Post on 29-Jan-2016
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