To optimize the success and sustainability of a new transitional care program, ensure that all key stakeholders are engaged as a vital part of the ongoing learning process. It is especially important to include insurers, senior health system executives, and patients.

Pamela Duncan, PT, PhD, is studying the impact of the Comprehensive Post-Acute Stroke Services (COMPASS) program on functional outcomes of stroke patients at 41 hospitals in North Carolina. In this program, both specialized clinicians and care coordinators deliver transitional care services.

Duncan notes that it is important to have a diverse set of hospitals and insurers participate. She also notes the need to demonstrate to stakeholders that the program addresses issues important to them. Duncan remarks, “Our hospitals are cash-strapped, and comprehensive care transition management requires significant resources to build the infrastructure to deliver these services. Current reimbursement policies do not fully cover the costs; hospitals need incentives to invest in complex, broad-scale service delivery changes.” A multi-stakeholder advisory council worked with Duncan to demonstrate that chronic conditions are costly to payers and that transitional care management strategies like COMPASS offer both clinical and financial benefits.

Duncan notes that each stakeholder has a unique perspective that needs to be shared. The patient perspective is fundamental in providing insight about patients’ needs and creating a program that is patient-centered. While a researcher can develop and test a model, unless health system executives and insurers “understand the value and buy into the program, it will not be sustained,” Duncan says.