The COMPASS Study is a pragmatic trial to investigate post-acute stroke care models in North Carolina hospitals. The pragmatic nature of the study emphasizes ease of implementation and sustainability given real-world practice and reimbursement models as well as the importance of meaningful patient outcomes. We are currently recruiting hospitals to participate in this study and are leveraging the successes of the North Carolina Stroke Care Collaborative hospital network to improve post-acute care.

The study aims are as follows:


Primary aim

  • Determine the comparative effectiveness of COMprehensive Post-Acute Stroke Service model vs usual care on stroke survivor functional status at 90 days post-stroke

Secondary aims

  • Assess caregiver strain at 90 days
  • All-cause readmissions at 30 and 90 days
  • Mortality, health care utilization, use of TCM billing codes using claims data at 1 year


Why is the COMPASS Study Needed?

This study was motivated by the high stroke burden and the needs of stroke patients for post-acute care management.


  • Post-acute care after stroke is currently fragmented and holistic approaches to prevention, recovery, self-management and support do not exist
  • 2 out of 5 stroke patients who are discharged home are not referred to any post-acute care
  • 1 in 4 stroke patients who are discharged home are re-admitted within 4 months of discharge
  • North Carolina has the 8th highest stroke mortality rate in the country
  • NC patients have identified the critical need for post-acute care management

What COMPASS Study stakeholders and patients are saying…

So what is in place for the patient? Nothing. Seriously: nothing. No visiting nurse, no one to answer questions, or help them to get what they need. That is why people end up back in the hospital. 60 year old, female, living in urban NC

(stroke at 45)

If there is one thing I advocate for, it is for a navigator or ombudsman for stroke patients. A follow-up phone call has got to be the prime piece that has to happen in stroke recovery. 60 year old, male, living in urban NC

Stroke is just as hard on family members. They carry a large portion of the weight of recovery. 31 year old, female, living in rural NC

(stroke at 22)

Preparing the arrangements at home was left to the family. There was no home visit, and no directions were given to help with getting other services. 62 year old, male, living in urban NC