Why Choose Compass Care Group In Severe Stroke?

• Integrated Transitional Care: The model bridges the gap between hospital discharge and a return to the community through services that combine hospital and community resources, which often lack coordination in standard care.
• Multidisciplinary Team Support: Care is coordinated by a team of specialists, including advanced practice providers (nurse practitioners, physician assistants, or physicians) and registered nurse post-acute care coordinators (PACs). This team approach helps manage the complexity of post-stroke needs.
• Individualised Care Plans: A key feature is the creation of a personalised electronic care plan (COMPASS-CP™) based on patient-reported outcomes, which helps identify and address specific medical, physical, social, and functional challenges, as well as caregiver needs.
• Structured Follow-Up: The program includes a structured follow-up process, including a telephone call within two days of discharge and a comprehensive clinic visit within two weeks, with additional follow-up calls at 30 and 60 days to monitor progress and adjust care.
• Focus on Patient and Caregiver Education: It emphasises education for both the patient and family caregivers on stroke recovery, secondary prevention (such as blood pressure monitoring), and self-management strategies.
• Reduced Adverse Events: Studies related to the COMPASS (Comprehensive Post-Acute Stroke Services) model have shown potential for improved outcomes, including a lower risk of skilled nursing facility (SNF) admissions and mortality, and a trend toward fewer 30-day rehospitalisations compared to usual care.
• Community Resource Navigation: The care plan integrates a local directory of community resources, helping patients and caregivers access necessary support services, which can be a major challenge after discharge.

Benefits of Choosing Compass Care Group for Severe Stroke

• Individualised Care Plans: An electronic care plan (COMPASS-CP) is generated in real-time based on standardised patient-reported assessments of medical, physical, social, and functional needs. This ensures care is tailored to the individual’s specific challenges and goals.
• Comprehensive Support: The model integrates medical management (e.g., medication reconciliation and blood pressure monitoring) with referrals to essential community-based resources and support services, such as rehabilitation, caregiver support groups, transportation, and meal services.
• Enhanced Patient and Caregiver Engagement: The process is designed to actively involve both the patient and their caregiver in education and decision-making, which improves patient engagement in managing their recovery and addresses caregiver strain.
• Improved Outcomes in Per-Protocol Analysis: While the main trial outcomes were not all statistically significant in a general analysis, a deeper “per-protocol” analysis of patients who fully received the intervention showed improved outcomes, including higher satisfaction with care, better function, less depression, and fewer falls.
• Focus on Secondary Prevention: The program emphasises education on stroke risk factors (like high blood pressure) and medication adherence to help prevent future strokes and complications.
• Coordinated Follow-up: A structured follow-up process includes phone calls within two days of discharge and a clinic visit within 7 to 14 days, ensuring a smooth transition from hospital to home and minimising fragmented care.

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