1. Dynamic Generation of Patient Specific eCare Plans in a Pragmatic Trial
Pamela W Duncan PhD. FAPTA , FAHA
Professor on Neurology
Wake Forest Baptist Health
PI COMPASS Trial

2. Clinical Informatics Solutions Require
Clinical Vetting
IT Partner
HIT
Vendor
Value

3. 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
Precision Medicine: “know thou patient” including the social and functional determinants of health and preferences for care

4. What is a PRO? Extremely Complex:
Less Complex: Symptomatic (i.e response to headache)
More Complex:
(Ability to carry out activities of daily living)
Extremely Complex:
Quality of Life (multi domain concept w/ physical, psychological and social components)

5. 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” .

6. Patient Reported Outcomes Should INFORM and Be Source of ACTIONS for Individualized Care
Patient Engagement
Patient Self Management
INDIVIDUAIZED CARE PLANS

7. COMPASS Principal Investigators
11/6/2018
COMPASS Principal Investigators
PI: Pamela Duncan, PhD, PT, FAPTA, FAHA Professor of Neurology, Wake Forest Baptist Health
Co-PI: Cheryl Bushnell, MD, MHS, FAHA Professor of Neurology and Director, WFB Comprehensive Stroke Center
Co-PI: Wayne Rosamond, PhD, MS, FAHA Professor of Epidemiology, UNC Gillings School of Global Public Health and Director, North Carolina Stroke Care Collaborative

8. Comprehensive Post Acute Stroke Services – Pragmatic Trial
11/6/2018
Comprehensive Post Acute Stroke Services – Pragmatic Trial
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
Does COMPASS…
Improve patients’ daily function?
Reduces caregiver strain?
Reduce hospital readmission rates?
Reduce use of health care?
Reduce mortality

9. COMPASS Care Model Model: Early supported discharge
2day
Phone call
7-14day Clinic Visit
30day
60day
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

10. 4. Neuro Deficits Persist 5. Stroke Related Complications
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

11. PRO example

12. Patient Specific Care Plans
Generated using proprietary algorithms
Gathers most current data we have from that patient or their care team
SAS code is dynamically run each time care plan is generated
Runs through a series of algorithms to determine what specific health concerns exist for this patient
Prompt provider for customizations
Generate customized Individual Care available electronically

13. eCare WebApp Two Day Post-Discharge Follow up EHR
Post Stroke Functional Assessment
Stroke Caregiver Assessment
Post Stroke Advanced Practice Assessment
eCare Assessments
EHR
Key EHR data delivered via FHIR (future version) CR
Local community resource lists
eCare WebApp
Mobile friendly eCare App
eCare downloadable reports
Patient eCare Plan
As I said, Compass is a web based application with 2 primary components: 1) a series of proprietary assessments that identify the social and functional determinants to health for a patient, and 2) a patent pending decision system that identifies the the key health concerns for a patient at that time. The assessments ask questions which are not consistently collected in the medical record and when they are, they are not frequently used in decisions about patient care. Questions like:
Can the patient manage their medications? Do they have cognitive issues ? Do they have a caregiver who can assist with daily functions or medication management?
We take those response and turn them into actionable data by running them through a decision algorithm that dynamically generates a patient specific care plan that identifies the health concerns for that patient.
In addition to the care plan, COMPASS also produces a series of reports for the clinical provider and the hospital or health system: including summary reports that help the physician both in communicating with the patient and their care team as well as simplifying documentation tasks within the health record. There are also a series of quality and performance reports as well as predictive analytics that use the data to determine needed refinements to the decision algorithms.
Provider report
eCare Data Repository at WFBH
Clinician handoff report
Performance reports
Risk Calc - 90day Outcomes

14. Key Team Pamela Duncan, PhD Professor, Neurology Scott Rushing
Expert in health policy, outcomes research and clinical epidemiology.
Scott Rushing
Director, Research Information Systems Unit
Expert in health information systems and technology platforms.
Cheryl Bushnell, MD, MHS
Professor, Neurology
Expert and nationally recognized leader in vascular neurology.
Ralph D’Agostino Jr, PhD
Professor, Biostatistical Sciences
Expert in biostatistics and research.
Allison Brashear, MD, MBA
Chair, Neurology
Expert in care plan implementation and integration in clinical workflow.

15. eCare App Patient Demo

16. Finding the Way Forward
11/6/2018
Finding the Way Forward
Numbers
Know your numbers -blood pressure, blood sugar, cholesterol, etc.
NUMBERS
ENGAGE
SUPPORT
WILLINGNESS
Engage
Be active - engage your mind and body
Support
Ask for help - for yourself and your caregivers from community resources
Willingness
Be willing – manage your medicines and lifestyle choices

18. Community Resources

21. A Tool for Clinical Trials : Assessment of Social and Functional Determinants of Health Could Support Adherence for Interventions ( behavioral or medication )

22. More Information on eCOMPASS
YouTube:

23. Thanks & Some Required Disclosures
FUNDING ACKNOWLEDGEMENT: Patient-Centered Outcomes Research Institute (PCORI) Award (PCS ).
REDCap support of the Wake Forest Clinical and Translational Science Institute (WF CTSI), which is supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through Grant Award Number UL1TR
DISCLAIMER: All statements are solely those of the presenters and do not necessarily represent the views of PCORI or its Board of Governors or Methodology Committee.
NCT Number for ClinicalTrials.gov: NCT