PROJECT SUMMARY/ABSTRACT The Comprehensive Post-Acute Stroke Services (COMPASS) Study, implemented across the stroke belt of North Carolina (NC), is a pragmatic trial of comprehensive transitional care for stroke. Forty hospitals were randomized to deliver the transitional care model (COMPASS-TC) or usual care. COMPASS-TC supports education, secondary prevention, rehabilitation and recovery following stroke. A key component of the model is the Movement Matters Activity Program. It is an evidence-based rehabilitation program to maximize survivor health, recovery, and function in the home and community. The COMPASS Study and its Vanguard site have collected data on over 11,000 NC patients hospitalized for stroke or transient ischemic attack (TIA) and discharged home. Baseline data provide rich information to control patient and clinical characteristics that may influence rehabilitation use (i.e., PT/OT visits) and patient outcomes. Two-day call and clinic visit data include information on social, behavioral, and functional determinants of health, in addition to clinical information. Ninety-day outcomes include several important patient-reported measures including the Stroke Impact Scale-16. Linkage of COMPASS data to NC administrative claims data provide valid information on rehabilitation use in the COMPASS sample. Together, the COMPASS Study and administrative claims data constitute a unique and robust data set on a large and diverse sample. Analyses of these data provide a tremendous opportunity to address gaps in understanding the use and effectiveness of rehabilitation care (i.e., physical and occupational therapy) after stroke. Using these data, we propose the following 3 aims: Aim 1 - Identify individual, hospital, and community-level factors associated with rehabilitation use and the extent to which COMPASS-TC moderates sociodemographic and geographic relationships; Aim 2 - Examine the effect of COMPASS-TC on rehabilitation use; Aim 3 - Evaluate the relationship between rehabilitation use and patient-reported and healthcare utilization outcomes and whether receipt of COMPASS-TC moderates these relationships; and the following 2 exploratory aims: Exploratory Aim 1- Examine the relationship between social, behavioral, and functional determinants of health (captured as part of the COMPASS-TC electronic care plan) and rehabilitation use; Exploratory Aim 2- Evaluate the added benefit of clinical data over and above claims-based data in controlling for confounding by indication. Results of this study will fill gaps in our understanding of the use and effectiveness of community-based rehabilitation in the context of “real world” care and will determine the effectiveness of a comprehensive transitional care model in improving access to/use of rehabilitation and outcomes for stroke survivors. Such information is critical as more individuals are surviving stroke and as the U.S. healthcare system moves towards value-based care delivery (e.g., bundled payments, accountable care organizations, transitional care).

PROJECT NARRATIVE This study will fill gaps in our understanding of access to and effectiveness of rehabilitation care for patients discharged home following stroke. It will also determine the potential effectiveness of a transitional care model in improving access to and appropriate delivery of rehabilitation care. Findings from this study will inform care delivery at the patient-, provider-, health system-, and policy-levels and may have a significant impact on the health of the nearly 800,000 persons per year who experience a stroke.