Pamela W. Duncan, PhD, PT, FAPTA, FAHA is Professor, Department of Neurology. She received her BS degree in Physical Therapy from Columbia University and a PhD in Epidemiology from the University of North Carolina. Her previous academic affiliations were with Duke University, University of Kansas, and University Florida and the Department of Veterans Affairs. She was PI of the VA Rehabilitation Outcomes Research Center and was C0-PI of the University of Kansas Pepper Center. She currently serves on the advisory board of the University of Pittsburgh Pepper Center. 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 the principle investigator of a PCORI funded large pragmatic trial to implement and evaluate an evidenced-based COMprehensive Post-Acute Stroke Services (COMPASS) model. This model of care combines CMS transitional care services provided by advanced practice providers (APP) and early supported discharge services coordinated by the APPs to develop with patients and families actionable care plans. 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. The cluster-randomized trial included over 40 North Carolina Hospitals and over 10,000 patients. The COMPASS transitional care intervention, supporting digital applications, and quality performance measures emerged from front line clinical practice at the Wake Forest Baptist Health Comprehensive Stroke Center. The evaluation of this intervention in a pragmatic trial continues to refine our delivery of post- acute stroke care at Wake Forest and will support scalability of .our applications and models of post- acute care to other health systems. In collaboration with Dr. Cheryl Bushnell, Dr Duncan and colleagues have received funding for a 30 million dollar multi-center, patient-randomized control trial This award will fund the first study of its kind to test two interventions to lower blood pressure in the first six months following a stroke—one utilizes telehealth, individualized care planning, and behavioral health coaching to manage physical activity, medication management, and diet, and the other is in-person clinic management. 200 plus publications ( H-Index 62)