Study Overview


COMPASS Study is a cluster-randomized pragmatic trial. Participating hospitals will be randomized (stratified by stroke volume and primary stroke center status) to receive the COMPASS intervention or usual care for the first year of the study (Phase I).


Phase I began in July 2016.  Phase 2 will start approximately one year later in the late summer of 2017.  During Phase 2, the Usual Care hospitals will cross over to the COMPASS intervention. The early intervention hospitals will sustain the COMPASS intervention using hospital-based resources.  In this design, all hospitals have an opportunity to provide the COMPASS Intervention. Link & Study Abstract




All hospitals capable of supporting the COMPASS intervention are eligible to participate in the study. To join or obtain more information, click here.

Patient eligibility requirements include:

  • Aged >=18 years
  • Diagnosis of ischemic stroke, TIA, or Hemorrhagic stroke (excluding subarachnoid and aneurismal hemorrhage)
  • Discharged home



The trial has three integrated intervention components:

  1. Comprehensive post-acute stroke services (COMPASS), which combines transitional care services provided by advanced practice providers (APPs) and early supported discharge services coordinated by the APPs. These services include:
    • A comprehensive patient evaluation by a nurse practitioner or physician’s assistant
    • Development of an individualized care plan for each stroke patient who is discharged home. A post-acute care coordinator (RN or at each hospital will assist in this care plan delivery. Key elements include management of stroke secondary prevention, medication management, and referrals as needed to stroke rehabilitation and community services.
    • Support for patient caregivers
  2. COMPASS-funded post-acute care coordinators who will engage patient and stakeholder communities to improve post-acute stroke comprehensive stroke services;
  3. Development of a stroke metrics score card for hospitals and primary care providers. Well-trained APPs and coordinators will have access to online learning and ongoing support/consultation from study personnel and board-certified vascular neurologists.



We will assess 90-day and 1-year health outcomes. At 90 days after discharge, telephone surveyors, blinded to the patient’s group assignment, will assess aspects of the patient’s status and recovery. The primary outcome will be patient-reported functional status (measured with the Stroke Impact Scale-16). Secondary outcomes at 90 days include caregiver stress; unadjusted 30-and 90-day all-cause hospital readmissions captured through linkage with administrative claims data; cognitive status, medication adherence, blood pressure control, depression, continuity of care, and use of community resources.

One-year post-stroke outcomes will be ascertained using administrative claims data. These include: mortality, recurrent stroke, use of transitional care management billing codes, proportion of patients with 7-and 14-day post-stroke hospitalization, physician follow-up, and health care utilization (emergency department visits, number of hospital admissions and inpatient days, and admissions to skilled nursing and inpatient rehabilitation facilities).




Our Patient and Stakeholder Engagement Committee will work with our community resource networks to advise and support the implementation of COMPASS, provide feedback to the researchers, and recommend ways to continue COMPASS in the future. These networks will help us tell others about the COMPASS results and (if merited) how to begin similar programs across the United States to improve life for stroke survivors and their caregivers.