# Presentation: 918214

## Using Clinical Decision Support Toolsto Implement Patient Self-management

- Jane Anderson, PhD, RN, FNP-BC
- Associate Director, Stroke Center
- Michael E. DeBakey VA Medical Center

**Notes:**
Thank you and good morning – it is an honor to be here to present the work we are doing in Houston to implement Self-management.  

## Translating and Documenting Evidence Based Care

- STOP
- Stroke Clinic

**STOP  Stroke Tool**

- Evidence-based practice

- Information Systems

**Self-management Support**

- Performance Improvement

**Notes:**
The STOP Stroke Tool was initially conceived as a decision support tool to facilitate care delivery in the STOP Stroke Clinic.
In designing care delivery for the clinic - Self-management was considered an essential component – 
First, because evidence  (Lorig & Holman, 2003) supports that persons with strong self-management skills are more successful in: 
managing chronic conditions –  many stroke risk factors are chronic conditions – i.e. – HTN, DM
(b) persons with strong self-management skill are also more successful at sustaining lifestyle behavior change -  multiple stroke risk factors require behavioral change – smoking cessation, obesity, physical inactivity. 
Secondly, accrediting organizations, such as The Joint Commission are requiring evidence of self-management interventions for disease specific certification programs.  
At the Michael E. DeBakey VA Medical Center we are developing our stroke program to meet the JC requirements for primary stroke center certification and our program is being structured to incorporate 4 required components for PSC certification –
evidence-based practices – information systems – self-management support and performance improvement –

The STOP Stroke Tool prompts on EBP for stroke secondary prevention – supports self-management, simultaneously automates guideline adherent documentation, and provides outcomes data collection for performance improvement. All this is possible using reminder dialog programming within CPRS

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

**Implementation Research**

**Clinical Research / Guideline Development**

**Mainstream Health Services Research**

**Step 3**

**Step M**

**Improved quality/health**

**Phase 1 **
- Pilot Projects

**Phase 2 **
- Small-Scale Demonstrations

**Phase 3**
- Regional Demonstrations

**Phase 4**
- “National Rollout”

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

**Step 2**

**Step 1**

**Step C**

**Steps 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 .

**Notes:**
The development of the STOP Stroke Tool falls under Step 4 – Phase 1 of the QUERI Implementation Pipeline
Step 4: – in the Development or adaptation of educational materials or decision support tools 
Phase 1: As a pilot project funded by VHA Office of Nursing Services 

## 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

**Notes:**
Alpha testing has been completed to develop the STOP Stroke Tool 

Alpha testing was focused on two specific aims: (a) to test the intended functionality of each component of the tool in simulation, and (b) to determine the overall usability of the tool among a sample of multidisciplinary clinicians. 
A pre-experimental before/after design and descriptive methods were utilized. 
Documentation of CPGs was compared among a sample of multidisciplinary providers (N=15) using test case scenarios and two documentation systems, the standard CPRS vs. the STOP Stroke Tool. 
Usability was evaluated with an investigator-developed questionnaire and one open-ended question. 

## Slide 5

**Notes:**
I have included a few slides to show how the STOP Stroke Tool Works in CPRS
There are three components to the STOP Stroke Tool  
Clinical Management, 
Patient Education
Patient Self-management

The evidence base for  the Clinical Management Component is American Heart Association/American Stroke Association (AHA/ASA) guidelines and The (VADoD) 

## Embedded Guidelines

**Embedded Guidelines**

**Patient specific information**

**Medication Algorithm**

**Notes:**
This slide is provided to show an example of how the STOP Stroke Tool incorporates CPGs for stroke risk factor management. 

When the patient’s risk factors is identified, providers follow check box prompts – the prompts direct the clinician in evidence base care. 
For example – here you see embedded guidelines – specific for management of Hyperlipidemia per AHA/ASA - 
Patient specific information, like lab values are displayed with recommended targeted values per guideline recommendations. 

Here a detailed medication algorithm

## Hyperlink to Education Materials

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

**Notes:**

Here you see how Hyperlinks to patient education materials are embedded throughout and are specific for each stroke risk factor. 
This functionality Allows the clinician to individualize patient education for each patient’s needs. 

Also, note below how selected check box prompts create automated documentation of guideline based actions. 
Many of the actions documented are stored as health factors in ViSTA.
This functionality works to provide  documentation of supporting evidence for JC regulations and data collection for monitoring performance measures

This same process is also applied for the self-management component ---

## Joint Commission Standardsfor 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

**Notes:**
The specific supporting evidence required by the Joint Commission for Primary Stroke Center Certification is: 
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 

So, how are these criteria are met  - 

## 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

**Notes:**
The tool Guides clinicians in an evidence-based self-management intervention known as --- Collaborative action planning
The patients is involved in the decision-making process by selecting a recommended lifestyle changes to reduce risk of second stroke

Patient’s educational needs are addressed in the context of the patient’s action plan 

The tool automates Documentation of collaborative action planning which provides supportive evidence for self-management interventions in the EMR --

Finally, The tool Stores elements of the action plan as health factors – providing 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

**Notes:**
This screen shot provides an example of how this process works – The tool is used with the patient during the clinic visit
The patient is coached to select an action to reduce stroke risk for the next week –
The action needs to be Something the PATIENT wants to do !
Reasonable (something that can accomplish within a week).
Behavior specific (for example, losing weight is not a behavior, but avoiding snacks between meals is a behavior).
Clearly Defined:
What? (for example, walking)
How much? (for example, walking 4 blocks)
When? (for example, after dinner, or M/W/F)
How often? (for example, 3 times)

## 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

**Notes:**
Then A Confidence level is established by the patient and indicates how much they believe they will accomplish their stated goal. 

Confidence level needs to be at least 7 or more. ( 0= no confidence to 10 = total confidence; that you will complete the ENTIRE action plan).
If not 7 – the provider helps patient rework their action plan until the patient has a higher confidence level.

As noted below – the entire process is documented in the patients encounter note and selected elements are stored as health factors

## Implementing Self-management in the STOP Stroke Clinic

- 3 Clinic visits

- 6 Self-management classes

**Notes:**
The action planning process provided during the clinic visit is introduced and reinforced in a Self-Management Course

This is accomplished by coupling 3 STOP Stroke Clinic Visits with 6 Self-management classes
Nurse Practitioner faculty and Nurse Practitioner Students are patient providers for the STOP Stroke Clinic

Self-management is implemented in:
3 Clinic Visits - During clinic visits the NP provides evidence-based secondary stroke prevention, evaluates and educates the patient on their specific risk factor profile and reinforces collaborative action planning (Using the STOP Stroke Tool) --
NP faculty and students provided the Stanford Chronic Disease SM Course (Lorig et al) during 6 group sessions

## 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

**Notes:**
This slide provides a schematic of the STOP Stroke Clinic Care Delivery Process 

The initial clinic visit is coupled with First SM Course Session

The next week the patient attends the SM course only – no clinic follow up

The third week includes a follow up clinic visit and the third SM class

Weeks 4 and 5 include the SM class without a follow up clinic visits
The Final week includes the last SM course and a final follow-up clinic visit

## 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

**Notes:**
Evaluation of this implementation process has revealed several barriers 

First – the duration of classes and number of visits – only about 30% completed all 6 visits 

Most frequent participants recommendations for improvement– fewer visits and shorter class

Most common reason for nonparticipation in course was – live too far to make frequent trips to 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

**Notes:**
This process requires significant staff to implement
NP students made possible multiple simultaneous Clinic Visits and were 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 – course offered as an elective 

Elective Course – NP students enrolled in Chronic Disease Self-manage course completed clinical rotations in the STOP Stroke Clinic as part of the course requirements. 

## Implementation Facilitators

- STOP Stroke Tool is Effective in:
- Prompting Guideline-based care
- Increases documentation
- Clinical Practice Guidelines
- Patient Education
- Patient Self-management

**Notes:**
Initial evaluation – during Alpha testing of the STOP Stroke Tool was positive showing the tools Prompted Guideline-based care and significantly increases documentation of 
Clinical Practice Guidelines
Patient Education
Patient Self-management

These findings support evidence that Clinicians are more apt to use and apply the recommendations for evidence-based care when automatic decision support is incorporated as part of their established workflow (Garg et al., 2005; Kawamoto et al., 2005).

## Slide 17

| Stroke Etiology
Risk Factor | AHA/ASA Stroke 
Secondary Prevention CPGs 
Outcome Measures |
| --- | --- |
| NonCardioEmbolic/Cardioembolic Stroke | Antiplatelet/ Anticoagulation Therapy Prescribed
 Aspirin, Plavix, Aggrenox or Warfarin  |
| Hypertension 

Hypertension + Diabetes  | Hypertension Medications Prescribed
Angiotensin Converting Enzyme Inhibitor-Thiazide Diuretic 
Angiotensin-Receptor Blockers  |
| 
Diabetes | Oral hypoglycemic agents/Insulin Prescribed
 |
|  | Dietary Counseling Provided |
| Hypercholesterolemia | Statin Agent Prescribed |
| Smoking | Smoking cessation recommended 
Pharmacologic support offered/prescribed |
| Overweight/Obesity BMI | Dietary Counseling and/or Exercise Training Recommended |
| Physical Inactivity | Exercise Training Recommended |
| Heavy Alcohol Consumption | Reduced alcohol consumption recommended 
Referral to alcohol dependency counseling |
| Patient specific risk factors | Patient Education Materials Provided
 |
| Behavioral risk factors  | Patient Self-management -Action Plan Completed  |

**Notes:**
CPG Outcomes
Participants’ documentation while using the Test Case Scenarios and both systems was captured in a patient encounter note.

Participants notes were printed out compared to an Answer Key based on AHA/ASA Secondary Stroke Prevention CPGs

This table lists the CPGs for secondary stroke prevention that should have been documented based on the stroke etiology and risk factor profiles described in the two test case scenarios. 
There were 11 CPG Outcome Measures
Documentation of correct CPGs - Record - (documented) 
Documentation of incorrect or missing CPGs - Record – (not documented)

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

| CPG Intervention | # Documented
CPRS | # Documented
STOP-ST | Documentation 
Change | p
value |
| --- | --- | --- | --- | --- |
| 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*

**Notes:**
The McNemar Change Test was used to determine if there was a significant Change in Providers’ Documentation of CPG

This table shows 
The Number of Providers that Changed Documentation of Clinical Practice Guidelines Using the STOP Stroke Tool Compared to baseline documentation using CPRS

There was a significant change from --not documented ---to documented 
for 6 out of 11 secondary stroke prevention CPGs (55%).

The tool prompted 100% improvement in documentation of patient education materials and patient self-management intervention

## What’s Next ?

- Application of Lessons Learned
- Restructure STOP Stroke Clinic
- Test implementation of STOP Stroke Tool
- Multiple Clinic Settings

## Possible Clinic Restructure - 

| 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

**Notes:**
During individual clinic visit an NP will use the STOP Stroke Tool to complete clinical management interventions to ensure patients receives evidence-based clinical management for stroke/TIA. 
The NP provider will also initiate patient specific education for stroke risk factor management and introduces patient self-management action planning process. 
Patients will then participate in a  Group clinic encounters are lead by the NP and introduce patient self-management, action planning and problem solving skills  - 2 hours
Follow up encounters will include 4 face-to-face video phone sessions lead by a registered nurse – will reinforce self-management skills of action planning and problem solving each week – 20 minute call 
Final group clinic  - group process to discuss progress with action planning - 
Final individual clinic will serve as a follow up visit for clinical management of stroke/TIA 

## Beta TestingImplementation 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

**Notes:**
next step for the STOP Stroke Tool – 

Based on Alpha test results we will make refinements to the tool to facilitate its use in other settings where stroke patients receive follow-up care.

Incorporating functionality into the tool that create communication between specialty care providers and primary care providers in the management of stroke risk factors. 

Then we are ready to move to Beta testing in larger scale clinical practice