COMPASS CP for Stroke: Precision health at its best

Pamela Duncan, Ph.DProfessor of Neurology

Wake Forest Baptist Health Scott Rushing, Director Research

Information Systems

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Disclosures and disclaimer

• Dr. Duncan receives salary support for COMPASS, which is funded by the Patient Centered Outcomes Research Institute (PCS 1403-14532).

• Disclaimer: All statements in this presentation, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of PCORI, its Board of Governors, or the Methodology Committee.

• Dr. Duncan is a co-founder of Care Directions, Inc.

Acknowledgments

• WFBH Innovations Funds- Catalyst Funds• Create an EHR agnostic application

– With Specific Intent to Commercialize For Scalability

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Clinical Informatics Solutions Require

Clinical Vetting

IT Partner

HITVendor

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Value

What is a PRO?

…is any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else.

– FDA 2009

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Why are PROs Important?

• Provide information not available from other sources. (i.e. insights of patient health status using past performance)

• Incorporates the patients personal standards, values, and expectations.

• Identify manageable drivers of self-management or “adherence” .

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Wake Forest Innovations

• Patient Reported Outcomes Should INFORM and Be Source of ACTIONS for Individualized Care

Patient EngagementPatient Self ManagementINDIVIDUAIZED CARE PLANS

Wake Forest Innovations

• CMS is mandating new care directions and payment models to improve care coordination and chronic care management.

CMS Mandates

• MACRA • Chronic Care Plus• TCM & CCM

• Common to all CMS mandates for new care models is an individualized electronically available care plan.

• The care plan must be electronically available to all providers and the patient.

COMPASS Overview

• Multi-site, pragmatic, clinical trial• Stroke patients who go home directly

from the hospital• COMPASS (combines transitional care

and early supported discharge for) Vs. usual care

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Does COMPASS…• Improve patients’ daily function?• Reduces caregiver strain?• Reduce hospital readmission rates?• Reduce use of health care?• Reduce mortality

Numbers Know your numbers -blood pressure, blood sugar, cholesterol, etc.

Engage Be active - engage your mind and body

SupportAsk for help - for yourself and your caregivers from community resources

WillingnessBe willing – manage your medicines and lifestyle choices

NUMBERS

ENGAGE

SUPPORT

WILLINGNESS

SS

NN

EEWW

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Finding the Way Forward

• Model: Early supported discharge• Care Team: stroke trained APP and post-acute coordinator

(RN) for care coordination• eCOMPASS:

– Chronic disease management: Connects hospitals, community providers, and community agencies

– Billable with Transitional Care Management or Complex Clinical Management, consistent with MACRA requirements

– Individualized care plan addresses the needs of stroke survivors and their caregivers

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COMPASS Care Model

2day Phone call

7-14day Clinic Visit

30day Phone call

60dayPhone call

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1. General Health

2. Global Disability

3. ∆ Neuro Deficits

4. Neuro Deficits Persist

5. Stroke Related

Complications

6. Depression 7. Stress 8. Risk Factors 9. Lifestyle Management

10. Medication Management

11. Physical Mobility 12. Falls 13. ADL 14. IADLs 15. Social

Support

16. Caregiver Available

17. Transportation

18. Financial to Medication Management

19. Advanced Directives

20. Access to PCP & HHOP

21. Readmissions

PRO example

Patient Specific Care Plans

• Generated using proprietary algorithms – SAS code is dynamically run each time care plan is

generated

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– Gathers most current data we have from that patient or their care team

– Runs through a series of algorithms to determine what specific health concerns exist for this patient

– Prompt provider for customizations– Generate PDF, available electronically

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Community Resources

EARLY FINDINGS FROM COMPASS-CP

Abstracts presented at the European Stroke Organization Conference and submitted to the International Stroke Conference

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Data from provider satisfaction survey

• 44 clinicians from 19 hospitals completed the survey

• About 75% agreed or strongly agreed that COMPASS-CP identified important factors impacting the patient’s recovery and ability to self-manage that they might have missed

• 66% were satisfied with the app overall• 58% stated it made their job easier

Wake Forest Innovations

PROVIDE THE RIGHT CARE AT THE RIGHT TIME, INDIVIDUALIZED TO EACH PATIENT’S AND CAREGIVER’S NEEDS AND PRIORITIES,

SHARED ACROSS POST-ACUTE PROVIDERS Real time and concurrent with care

Patient and caregiver reported assessments, iPad and computer adapted

COMPASS CP Plans

• Compass - EHR Integration will be required– Eventual development of a SMART/FHIR-based

version of eCompass– Cloud-hosted making it available to any number of

health systems which have a FHIR-enabled EHR platform

– Integrated chronic health care plans for patients with multiple chronic conditions

– Addition of predictive analytics to improve the current ‘static’ algorithms

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eCare(Smart on FHIR)

Secure Cloud Storage for eCare form data

eCare Assessments

EHR•Key EHR data delivered via FHIR

CR•Local community resource lists

Mobile friendly eCare App

Patient eCare Plan

Clinician handoff report

Provider report

eCare downloadable reports

Performance reports

More Information on eCOMPASS

• YouTube: https://www.youtube.com/watch?v=K7dCCTvRxa4&

• pduncan@wakehealth.edu

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