Pamela W. Duncan, PhD, PT, FAPTA, FAHA is Professor, Department of Neurology She joined the Wake Forest Faculty in 2011 to develop and evaluate innovative models of care to manage post-acute services for patients with medically and socially complex chronic conditions. She is principal investigator of a PCORI funded large pragmatic trial to implement and evaluate an evidenced-based COMprehensive Post-Acute Stroke Services (COMPASS) model and a founding investigator of the PCORI funded TEAMS BP. The care models for COMPASS and TEAMS_BP incorporate CMS transitional care and chronic care management services. These care models led by advanced practice providers (APP) develop patient centered care plans and engage patients and providers to coordinate BP management and recovery post stroke. Standardized assessments of the social and functional determinants of health are used to individualize care plans to manage blood pressure and stroke risk factors, manage medications, increase physical activity, reduce falls risk, optimize functional recovery, self-management of health and optimize access to primary care and community based services.

Dr. Duncan and her colleagues in the Atrium Wake Forest Baptist Comprehensive Stroke Center and in Informatics developed an electronic medical record integrated digital health platform, COMPASS-CP, to support and improve the clinical efficiency of post stroke secondary prevention and recovery. This platform identifies stroke patients on hospital admission for post-acute follow-up, facilitates the integration of clinical data and patient-reported outcomes to quickly develop individualized care plans, links to community based resources, and educational materials and tracks 90 day outcomes. In particular, COMPASS-CP is enhancing post- acute stroke care by allowing health care providers, health coaches, and patients to employ individualized care plans for lifestyle modification for blood pressure, physical activity, and medication management. Remote patient monitoring with the use of Bluetooth and/or cellular BP devices, activity sensors, medication adherence, creation of BP management dashboard, and timely development of individualized care plans empowers providers and patients to manage post- acute stroke care in a patient centered manner. In 2020, she was awarded the Wake Forest School of Medicine Entrepreneurship of the Year for her innovation in development and scaling of the COMPASS CP platform for clinical use.