Using Clinical Decision Support Toolsto Implement Patient Self-management

Jane Anderson, PhD, RN, FNP-BCAssociate Director, Stroke Center

Michael E. DeBakey VA Medical Center

Translating and Documenting Evidence Based Care

STOP Stroke Clinic

STOP Stroke Tool

Evidence-based practice

Information Systems

Self-management Support

Performance Improvement

Implementation Research

Clinical Research / Guideline

Development

Mainstream Health Services Research

Step 3Step M

Improved quality/health

Phase 1 Pilot Projects

Phase 1 Pilot Projects

Phase 2 Small-Scale

Demonstrations

Phase 2 Small-Scale

Demonstrations

Phase 3Regional

Demonstrations

Phase 3Regional

Demonstrations

Phase 4“National Rollout”

QUERI’s Six Step Process Implementation Pipeline (B Mittman)

Step 2

Step 1

Step CSteps 4/5/6

Step 4: – in the Development or adaptation of educational materials or decision support tools.Phase 1: as a pilot project – Alpha stage development and testing was recently completed to develop the STOP Stroke Tool .

Pilot Project

Two specific aims: Test the functionality of each component of

the tool in simulation Determine overall usability of the tool

among a sample of multidisciplinary clinicians.

A pre-experimental before/after design Documentation of CPGs was compared

among a sample of multidisciplinary providers (N=15) using test case scenarios and two documentation systems, standard CPRS vs. the STOP Stroke Tool.

Usability was evaluated with a questionnaire

Clinical Management

Patient EducationPatient Self-management

Embedded Guidelines

Patient specific information

Medication Algorithm

Hyperlink to Education Materials

Automates Documentation of guideline based actions – providing supporting evidence of JC regulations

Joint Commission Standardsfor Self-Management

Joint Commission Standards for Primary Stroke Center Certification

Supporting Evidence (SE) SE 1 - Patients are involved in the decision-

making process for managing their disease or condition

SE 2 – Recommended lifestyle changes support patient self-management actions

SE 3 - Patient’s educational needs are addressed in the context of self-management

Supporting Self-Management with Information Systems

The STOP Stroke Tool Guides clinicians in an evidence-based

self-management intervention Collaborative action plan

Facilitates documentation of supportive evidence for self-management

Stores supportive evidence data for outcomes monitoring and JC reporting

Patient selects an action to reduce stroke risk Action needs to be something the patient wants to do

Provider steps patient through specifics of their stated goal

Confidence level is established by the patient and indicates how much they believe they will accomplish their stated goal.

Needs to be at least 7 or more. If not 7 – provider helps patient rework their action plan until the patient has a higher confidence level.

Automates Documentation of action plan– providing supporting evidence of JC regulations

Health Factor

Implementing Self-management in the STOP Stroke Clinic

3 Clinic visits 6 Self-management classes

STOP Stroke Clinic – Care Delivery

Initial Clinic Visit

Group SM Course

Group SM Course

Group SM Course

Clinic Follow-up

Group SM Course

Group SM Course

Group SM Course

Final Clinic Follow-up

Self-management course – Stanford CDSM Program - 6 group sessions

2 hours duration

Self-management course continued

Final clinical management visit, RF education, Reinforce action planning

Clinical management follow-up, RF education, Reinforce action planning

Stroke secondary prevention & risk factor profile – 20 minutes

Implementation Barriers Clinic Structure Time required to participate in SM Class

30% participants completed all 6 visits Most frequent participant recommendations

– fewer visits and shorter class time

Geographic constraints 48% patients > 50 miles from main facility Most common reason for not participating in

course - I live too far from the VA

Implementation Barriers Care Delivery

Heavy burned for staff resources NP students made possible multiple

simultaneous clinic visits and served as course facilitators

1 NP faculty and 3 NP students for clinic visits 1 NP faculty and 2 NP students for Self-

management course NP Students only available during Spring

and Summer Elective course

Implementation Facilitators

STOP Stroke Tool is Effective in: Prompting Guideline-based care Increases documentation

Clinical Practice Guidelines Patient Education Patient Self-management

Stroke EtiologyRisk Factor

AHA/ASA Stroke Secondary Prevention CPGs

Outcome MeasuresNonCardioEmbolic/Cardioembolic Stroke

1. Antiplatelet/ Anticoagulation Therapy Prescribed Aspirin, Plavix, Aggrenox or Warfarin

Hypertension

Hypertension + Diabetes

2. Hypertension Medications PrescribedAngiotensin Converting Enzyme Inhibitor-Thiazide

Diuretic Angiotensin-Receptor Blockers

Diabetes3. Oral hypoglycemic agents/Insulin Prescribed

4. Dietary Counseling Provided

Hypercholesterolemia 5. Statin Agent Prescribed

Smoking 6. Smoking cessation recommended Pharmacologic support offered/prescribed

Overweight/Obesity BMI 7. Dietary Counseling and/or Exercise Training Recommended

Physical Inactivity 8. Exercise Training Recommended

Heavy Alcohol Consumption 9. Reduced alcohol consumption recommended Referral to alcohol dependency counseling

Patient specific risk factors 10. Patient Education Materials Provided

Behavioral risk factors 11. Patient Self-management -Action Plan Completed

CPG Intervention # DocumentedCPRS

# DocumentedSTOP-ST

Documentation Change

pvalue

Anti-platelet/coag 14 15 1 1.0

HTN medications 13 15 2 .50

DM medications 9 15 6 .031*

DM diet counseling 8 15 7 .016*

HCL/Statin agent 6 15 9 .004*

Smoking cessation 13 15 2 .50

Reduce alcohol 13 15 2 .50

BMI -diet/exercise 7 15 8 .008*

PI/Exercise program 12 15 3 .25

Education materials 0 15 15 .000*

Self-management 0 15 15 .000*

CPG = clinical practice guideline, CPRS = computerized patient record system, STOP-ST = STOP Stroke Tool®, HTN= hypertension, DM = diabetes, HCL = high cholesterol, BMI = body mass index, PI = physical inactivity

Number of Providers that Changed Documentation of Clinical Practice Guidelines Using the STOP Stroke Tool Compared to CPRS

What’s Next ?

Application of Lessons Learned Restructure STOP Stroke Clinic Test implementation of STOP

Stroke Tool Multiple Clinic Settings

Individual Clinic

Initial Group Clinic

Video Phone 1

Video Phone 2

Video Phone 3

Video Phone 4

Final Group Clinic

Individual Clinic

Clinical management provided during individual clinic visit – followed by

Initial group clinic – Group session for self-management counseling, action planning and problem solving 4 video phone follow-up sessions provided to reinforce. Specific risk factor management, patient self-management, action planning, and problem solving

Final follow up clinic provide during individual clinic visit – followed by

Final group encounter to review patient self-management, action planning and problem solving skills

Possible Clinic Restructure -

Staff Nurse Practitioner

Staff Registered Nurse

Staff Nurse Practitioner

Beta TestingImplementation of the STOP Stroke Tool in Clinical Practice

Beta test the STOP Stroke Tool in primary care and other practice setting where veterans receive follow-up care for stroke and TIA

Test components of the tool Primary Care Clinics Rehabilitation Medicine Clinics Neurology Clinics