SPECIAL COMMUNICATION| Volume 102, ISSUE 8, P1658-1664, August 2021

Hospital to Home Transition for Patients With Stroke Under Bundled Payments

Published:March 31, 2021DOI:


      Bundled payments are a promising alternative payment model for reducing costs and improving the coordination of postacute stroke care, yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Centers for Medicare & Medicaid Innovation Bundled Payment for Care Improvement Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.


      List of abbreviations:

      APP (advanced practice provider), BPCI (Bundled Payments for Care Improvement), BPCI-A (Bundled Payments for Care Improvement Advanced), CMMI (Center for Medicare and Medicaid Innovation), CMS (Centers for Medicare & Medicaid Services), COMPASS (COMprehensive Post-Acute Stroke Services), IRF (inpatient rehabilitation facility), SNF (skilled nursing facility), TC (transitional care), TIA (transient ischemic attack)
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