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Wake Forest Launches Digital Health Program for Post-Discharge Stroke Patients

Analysis  |  By Eric Wicklund  
   August 12, 2022

The COMPASS-CP program, accessible through a hospital's EHR platform, pulls together care providers, patients, their families, and other participants to create a care management plan that includes remote patient monitoring, medication management, and resources to address social and functional determinants of health.

Atrium Health Wake Forest Baptist has partnered with the Wake Forest University School of Medicine to develop and launch a digital health platform to improve care coordination and management for stroke patients after they've left the hospital.

COMPASS-CP (COMprehensive Post-Acute Stroke Services – Care Plan), which can be accessed through the electronic health record platform, pulls together a variety of resources, including remote patient monitoring services, wearables, virtual care, medication management services, and algorithms identifying relevant social and functional determinants of health.

The program aims to facilitate stroke care and recovery outside the hospital on one platform, pulling together not only care teams but patients and their families, therapists, pharmacists, and even social workers.

According to the health system's website, the program "is a patient-centered electronic application that captures the social and functional determinants of an individual’s health at the point of care. Designed to be administered by a clinician in a clinical or home setting, the tool also assesses caregiver abilities and resources critical for patients during the post-stroke care period. Housed as a web-based or iPad application, the functional assessment is simple to administer, yet provides a comprehensive overview of potential barriers that can impair a patient’s ability to manage their personal health and recovery."

“COMPASS-CP allows clinicians to securely receive and easily interpret remote monitoring data, such as blood pressure and physical activity, which helps them, their patients and coaches make timely decisions and adjustments to lifestyle behaviors and medications aimed at reducing the likelihood of patients suffering future strokes,” Pamela Duncan, PhD, a professor of neurology at the Wake Forest University School of Medicine, said in a press release. “This is a great example of how our academic learning health system can take research findings and develop solutions to help improve the health of patients right here at home and across the country.”

The program is supported by the results of the massive COMPASS study, launched in 2015, which tested a digital health model of care on roughly 3,000 patients across 41 North Carolina hospitals and compared the outcomes to 3,000 patients undergoing traditional post-discharge care. The study was supported by a five-year, $14 million grant from the Patient-Centered Outcomes Research Institute (PCORI).

To help pitch the program to other health systems, Wake Forest Innovations helped launch Care Directions, a start-up targeting the stroke care space.

Officials say the program could position participating health systems for value-based care incentives from the Centers for Medicare & Medicaid Services, and eventually be scaled up and out to other settings, such as primary care and sub-specialty sites, and chronic diseases.

Eric Wicklund is the Innovation and Technology Editor for HealthLeaders.


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