Hospital to Home Transition for Patients with Stroke under Bundled Payments.

Bundled payments are one of the promising Alternative Payment Models for reducing costs and improving the coordination of post-acute stroke care. Yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention, focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Center for Medicare and Medicaid Innovation Bundled Payment for Care Improvement (BPCI) Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.