# Presentation: 546449

## QUERI National Meeting 2008The Implementation of A Stroke Self-Management Program: Process Challenges

- Teresa Damush, Ph.D., Laurie Plue MA, Gloria Nicholas, RN,
- Linda S. Williams, MD
- VA Stroke QUERI Center, HSRD Center of Excellence on Implementing Evidence-Based Practices, Roudebush VAMC,  Indiana University Center for Aging Research,
- Regenstrief  Institute, Inc., Indianapolis, IN
- Funded by VA HSRD IIR –IMV #04-096

## Objectives

- Challenges encountered and
-     modifications made to a small scale demonstration of a stroke self management program at 2 VA Centers (Indy & GV)
-  Points for Group Discussion

**Notes:**
The objectives of this presentation are twofold. First, I will discuss the challenges encountered as we implemented the stroke self-management and modifications we made along the way. Second, I will briefly ask questions to be considered for our group discussion.

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

**Implementation Research**

**Steps 4/5/6**

**Clinical Research / Guideline Development**

**Mainstream Health Services Research**

**Step 3**

**Step 1**

**Step M**

**Step 2**

**Step C**

**Improved quality/health**

**Phase 1 **
- Pilot Projects

**Phase 2 **
- Small-Scale Demonstrations

**Phase 3**
- Regional Demonstrations

**Phase 4**
- “National Rollout”

**Notes:**
Our implementation study covers Steps 4 and 5, Phase 2 on the QUERI implementation pipeline. Included as a handout is a description of the QUERI Six Step Implementation Process. 

## Study design

- System/provider intervention Indy (N = 56)

- System/provider intervention GV               (N = 84)

- Patient self-management intervention

- Social Control

- Social Control

- 28

- 28

- 42

- 42

**Notes:**
The randomized controlled trial to evaluate our stroke self management program was embedded into a system/provider intervention to increase screening for post stroke depression during outpatient follow up care in neurology and primary care services. In the randomized trial, patients were randomized to receive the stroke self-management program or a social control telephone follow up on the same schedule as the program.

## Development of Stroke Self-Management Program

- Formative Developmental Evaluation
- Began with the Stanford Arthritis and Chronic Disease Self-Management format (Lorig et al)
- Key informant survey of structure of patient education and self-management resources
- Received stakeholder input and preferences
- Stroke Survivors
- Caregivers
- Neurologists
- General Internists

**Notes:**
The Department of Defense/VA guidelines, the American Stroke Association and the Joint Commission promote the delivery of secondary stroke prevention after stroke/TIA events. The majority of VA facilities lack systematic support to facilitate patient self-management. Patient education materials may be handed out or videos may played in patient areas within the hospital but often lack key interactive components to motivate patients to change as part of self-management. We adapted the Stanford program to stroke through formative developmental evaluation with stakeholder inputs.

## Self-Efficacy Theoretical Concepts & Program Applications

_**1. Verbal Persuasions**_
- Staff explanations
- Promotion of physician and therapeutic recommendations
_**2. Social Modeling/ Vicarious Experiences**_
- Staff demonstration of all strategies and new behaviors
- Peers practice behavior in group meetings and share vicarious experiences
- View material of stroke patients similar to them

- 3_**. Past Achievements**_
- Set realistic, achievable goals
- Gain an understanding of the course of stroke rehabilitation and realistic expectations
- Tackle one stroke risk factor at a time
_**4. Reinterpretation of Sensations/physical state**_
- Discuss symptoms and how to diminish
- Distraction – Mental Imagery
- Relaxation

**Notes:**
We incorporate Social Cognitive Theory as a guide for our program contents to promote behavioral change.

## Stroke Self-Management Menu

- Expectations after stroke – What is normal?
- Negative/Positive thinking
- Addressing Fears
- Another stroke
- Falling
- Having Something to do
- Creating a weekly routine
- Follow – Up Medical Visits
- Communication
- Provider
- caregivers

- Adapting/coping with disabilities-Rehabilitation
- Finding a buddy
- Meds for Mood
- Relaxation
- Distraction – Mental Imagery
- Move to improve Mood & Energy
- Following PT guide
- Community Resources
- Management of Stroke Risk Factors

**Notes:**
Patients are offered a menu of stroke self-management topics in the program and have the choice to focus on particular components.

## Build Self-Efficacy

- Goal Setting
- Behavioral Planning
- Problem-solving
- Feedback
- Social Support

**Notes:**
The program builds patient self-efficacy to manage their health using goal setting, behavioral planning, problem-solving, feedback, and social support.  From another study we recently completed with primary care patients with pain and depression, patients reported that they wanted to incorporate goals and behaviors that were relevant to their life. For example, fishing and hunting activities were popular. This is key for patient retention in that we spent time in staff training on how to assist the patient with incorporating their preferences into their plans.

## Intervention - RCT

- Self-Management
- 6 sessions
- Phone
- Face to face
- Booster call
- Fidelity measurement of session contents
- Database for action plans/checklist

- Social Control
- 6 calls
- How are you doing?
- Refer ? To MD
- Booster call

**Notes:**
The two arms of the intervention included 6 sessions either in person or by phone. The social control group received all 6 by phone unless they had hearing problems. The patient would schedule a face to face meeting when he had an appointment that day at the VA. The social control calls basically asked the veteran how he was doing? And they seemed to enjoy receiving these calls. The staff would advise the patient to take any health related questions to their physician. For the self-management intervention, the staff would track the fidelity of the delivery of the  session contents. We also created a database for the action plans to analyze the contents.

## Patient Recruitment

- Staff monitored admissions and received approval from neurology to approach pt
- Staff introduced program during hospitalization and followed up after discharge
- Initially attempted to deliver while hospitalized
- Patients were overwhelmed with clinical experience
- What is the best method to recruit pts?
- Do pts have right to join program directly?

**Notes:**
The staff recruited patients during hospitalization for stroke and follow up prior to discharge or soon after they arrived home. Initially we attempted to deliver the program during hospitalization but the patients were overwhelmed. At one site, we experienced some difficulty with one of the providers in approving referrals. So a thought for discussion is what is the best method to recruit pts into these programs? Do patients have the right to join the programs directly?

## Social Marketing

- What materials are used to invite patients to participate in self-management programs?
- Program brochures, pictures, logos
- Contents of invitation
- How are these programs marketed to facility providers?
- Do pt self-management programs assist providers?
- Do providers value these programs?

**Notes:**
Social marketing is the systematic application of marketing along with other concepts and techniques to achieve specific behavioral goals for a social good.  A good example are public health messages for smoking cessation and illicit drugs.

How are these programs marketed to patients and providers?

## Patient Functioning

- Cognitive -Screen with Short Portable Mental Status Questionnaire (SPMSQ)
- Dx of Dementia – pass  SPMSQ then eligible
- Language Functioning
- National Institutes of Health (NIH) Stroke Scale
- How do we include patients with mild cognitive impairment? Large % GV patients

**Notes:**
In our study at one site, we had a large proportion of the screened patients with cognitive impairment. How do we include patients with mild cognitive impairment? Do we target caregivers?

## Patient Discharged to Rehabilitation Facility from VA

- Followed patient through rehabilitation
- Recruited, conduct baseline assessment and consent within 2 weeks of discharge from rehab to home ---the beginning of self care.
- Randomization blocked on discharged to rehabilitation facility

**Notes:**
For some patients, they may spend time in a rehabilitation facility after discharge from the VA. We experienced this in our trial and decided patients did not have the opportunity to self-manage in this facility so we followed until discharged home and randomized within 2 weeks. To control for this, we randomized in blocks based on discharged to rehabilitation facility.

## Behavioral Action Plans

- Goal setting to increase self-efficacy
- Use a paper based action plan
- Experienced reading and writing problems among some stroke patients
- Modified action plan to a behavioral checklist

**Notes:**
Veterans with stroke experienced difficulties with printed materials. They struggled with the typical action plan that was open ended. We created a behavior checklist to simplify the process.

## Secondary Stroke Prevention and Risk Factor Management

- Many Risk Factors
- Multiple behavior change is challenging
- Facilitate pt negotiation to start with one risk factor – staff training
- Challenge
- Focus on one before moving on to another
- When to move onto next behavior
- Simultaneous preferences – realistic goals
- Patient choice may not be the most pressing risk factor

**Notes:**
As Jane described, there are many risk factors that may be modified for secondary stroke prevention. Multiple behavior change is challenging. We train our staff to facilitate patient negotiations to start with one risk factor before moving on to another. This is delicate as we want to respect patient autonomy but do not want to set them up for failure. I find it interesting that the patient choice for risk factor change may not be the most pressing risk factor.

## Delivery of Intervention

- Individual session vs group meeting
- Sufficient number of pts for clinical group on regular schedule
- In person vs telephone
- Hearing or speech problems
- Telehealth tools - videophones
- Cell phones
- Best use of personnel time to deliver
- Nurse, rehab professional, social worker, other

**Notes:**
During our implementation trials, the delivery of patient self-management is a critical issue and affect the reach within the VA population. We intend to delivery by group but it is not always feasible due to patient flow through the facility.  In addition, we had to utilize the telephone to deliver sessions when the veteran could not travel to the facility. Finally, we have utilize nurses, physician assistants and bachelor degree trained staff to deliver programs; however, it is unclear who is the best personnel within VA to deliver. How can we integrate within usual workflow?

## Geographic Coverage –VAMC

- Indy - Patients drive up to 2 hours to facility
- Follow up care at CBOCs
- Pt geographic mobility during the year
- Snow birds,
- visit relatives out of state

- Gainesville – covers North Florida from Ocala to Tallahassee to South Georgia
- Follow up care at CBOCs
- Pt geographic mobility during the year

**Notes:**
The large geographic coverage that a VA facility covers may be problematic for delivering group sessions in person. Our 2 sites covered a large area where patients receive follow up care at a CBOC. In addition, we experienced patient geographic mobility during the year. 

## Quality Control/Fidelity: Use of Telephone Conferencing

- Used Teleconference system to listen to self-management sessions at secondary site.
- Patient agreed to call in and participate in the session while the quality control listened.
- Worked very well = potential resource for future program delivery

**Notes:**
For a multi site study, we utilized the VANTS line to assess quality control/program fidelity and this worked very well. 

## Summary

- Variation in functional status among patients with a stroke is challenging for logistical planning
- Addressing multiple stroke risk factor management may be overwhelming to patients attempting to self-manage
- Telehealth tools may increase reach of programs into Veteran population

## National QUERI MeetingThe Implementation of Self-Management Programs in VA Workshop 

**WORKING GROUP GOALS**
- To share knowledge across QUERI and generate specific ideas for follow-up activities to improve QUERI methods
- To brainstorm about solutions to improve QUERI processes, both internal and in collaborations with operations
- To generate ideas for collaboration across QUERI groups on research projects
- To generate specific ideas for collaborating with operations on implementation and implementation research
- To generate specific ideas for strengthening QUERI impact on VA healthcare

**Notes:**
I just want to remind you of the working group goals for this morning’s session.

##            Points of Discussion

**     **_**Operations Collaborations**_

- VA Personnel
- Site champions
- Training/Delivery of programs
- Workflow integration
- CPRS
- Software
-  Patient Referrals
- Self
- Providers
- Social Marketing

_**Program/Research Issues**_

- Disease Specific vs
-      Global Program
- Multiple behavior change
- Technology
- Reach into Veteran population
- Caregivers
- Program fidelity

**Notes:**
These are some points to facilitate the discussion. However, you may have other pressing issues that have not been mentioned this morning and that is the goal of our group discussion is to build a consensus on priority points for implementing patient self-management in VA. Thank you.