Abstract WP328: Impact of Comprehensive Transitional Care Management on Community-Based Rehabilitation Care after Stroke

Background: Community-based physical therapy (PT) and occupational therapy (OT) are critical for functional recovery from stroke but are underutilized. Whether transitional care (TC) programs designed to improve hospital-to-home transitions improve the use of PT and OT is unknown. To evaluate this question, we conducted a secondary analysis of data from the COMPASS Study, a pragmatic trial comparing a TC intervention vs usual care on post-stroke functional status. Methods: The COMPASS Study randomized 40 hospitals to implement a comprehensive post-acute stroke TC model (COMPASS-TC) or maintain usual care for patients with stroke or TIA discharged home ( Figure 1 ). In Phase 2, hospitals assigned to usual care implemented COMPASS-TC. COMPASS-TC was aligned with CMS policy, comprising early phone and in-person clinic follow-up with individualized care planning supported by assessments of medical, functional, psychological, and social needs. We linked participants to administrative claims (Medicare FFS, Medicare Advantage, NC Medicaid, and Blue Cross Blue Shield of NC) to assess use of community-based PT and OT. Adjusted generalized estimating equations compared COMPASS-TC to usual care within the trial and crossover cohorts on 30 and 90-day PT or OT use, time to first visit, number of visits in 90 days, and receipt of PT and OT versus single therapy. Per protocol (PP) analysis estimated complier average causal effects using an instrumental variable approach. Results: COMPASS enrolled 8,377 patients from July 2016-March 2019; 5,261 were linked to administrative claims. Thirty-day PT or OT use ranged from 22.6% in usual care to 37.5% in Phase 2 COMPASS-TC. Receipt of intervention components was 73% for phone follow-up and 36% for the 30-day clinic visit. Figure 2 presents intention-to-treat and PP estimates of COMPASS-TC vs usual care on therapy use outcomes. Discussion: COMPASS-TC was consistently associated with shorter time to PT or OT, and with greater probability of therapy receipt in the crossover, but not the trial, analysis. Inconsistencies in results across cohorts may reflect unmeasured confounding or differences in hospitals that chose to adopt the intervention in Phase 2. PP results further support that, when received, COMPASS-TC may also increase the intensity and comprehensiveness of therapy. Implementation studies are needed to refine and test strategies to improve care transitions after stroke that facilitate access to post-acute rehabilitation.