to determine satisfaction with care; scores range from 0-100; higher scores correspond to higher satisfaction of care | Of the 5,882 that were enrolled in the study, 2,929 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure. | Posted | | Mean | Standard Deviation | score on a scale | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Number of Participants Who Do or Do Not Monitor Blood Pressure at Home | Participants are asked 2 questions to determine whether they monitor their blood pressure at home (yes or no) and, if they answer in the affirmative, how frequently (daily, weekly, and monthly). Home blood pressure monitoring was analyzed as a dichotomous endpoint (monitoring with any frequency versus no monitoring). | Of the 5,882 that were enrolled in the study, 3,033 provided a response to the survey question. However, we utilized inverse probability weight to perform the analysis in a way to account for missing data. The final analysis included 5,882 for this outcome measure. | Posted | | Count of Participants | | Participants | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
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|
| Secondary | Self-reported Blood Pressure | 1 question to determine self-reported blood pressure. Self-reported systolic and diastolic BP will each be analyzed as a continuous endpoint. In addition, self-reported systolic and diastolic BP will be used to create a dichotomous hypertension endpoint (systolic BP >= 140 versus systolic BP < 140). | Data was not considered reliable and was therefore not used for analysis. Responses to blood pressure was frequently "120 over 80". This response was so frequent that investigative team did not think the data was a valid measured blood pressure. | Posted | | | | | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Number of Subjects With Claims-based All-cause Hospital Readmissions | | Of the enrolled patients, 2,262 were linked to Fee-For-Service (FFS) Medicare claims and included in the analyses. | Posted | | Count of Participants | | Participants | | post-stroke day 30 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
| |
| Secondary | Number of Subjects With Claims-based All-cause Hospital Readmissions | | Of the enrolled patients, 2,262 were linked to Fee-For-Service (FFS) Medicare claims and included in the analyses. | Posted | | Count of Participants | | Participants | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
| |
| Secondary | Number of Subjects With Claims-based All-cause Hospital Readmissions | | Of the enrolled patients, 2,262 were linked to Fee-For-Service (FFS) Medicare claims and included in the analyses. | Posted | | Count of Participants | | Participants | | post-discharge year 1 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
| |
| Secondary | Number of Subjects With All-cause Mortality Using NC State Death Index | Deaths within 90 days of index discharge were ascertained from the North Carolina State Death Index as well as insurance claims beneficiary summary files (i.e. FFS Medicare). A death identified in either database is considered a death. | Mortality by 90-days post-stroke according to the NC State Death Index was collected on all 5,882 enrolled patients. | Posted | | Count of Participants | | Participants | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Number of Subjects With All-cause Mortality Using NC State Death Index & Fee-For-Service (FFS) Medicare | Deaths within 1 year of index discharge were ascertained from the North Carolina State Death Index as well as insurance claims beneficiary summary files (i.e. FFS Medicare). A death identified in either database is considered a death. | Of the enrolled patients, 2262 were linked to Fee-For-Service (FFS) Medicare claims and included in the analyses. | Posted | | Count of Participants | | Participants | | post-discharge year 1 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Number of Subjects With Claims-based Emergency Department Visits | | Of the enrolled patients, 2262 were linked to Fee-For-Service (FFS) Medicare claims and included in the analyses. | Posted | | Count of Participants | | Participants | | post-discharge year 1 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
| |
| Secondary | Number of Subjects With Claims-based Admissions to Skilled Nursing Facilities (SNF) and Inpatient Rehabilitation Facilities (IRF) | | Of the enrolled patients, 2262 were linked to Fee-For-Service (FFS) Medicare claims and included in the analyses. | Posted | | Count of Participants | | Participants | | post-discharge year 1 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Secondary | Number of Subjects With Claims-based Use of Transitional Care Management Billing Codes | | Of the enrolled patients, 2262 were linked to Fee-For-Service (FFS) Medicare claims and included in the analyses. | Posted | | Count of Participants | | Participants | | post-discharge day 14 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
|
|
| Other Pre-specified | Subgroup Analysis: Race | Analyze the main endpoint of the study in white and non-white individuals | This was a Subgroup Analysis: Race | Posted | | | | | | post-stroke day 90 | | | | ID | Title | Description |
|---|
| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
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| Other Pre-specified | Subgroup Analysis: Sex | Analyze the main endpoint of the study in female and male individuals | | Posted | | | | | | measured 90 days post-stroke | | | | ID | Title | Description |
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| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
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| Other Pre-specified | Subgroup Analysis: Age | Analyze the main endpoint of the study in <45; 45-<55; 55-<65; 65-<75; >=75 individuals | | Posted | | | | | | measured 90 days post-stroke | | | | ID | Title | Description |
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| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
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| Other Pre-specified | Subgroup Analysis: Diagnosis (Stroke Versus TIA) | Analyze the main endpoint of the study in stroke versus TIA individuals | Subgroup analysis: diagnosis (stroke versus TIA) | Posted | | | | | | measured 90 days post-stroke | | | | ID | Title | Description |
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| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
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| Other Pre-specified | Subgroup Analysis: Stroke Severity | Analyze the main endpoint of the study in NIHSS=0, NIHSS=1-4, NIHSS>4 individuals | Subgroup analysis: stroke severity | Posted | | | | | | measured 90 days post-stroke | | | | ID | Title | Description |
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| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
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| Other Pre-specified | Subgroup Analysis: Type of Health Insurance | Analyze the main endpoint of the study in insured and uninsured individuals | Subgroup analysis: type of health insurance | Posted | | | | | | measured 90 days post-stroke | | | | ID | Title | Description |
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| OG000 | Usual Care | Participating hospitals randomized to the usual care group will provide their usual, post-acute stroke care to their patients. | | OG001 | COMPASS Intervention | Participating hospitals randomized to the intervention will change the structure and process for delivery of post-acute stroke care. COMPASS Intervention: *A Post-Acute Coordinator (PAC) will visit each patient prior to discharge from the hospital.
- Patient will receive a follow-up telephone call two days after having been discharged.
- 7-14 days after discharge, the patient will attend post-acute stroke clinic visit and receive an assessment from an Advanced Practice Provider (APP), a brief patient-reported functional assessment to generate an individualized Care Plan, and referrals from an APP. The patient's primary caregiver will be assessed to ensure caregiver availability and ability to support the patient and the caregiver's ability to cope with the new challenges of caregiving.
- Patient will receive a call at 30 and 60 days post-discharge for follow-up of functional status, recovery, risk factor management and their access or utilization of recommended services.
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