Abstract
Objectives
To examine the effect of a comprehensive transitional care model on the use of skilled
nursing facility (SNF) and inpatient rehabilitation facility (IRF) care in the 12
months after acute care discharge home following stroke; and to identify predictors
of experiencing a SNF or IRF admission following discharge home after stroke.
Design
Cluster randomized pragmatic trial
Setting
Forty-one acute care hospitals in North Carolina.
Participants
2262 Medicare fee-for-service beneficiaries with transient ischemic attack or stroke
discharged home. The sample was 80.3% White and 52.1% female, with a mean (SD) age
of 74.9 (10.2) years and a mean ± SD National Institutes of Health stroke scale score
of 2.3 (3.7).
Intervention
Comprehensive transitional care model (COMPASS-TC), which consisted of a 2-day follow-up
phone call from the postacute care coordinator and 14-day in-person visit with the
postacute care coordinator and advanced practice provider.
Main Outcome Measures
Time to first SNF or IRF and SNF or IRF admission (yes/no) in the 12 months following
discharge home. All analyses utilized multivariable mixed models including a hospital-specific
random effect to account for the non-independence of measures within hospital. Intent
to treat analyses using Cox proportional hazards regression assessed the effect of
COMPASS-TC on time to SNF/IRF admission. Logistic regression was used to identify
clinical and non-clinical predictors of SNF/IRF admission.
Results
Only 34% of patients in the intervention arm received COMPASS-TC per protocol. COMPASS-TC
was not associated with a reduced hazard of a SNF/ IRF admission in the 12 months
post-discharge (hazard ratio, 1.20, with a range of 0.95-1.52) compared to usual care.
This estimate was robust to additional covariate adjustment (hazard ratio, 1.23) (0.93-1.64).
Both clinical and non-clinical factors (ie, insurance, geography) were predictors
of SNF/IRF use.
Conclusions
COMPASS-TC was not consistently incorporated into real-world clinical practice. The
use of a comprehensive transitional care model for patients discharged home after
stroke was not associated with SNF or IRF admissions in a 12-month follow-up period.
Non-clinical factors predictive of SNF/IRF use suggest potential issues with access
to this type of care.
Keywords
List of abbreviations:
CMS (Centers for Medicare and Medicaid Services), COMPASS (COMprehensive Post-Acute Stroke Services), COMPASS-TC (COMprehensive Post-Acute Stroke Services transitional care), FFS (fee-for-service), HbA1C (glycated hemoglobin), ICD-10 (International Classification of Diseases, 10th Revision), IRF (inpatient rehabilitation facility), LOS (length of stay), NIHSS (National Institutes of Health Stroke Scale), PAC (postacute care), PCORI (Patient-Centered Outcomes Research Institute), SNF (skilled nursing facility), TC (transitional care), TCM (transitional care management), TIA (transient ischemic attack), UC ( = usual care)To read this article in full you will need to make a payment
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References
- Improving transitions in acute stroke patients discharged to home: the Michigan stroke transitions trial (MISTT) protocol.BMC Neurol. 2017; 17: 115
- Transitions of care for stroke patients: opportunities to improve outcomes.Circ Cardiovasc Qual Outcomes. 2015; 8: S190-S192
- Recommendations for the establishment of stroke systems of care: a 2019 update.Stroke. 2019; 50: e187-e210
- Factors associated with 90-day readmission after stroke or transient ischemic attack: linked data from the Australian Stroke Clinical Registry.Stroke. 2020; 51: 571-578
- Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association.Circulation. 2020; 141: e139-e596
- Inactive and alone: physical activity within the first 14 days of acute stroke unit care.Stroke. 2004; 35: 1005-1009
- Falling through the cracks: a literature review to understand the reality of mild stroke survivors.Top Stroke Rehabil. 2009; 16: 454-462
Stroke Foundation. National stroke audit—rehabilitation services report. Available at: https://informme.org.au/-/media/42056DD67049480FACAE79440B440FEC.ashx?la=en. Accessed October 11, 2019.
- Randomized pragmatic trial of stroke transitional care: the COMPASS study.Circ Cardiovasc Qual Outcomes. 2020; 13e006285
- Access to postacute rehabilitation.Arch Phys Med Rehabil. 2007; 88: 1488-1493
- Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases.Arch Phys Med Rehabil. 2011; 92: 1220-1229
- Stroke survivors' and informal caregivers' experiences of primary care and community healthcare services—a systematic review and meta-ethnography.PloS One. 2018; 13e0192533
- Transitions of care interventions to improve quality of life among patients hospitalized with acute conditions: a systematic literature review.Health Qual Life Outcomes. 2021; 19: 36
- Transition of care for acute stroke and myocardial infarction patients: from hospitalization to rehabilitation, recovery, and secondary prevention.Evid Rep Technol Assess (Full Rep). 2011; : 1-197
- Transitional care after hospitalization for acute stroke or myocardial infarction: a systematic review.Ann Intern Med. 2012; 157: 407-416
- Early Supported Discharge Trialists. Early supported discharge services for people with acute stroke.Cochrane Database Syst Rev. 2017; 7CD000443
- The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial.BMC Neurol. 2017; 17: 133
- A person-centered approach to poststroke care: The COMprehensive Post-Acute Stroke Services Model.J Am Geriatr Soc. 2018; 66: 1025-1030
- COMPASS-CP: An electronic application to capture patient-reported outcomes to develop actionable stroke and transient ischemic attack care plans.Circ Cardiovasc Qual Outcomes. 2018; 11e004444
- Implementation of a billable transitional care model for stroke patients: the COMPASS study.BMC Health serv res. 2019; 19: 978
- implementation of a transitional care model for stroke: perspectives from frontline clinicians, administrators, and COMPASS-TC implementation staff.Gerontologist. 2020; 60: 1071-1084
- Introduction to the analysis of survival data in the presence of competing risks.Circulation. 2016; 133: 601-609
- A proportional hazards model for the subdistribution of a competing risk.J Am Stat Assoc. 1999; 94: 14
- Ensuring respect for persons in COMPASS: a cluster randomised pragmatic clinical trial.J Med Ethics. 2018; 44: 560-566
- Value and efficacy of early supported discharge from stroke units.Ann Phys Rehabil Med. 2009; 52: 224-233
- Early home-supported discharge of stroke patients: a health technology assessment.Int J Technol Assess Health Care. 2006; 22: 313-320
- Comprehensive stroke care and outcomes: time for a paradigm shift.Stroke. 2021; 52: 385-393
- Disparities in postacute stroke rehabilitation disposition to acute inpatient rehabilitation vs. home: findings from the North Carolina Hospital Discharge Database.Am J Phys Med Rehabil. 2009; 88: 100-107
Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Available at: http://www.medpac.gov/docs/default-source/reports/mar19_medpac_entirereport_sec.pdf?sfvrsn=0. Accessed April 1, 2021.
Medicare Payment Advisory Commission. Health Care Spending and the Medicare Program: A Data Book. Available at: http://www.medpac.gov/docs/default-source/data-book/jun18_databookentirereport_sec.pdf. Accessed April 1, 2021.
- Higher Medicare SNF care utilization by dual-eligible beneficiaries: can Medicaid long-term care policies be the answer?.Health Serv Res. 2015; 50: 161-179
- Effect of long-term care use on Medicare and Medicaid expenditures for dual eligible and non-dual eligible elderly beneficiaries.Medicare Medicaid Res Rev. 2013; 3 (:mmrr.003.03.a05)
- Better quality of care or healthier patients? Hospital utilization by Medicare Advantage and fee-for-service enrollees.Forum Health Econ Policy. 2013; 16: 137-161
- How much favorable selection is left in Medicare Advantage?.Am J Health Econ. 2015; 1: 1-26
- Less intense postacute care, better outcomes for enrollees in medicare advantage than those in fee-for-service.Health Aff (Project Hope). 2017; 36: 91-100
Article info
Publication history
Published online: November 02, 2021
Accepted:
October 6,
2021
Received in revised form:
September 29,
2021
Received:
July 19,
2021
Footnotes
This research was supported through a PCORI Project Program Award (PCS-1403-14532).
Disclosures: Drs Duncan and Bushnell have ownership interest in Care Directions, and Dr Duncan serves as a consultant to BQ Technologies. The other authors have nothing to disclose.
Identification
Copyright
© 2021 by the American Congress of Rehabilitation Medicine.
