S i ess on II (L t ec ure 4):

The Role and Selection Selection of Theo

Theo

Frameworks in Implementat

Research

Teresa M. Damush, PhD

Implementation Research Coordinator

VA Stroke QUERI Center

Ind l ianapolis VA Center for Implementation of Evidence Based Pract

Indiana University School of Medicine, Regenstrief Institute, Inc
Acknowledgements

• Funded by QUERI in VA

• Insightful reviews and collaboration collaboration

– Laura Damschroder– B ir an Mittman

– Cheryl Stetler
Poll Questions 1‐3
Outline Outline for Lecture Lecture 4, Par

• Resources Resources available available on practice practice chang

implementation intervention

• Tools for pl i ann ng il i mp ementation str

design

– Intervention Mapping and Study Exampl

• Implementation study example example• Key points
Session Objectives

• Understand the application of theory 

implementation research

• Learn about tools for implementation 

design
A word on THEORY (From Lecture 

1)

• A generalized definition of theory in s

will be used today

– A set of statements or principles devised 

explain explain a group of facts or phenomena phenomena

• May be embodied by frameworks, models, s

theory

The American Heritage Science Dictionary. http://dictionary.reference.com/browse/theory
Implementation Defined (From 

1

– Lecture 3)

• Efforts Efforts designed designed to get evidence evidence

‐based 

and related products into use

• I l t ti Implemen

t

ation t i ll yp call

y f ll o ows di 

disse

and includes:

– Identifying barriers, facilitators and strate

reduce

, overcome

, levera

g

e them

– Adapting the targeted practice to the con– Developing Developing

a tailored tailored implementation implementation str

str

Stetler C, Mittman B, Francis J: Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: 
Implementation Research – (F

lecture 3 (Part 1))

• “ th i tifi t d f th d t 

“ the scientific study of methods to prom

uptake of research findings for the purp

improving quality of care improving quality of care ”McDonald et al., 2004 Toward a Theoretic Basis for Quality ImInterventions in K.G. Shojania et al., Closing the Quality Gap.

• “ . . .scientific investigations that suppor

movement of evidence movement of evidence-based effective 

based, effective 

care approaches (e.g., as embodied in 

guidelines) from the clinical knowledge guidelines) from the clinical knowledge 

routine use.” Rubenstein & Pugh, 2006
Resources on Practice Change

Implementation intervention

• C h oc rane Eff ti ec ve P ti rac ce and O i 

rganiza

Care Group in Implementation Science

epoc cochrane org epoc.cochrane.org

• Grimshaw JM, Eccles MP, Lavis JN, Hill SJ

JE. Knowledge Knowledge translation translation of research research fin

fin

Implementation Science, 2012, 7:50.

• Powell BJ, McMillen McMillen JC, Proctor Proctor EK, et al. 

Implementation strategies: A menu for c

innovators and administrators. St. Louis 

Center for Mental Health Services Resea

Washington University in St. Louis.
Tools for Implementation

Strategy Design

• Intervention Intervention Mapping Mapping (Bartholomew (Bartholomew, • *Pragmatic‐Explanatory Continuum In

Summary (PRECIS) (Thorpe KE et al.)

• *PRECEDE‐PROCEED Model (Green et 

http://lgreen.net/precede.htm

• *RE‐AIM framework framework (Glasgow (Glasgow et al)*Gaglio B, & Glasgow RE. Evaluation approaches for dissemination and im

research. In Brownson RC, Colditz GA, Proctor EK (eds). Dissemination a

implementation research in health. 2012, Pp 327‐356. Oxford Universit
INTERVENTION MAPPING

6 

•

1. N d ee

d

s

Assessment

–

4

P l

• 2. Create Matrices of

E d Ch

•

4. Program

pla

develop and p

E materials xpecte

d Change

Objectives and SpecifyDeterminants

materials

• 5. Specify Ado

Determinants Implementati

• 3. Identify Theory

‐

Based Methods and

Implementati

• 6. Generate a

Based Methods and Evaluation PlaPractical Strategies toDesign intervention

Evaluation Pla

intervention

strategies
INTERVENTION MAPPIN

• Intervention Mapping is

a planning fram

that utilizes theory, evidence, practical st

to design implementation interventions 

tar

get multi

‐level chan

ges.

• Developed for Health Promotion Program• A li d pp

e

d across fi ld e

s i l di nc

uding h lth ea car

Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Planning Health Pr

Programs: An Intervention Mapping Approach.

2nd ed. 2006, Jo

Francisco, CA.
Intervention Mapping: Exam

• U d se i t ti n ervention mapping to d l eve op and il 

mp e

locally tailored, evidence‐based secondary strok

prevention program in two VA medical centers

• Practice Gap = VA/DoD Guidelines and American 

Association Association recommend recommend the provision provision of second

second

prevention at time of acute stroke event prior to 

and across continuum of stroke care

Schmid A, Anderson J, Kent T, Williams LS, Damush TM. Using intervention mapping to develop and adapt 

prevention program in VHA medical centers. Implementation Science, 2010, 5:97
Intervention Mapping Ste

• NEEDS ASSESSMENT ASSESSMENT‐d ib escr e the problem, id 

barriers and facilitators to systematically deli

secondary secondary stroke prevention prevention, describe describe the ta

population, understand current processes

• Conducted formative evaluation

– Semi structured structured interviews interviews with clinical clinical provide

provide

stroke patients with capacity to deliver seconda

prevention

– Record current processes at both sites

– Focus groups of patients/partners
Step 1: Needs Assessmen

/Formative Evaluation: Provi

• It i d n erviewed 45 cli i l n ca providers @ 2 VA sites 

current stroke prevention practices, barriers 

to support risk factor manag , ement and pref

and suggestions for program elements andimplementation strategies

• Unaware of how to access l l oca resources for 

factors to promote to patient

– Wanted accessible info

• Believed they were unprepared to motivate p

lifestyle modifications

– Some wanted tools

– Some wanted to refer to another to tackle
Step 1: Needs Assessment 

Formative Eval i uat on: Patie

• Focus Groups

– Patients

• Presented Presented existing existing tools and programs programs available available for secon

secon

prevention programs and asked patients (i.e., users) to rasuggestions for how to implement to a patient after an ac

• Amer Stroke Association ‐ Peer Visitor Program

– Useful 1‐10 scale = Average = 8.32

– Likely to use Average = 7.61

– Easy Average =8.63

– Comments:

» Visit in hospital, not in home

» N d ee V t e erans with Sunny P lit ersonality

» Keep a list of Veteran volunteers to be on call

» Willing to open up with peer more than MD – e.g. dru

» Helpful Helpful to know what to expect, hope for recovery recovery» Informally received peer visits in hospital – very helpf
Step 2: Performance Performance Objec

Objec

• S bdi id Subdivide bh i l e avioral and envi l ronmental

outcomes into performance objectives

( ifi ll ) (specifically)

• Exact performance expected from some

affected by the intervention

• What do participants in this program or

organization need to do to perform the bor make the environmental change.

• Differentiate for the subgroups targeted

(providers, p ) atients)
Step 2: Specify Specify Determina

Determina

• Factors associated with the performan

the behavior or environmental condit

– Personal determinants (beliefs, values, s– External External determinants determinants (resources (resources, policie

policie

• Sources of influence on behaviors• List across the top of the change matr

the performance performance objectives objectives are listed 

the left column.
Step 2: Matrices of Chang

Provider Performance Community Resources for Delivery Sys

Secondary Stroke prevention program matrix of program objectives (Prov

Objectives Stroke Risk Mang.Assesses pt stroke risk Access to local resources Work flow ofactors duringhospitalization for acutestroke

available to assess stroke

risk factors

planning inc

risk factor a

Orders lab tests as needed Access to lab tests and

interpretation of results

System aler

prescribes b

Prescribes Prescribes appropriate appropriate Access and provides pt eds Med reconc

medications

Access and provides pt edsmaterials on meds

Med reconc

discharge

Motivates Motivates pt to modify Write orders for home Motivationa

lifestyle

Write orders for home

equipment

Motivationabuilt into pt 

Refers pt to local programs Recommends and refers pt

l l

Access to lo

to local support programs avail bl a e an
Step 3: Theory based method

P ti l ractical St t i ra eg es

Provider Performance h il S i f i l S 

Objectives

Theoretical Strategies of

(Theory of Planned

Behavior)

Practical St

provider in

Assess patient stroke risk

factors duringhospitalization for stroke

Perceived Social Norms –

clinical champion

promotes; added into

Stroke risk f

assessment included in 

annual competencyevaluationAttitudes, Beliefs, Values –

i i

medical recChecklist av

training l 

Self‐efficacy – role playing

to improve skills,

vicarious/peer modeling

neurology w

where dischfor stroke p

vicarious/peer modelingBehavioral Intentions – ask

commitment to perform
Step 3: HOW TO FIND THEO

THEO

• Search the literature

– Topic – Clinical topic or specific task

• Theoretical and empirically based literature

– Concept – e g. ., Facilitation Facilitation

• Literature may list theories including this co

– G l enera Th i eor es

• Change

– O i ti rganization, I di id l ndividuals
Using the Chronic Care Model to improve Stroke Risk Factors

Community Resources

American Heart Association

American Stroke Association

Health System

VA FIM Performance Mea

Self‐managementPatient Readiness to

Delivery SystemLocal champion of stroke

Decision SupportVA/Dept of Defense

Cl

American Stroke Association

Change

Promote self‐efficacy to

activate lifestyle and

meds changes

risk reduction in

inpatient/outpat services

Discharge planning

Open access gym/rehab

Guidelines for strokereduction

JCAHO guidelines to

educate stroke

Cl

g Ch

Individual/Group meetings

Telephone support

Open access gym/rehab

facilities at VA patients

Informed, Empowered Patients

• Who recognize symptoms of stroke

Prepared, Proac

• Who initiate 

• Who adhere 

to prescribed meds

• Who practice lifestyle strategies in

collaboration with provider

• Who counsel 

• Who collaborat

• Who conduct 

stroke 

Goals:↑ Medication Adherence

↑ Patient activation for lifestyle change

↑ Physical functioning and Quality of Life
Step 4: Program Program Plan

• Operationalize strategies into plans –d

protocols

• Design program materials• Pretest program materi l a s wi ht target 

• Consult with intended

participants/implementers
Menu of Existing Tools to Adapt ba

CCM

• Community Resources

– Outpatient clinics

• Patient Self‐

Management

• Decision Support

– Clinical reminders

– Peer Support – Stroke Self‐M

• Information Support

– Stroke risk factor

• Delivery Supp

– Staff lifestyle 

Stroke risk factor

management tools

y 

training
System/provider intervent

• Neurology residents are responsible for d

planning

• High changeover – needed to reinforce g

care

–

provided dischar

g

e checklist from 

resident workstations

• Motivational Motivational Interviewing Interviewing skills

‐ gave tra

tra

presentation including sample dialogues

• Access to risk factor programs programs within faci

faci

nearby community

‐created local Risk Fac

prescription pads

–
Patient Activation

• S k tro e S lf e I di id l 

Management sessions

S k S G

• Individual sess

• Local variation

• Stroke Support Groups

• Stroke Peer Support

– Person vs pho

– Hospital vs o

– # sessions

– Program cont
Step 5: Adoption and Implemen

Plan

• S if pec y performance obj ti ec ves for prog

adoption, implementation, sustainability

• Specify determinants determinants of adoption adoption,

implementation and sustainability

• Create program program use matrices matrices – perf obje

first column, determinants across top ro

• Implementation Implementation is often multiple multiple tasks p

p

by a variety of roles.

• What do the program program implementers implementers nee

to implement the program with fidelity ?
Step 5: Implementation Implementation P

Performance Obj i ect ves Fid li e ty Site

Provider gave stroke ptrelevant stroke risk factor

Documented note in

electronic medical records

VA site 1VA site 2

education materials

Pt enrolled in VA support

program (smoking

Documented note in

electronic medical records

VA site 1

p g ( g VA site 2cessation)
Step 6: Evaluation Evaluation Plan

• System: Provider Practices documenta

secondary stroke prevention methods

extracted from medical records at two

facilities as intervention sites and two

additional facilities as control sites

• Patient level: self‐reported outcomes 

management, self‐efficacy, health‐relaquality of life

– Pharmacy benefits data on medication re
Intervention Mapping: Key p

• Useful Planning Tool

• Useful for specifying specifying multi – level

interventions

• Process for appl i y ng theory to il 

mp em

interventions

• Evaluation plan enables assessment o

theoretical usefulness/goodness of fit
Using Theory: Theory: A Few Not

• There are better fitting theories that 

why a specific strategy or mechanism 

the intended change

• Evaluating Evaluating the practice practice gap can help g

application of theory

• The implementation strategy(s) may b

operationalized from the theoretical theoretical c

c

Note: Operational definition= a clear, concise detailed definition of a con

and actionable components so that all have the same understanding of h

practice and collect it or determine whether its correct or not.
What is the mechanism/strategy for w

expect the change to occur?

• How do you expect the organization,

practitioner, patient to get from

CURRENT PRACTICE I

• Where are they now?

• Where do they want to be?

• Potential Barriers to change?

• Possible facilitators to Change?

I 

=HOW to get to desired outcomes, EBP
Conducting Theory‐based Implemen

Studies (From Part 1, Lecture 3

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Dev

imp

co te t 

A fit f

at o a e 

Assess fit of

findings with 

initial theory

Evaluate effectiveness Exe

imp

of implementation

strategy

Adapted from: Sales A, Smith J, Curran G, Kochevar L: Models, strategies, and tools. Theory evidence-based findings into health care practice. J Gen Intern Med 2006, 21 Suppl 2:S43-4
Using Theory: Key Issue

•What are the change objectives? What are the change objectives?•Who are the targets? 

-Wh t i th l l ( ) t hi h What is the level (s) at which

change occurs? 

•Identify characteristics of the change
Case Example: Post Stroke

Depression (PSD) Screening an

• Adapted and implemented VA annual de

clinical reminder for stroke patients rece

follow up care in primary or neurology o

care clinics

• Objective was to improved PSD screening 

veterans veterans with recent ischemic ischemic stroke and 

support providers in taking action when 

detected

• 2 VA Medical Centers (2 PC and 2 Neuro 

Williams 

, Ofner, Yu, Beyth, Plue, Damush. Pre‐post evaluation of automated reminders m

management of post‐stroke depression. JGIM, 2011; 26(8): 852—7.
Case Example: PSD contin

contin

• Q i uas experi l menta• Compared patients receiving post stroke

outpatient care one year prior to interve

period (control group) to patients receiv

stroke outpatient care during the (intervperiod).

• Formed teams (including front line clinic

clinical application coordinators) at both 

develop the local clinical reminders and

implementation strategies
Hybrid Trial Designs

Intervention Focus Implementation Approa

YES 

Hybrid Type II:

Hyb

Te

YES Test clinical intervention,

test implementation

intervention

int

obs

info

ClinicalEffectiveness

imp

Hybrid Type III:

Test implementation

NO

intervention,

observe/gather

information on clinical Observ

intervention and

outcomes

Implementation Study

p

From: Combining Elements of Clinical Effectiveness and Implementation Research Trials: Hy

Designs. Curran G., Bauer M., Mittman B., Stetler, C. Enhancing Implementation Science Ser

CyberSeminar. January 2011.
Assess targeted EBP change & 

• Wh t a are the change obj ti ? ec ves?

– HEALTH DELIVERY SYSTEM INTERVENTION– Screening Screening for depression depression within 6 months p

during primary care or neurology outpatien

– Treatment provided provided when PSD detected detected

• Who are the targets? [Identify level at w

change occurs]

– Individual Clinicians and Clinic Check‐In

• Primary Care Providers• Neurologists• Nurses• Regions (2)
Case Example: PSD Contin

Contin

• Identify Characteristics of the Change

– Change is p p eri heral to p p erce tion of cu

practices

– Motivation Motivation to change = Improve Improve patient patient – [PSD at risk for worse functional outcom

mortality]
Conducting Theory‐based Implemen

Studies

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Dev

imp

co te t 

A fit f

at o a e 

Assess fit of

findings with 

initial theory

Evaluate effectiveness Exe

imp

of implementation

strategy

Adapted from: Sales A, Smith J, Curran G, Kochevar L: Models, strategies, and tools. Theory evidence-based findings into health care practice. J Gen Intern Med 2006, 21 Suppl 2:S43-4
Map out the Current Current State of 

• Neurology Outpatient Clinic Visit

– Patient checks into clinic w/nurse– Patient sees Neurologist– Neurologist Neurologist may or may not screen for P

to MH or prescribe RX

– Pt accepts or refuses Rx/f l re erral
IDEAL STATE of TASKS

• PSD Screening & Treatment in NEURO

OUTPATIENT CLINICS

– PT CHECKS IN– PT SCREENED FOR STROKE DURING PAST 

months

– If yes, screened for depression.– Positive screen is flagged to neurologist– Neurologist Neurologist confirms confirms dx, treats or refers – PT accepts or refuses RX
Differences Between Current an

States

ACTIONABLE FACTORS RATIONALE SUPPORTING 

Clinical Informatics Support

–check in screener for

stroke during past 6months – nurse

Neurology knowledge and

acceptance of depression

screening in post stroke

care
Rationale for the Theory

Theory

• RATIONALE = Justification for selection 

operational definition of the concept 

applied to your specific implementatioprogram.
Select Theory and Provide Ra

ACTIONABLE FACTORS RATIONALE SUPPORTClinical Informatics Support –check in screener for strokeduring past 6 months –

Use of built in electronic

prompt as a cue to action;

Establish as a perceived social

Theory o

during past 6 months

Neurology and clinical

reminder

Establish as a perceived social

norm with local clinical

champion modeling and

promoting practice

Neurology knowledge and

acceptance of depression

screening in post stroke care

Include in competencyevaluations ; use of localclinical champions to

Theory o

screening in post stroke care clinical champions to

promote the need and value,establish as a perceived social

norm; model the behavior; behavior;

peer support/vicariouslearning
Individual Level Change

Theory of Planned Behavior

Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179‐211. http://people.umass.edu/aizen/tpb.diag.htm l
Conducting Theory‐based Implemen

Studies

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Dev

imp

co te t 

A fit f

at o a e 

Assess fit of

findings with 

initial theory

Evaluate effectiveness Exe

imp

of implementation

strategy

Adapted from: Sales A, Smith J, Curran G, Kochevar L: Models, strategies, and tools. Theory evidence-based findings into health care practice. J Gen Intern Med 2006, 21 Suppl 2:S43-4
Assess Context (CFIR constr

constr

• Ad bl apta ility – the degree to wh hic an

intervention can be adapted, tailored, 

or reinvented to meet local needs;

• Peer Pressure – Competitive pressure 

implement an intervention (Service ch

endorses or discourages p ) ractices)

• Implementation Climate – the capacit

change and extent to which use will b

rewarded
Execute & Evaluate

• Evaluation

– Processes

• PSD screening i d ncreased (85% i t ti n ervention vs 50• Treatment action was received (83% interventio

– Lack of clinical clinical champions champions in specific specific clinics clinics 

to less use of clinical reminder

• 1 site = neurology outpatient service did not be

screen for depression; however their PC did welscreening in general and found it easy to adapt

• 1 site=neurology site=neurology service service had strong champion champion w

PSD screening and Rx; however their PC did not 

patients should be flagged in PC and lacked a ch
Was the Theory Useful? Useful?

• We used theory to guide the interventio

• Did not evaluate each component of the 

• Do over

– Survey the f t ron line cli i i n c ans who h da the

opportunity to use the clinical reminders

– Measure the const t ruc s of the theory ( 

perc

social norms, behavioral intention, etc)

– El t va ua e the th ti l theoretical i t mpac on the

implementation of the PSD clinical reminde
Key Points for Applying Theo

Implementation Interventio

• Use pre‐il i mp ementation work to target your

implementation critical factors

• P id rov e rati l ona e for sel ti ec on of theory

• Consider use of a planning theory/tool to ass

with specification and planning planning.

• Clearly define your strategies so that others m

replicate replicate to generalize generalize beyond your specific specific e

e

• Balance theoretical components with pragma

identified identified from the targeted targeted users of EBP

• Evaluate usefulness of theory(s) used
Contact information

• Teresa.Damush@va.gov• Roudebush VAMC, HSR& D, COE India

IN
R E S EARCH AR TIC L E Open Access

Using intervention mapping to develop and

adapt a secondary stroke prevention program in

Veterans Health Administration medical centers

Arlene A Schmid1,2,3,4,6*, Jane Andersen5, Thomas Kent5, Linda S Williams1,2,6,7, Teresa M Damush1,2,4,6,8

Abstract

Secondary stroke prevention is championed by the stroke guidelines; however, it is rarely systematically delivered.

We sought to develop a locally tailored, evidence-based secondary stroke prevention program. The purpose of this

paper was to apply intervention mapping (IM) to develop our locally tailored stroke prevention program and

implementation plan. We completed a needs assessment and the five Steps of IM. The needs assessment included

semi-structured interviews of 45 providers; 26 in Indianapolis and 19 in Houston. We queried frontline clinical providers of stroke care using structured interviews on the following topics: current provider practices in secondary

stroke risk factor management; barriers and needs to support risk factor management; and suggestions on how to

enhance secondary stroke risk factor management throughout the continuum of care. We then describe how we

incorporated each of the five Steps of IM to develop locally tailored programs at two sites that will be evaluated

through surveys for patient outcomes, and medical records chart abstraction for processes of care.

Background

The development of an implementation intervention is

complex and involves many components. Often the outcomes of such interventions are published without the

details of how the intervention was developed or from

where the components were derived [1]. Intervention

mapping (IM) is a technique used to develop an evidence-based intervention that provides and balances

both theoretical and practical strategies while incorporating formative evaluation, a needs assessment, program

development, and evaluation [2]. We used IM to guide us

through the development of a theory-based, multi-site,

secondary stroke prevention program.

Stroke prevention

The used of an evidence-based intervention to manage

stroke risk factors could have great impact due to the high

prevalence of stroke, with approximately 795,000 people

in the United States sustaining a stroke annually [3]. With

its deleterious effects, stroke is classified as the most disabling chronic disease with negative consequences for

individuals, families, and society [4,5]. Future stroke risk

increases after a cerebrovascular event [6]; importantly,

200,000 of all strokes are recurrent strokes. For example,

more than 12% of those with stroke or transient ischemic

attack (TIA) experience a second stroke within the year

[7,8]. This increased risk persists for at least five years [9].

Furthermore, 15% of strokes are preceded by a TIA [10].

Significantly, the risk of death is doubled after a second

stroke [11].

Such a cerebrovascular event may be an opportunity

for targeting secondary stroke prevention [12]. Hoenig

and colleagues reported that stroke survivors often continue unhealthy lifestyle choices regarding stroke risk

factors and are therefore at increased risk for a second

stroke [13]. Despite knowledge and impact of risk

reduction, clinical providers may not aggressively counsel or treat patients with behavioral or medical interventions for stroke prevention [14].

Prevention of a first or second stroke is possible by

identifying and controlling stroke risk factors [15].

While some risk factors are permanent (e.g., age, hereditary), the majority are modifiable (e.g., atrial fibrillation,

obesity, tobacco and alcohol use, hypertension, and

* Correspondence: arlene.schmid@va.gov

1

Roudebush Veterans Administration Medical Center; Health Services

Research and Development (HSR&D) Center on Implementing EvidenceBased Practice, 1481 W. 10th Street, 11 H, Indianapolis, Indiana 46202-5199,

USA

Full list of author information is available at the end of the article

Schmid et al. Implementation Science 2010, 5:97

http://www.implementationscience.com/content/5/1/97

Implementation

Science

© 2010 Schmid et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons

Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in

any medium, provided the original work is properly cited.
physical inactivity) [16,17]. Modifiable risk factors are

best managed through lifestyle and medication management. To achieve optimal management, it is likely that

providers and stroke survivors will need to work

together through complex interventions to truly prevent

a secondary stroke [18-20].

Clinical and practice guidelines are common and exist

for post-stroke care. Such guidelines are developed to

guide practice and generally consist of a guideline text, a

one-page summary, and a significant background document including recommendations based on levels of evidence. Stroke care guidelines, such as the Veterans

Administration/Department of Defense (VA/DoD) Stroke

Rehabilitation Guidelines, the Agency for Healthcare

Research and Quality (AHRQ) Clinical Guidelines For

Stroke, and the American Stroke Association all advocate

for the implementation of secondary prevention programming that addresses stroke risk factor modification after a

cerebrovascular event [7,21-23]. Although there are

resources for the management of some risk factors – e.g.,

blood pressure (BP) and diabetes – these resources are not

routinely targeted to or used by veterans with recent

stroke or TIA. We are not aware of any systematic programming or standardized support available in the VA to

enhance stroke risk factor management. Thus we have

used IM to guide us in the planning, development, and

implementation of a complex stroke prevention program.

Intervention mapping

Given the effect of stroke on morbidity and health-related

quality of life, interventions designed to address the needs

of stroke survivors and their providers are complex and

involve multilevel strategies to produce system and individual changes to improve outcomes. Planning for the

implementation of such complex interventions may be

guided through IM [2,24]. IM is a process for developing

theory and evidence-based programs, and is used to provide a systematic framework for planning, development,

and implementation of health promotion and prevention

programs [2,24-34]. For example, IM has been used in

guiding program development and implementation for

adapting effective sexually transmitted disease and pregnancy programs [33], for applying health psychology

theory to prevention programs [34], in designing an occupational health guideline to prevent weight gain among

employees [26], and other health promotion and prevention programs. IM helps the user to apply a framework or

a model by operationalizing the theoretical components to

link performance objectives with intervention methods

and implementation strategies [2,24,28]. The result of IM

is a systematic and practice-friendly process for implementing evidence-based programming [33].

Methods

We employed IM techniques, including a needs assessment, to develop a systematic stroke prevention program locally tailored to two healthcare facilities within a

national organization. This was completed to support a

VA Health Services Research and Development Implementation grant: Teaching Others tOLive with Stroke

(TOOLS). TOOLS focuses on implementing existing

stroke prevention tools into usual care at two VA medical centers (VAMCs). All research reported in this study

was approved by both sites’ local institutional review

boards and VA research and development committees.

Intervention Mapping

Bartholomew and colleagues identified the five Steps of

IM [2]. The Steps and subsequent tasks of IM include a

planned process using matrices for the systematic development, implementation, and evaluation of the program.

In addition to a needs assessment (Step 0), IM includes

the following five Steps (See Table 1 for Steps and

tasks): 1) creation of a matrix of proximal program

objectives; 2) selection of theory-based intervention

methodologies (the Chronic Care Model [35] was used

to organize the elements of the healthcare system, practice delivery, and patient self-management, and the Theory of Planned Behavior [36] was used to guide the

implementation strategies) practical strategies and suggestions from targeted users; 3) design and organization

of the program; 4) adoption and implementation of the

program; and 5) monitoring and program evaluation [2].

We completed a needs assessment and utilized the five

Steps of IM to develop our intervention program and

implementation strategies, and report the results.

Step 0: Needs assessment

In order to develop an intervention program to locally

tailor and implement the use of available tools for secondary stroke prevention into an existing healthcare system, we began with a needs assessment of the targeted

users of the program. We conducted the needs assessment using semi-structured interviews to elicit providers’ needs and barriers to systematic delivery of

secondary stroke prevention, and preferences and suggestions for program elements and implementation strategies to guide our IM and future implementation

program [28,29]. Because our planned intervention targeted both providers of stroke care and stroke patients,

we also conducted focus groups with key stakeholders,

the veteran stroke survivors, and their caregivers to

understand their barriers to and preferences for secondary stroke prevention services. Those results are published elsewhere and incorporated into the patient

self-management element of the program [37].

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We based our semi-structured interviews on elements of

the chronic care model [38], the components of guideline

care for secondary stroke prevention [39], and practical

strategies currently used. For example, we included questions from the decision support domain of the chronic

care model that queried providers on the use of health services tools (for example, computer reminders and use of

pocket cards). For guideline care, we included the components delineated by the VA/DoD and the American Stroke

Association: ordering tests, prescribing medication, assessing and counseling on risk factors, and making referrals

to local community resources and programs.

Specifically, this aspect of the TOOLS study focused on

multiple providers who represented the continuum of

stroke care at the Indianapolis and Houston VAMCs:

neurologists; neurology residents; general internists; physician assistants; nurse practitioners; nurses; occupational, physical, and recreational therapists; and social

workers. We conducted all interviews in a one-on-one

setting. We evaluated their current roles/perceived roles

in secondary stroke prevention and the current state of

and capacity for stroke prevention programming. We

also sought to gain their guidance as we moved forward

to develop, implement, and evaluate the TOOLS program. Specifically, the objectives of the needs assessment

were to: determine provider perceptions of their current

role and practices in secondary stroke prevention; identify the needs to support providers in providing secondary stroke prevention; and elicit practical suggestions for

improving the delivery of secondary stroke prevention at

the local site (Table 2). These semi-structured interviews

were synthesized and used to plan our local adaptation of

the secondary stroke prevention program and evaluation.

Interview

We developed semi-structured interview guides that were

based on the chronic care model with questions from the

model domains including: the local community resources

available and utilized; patient self-management; delivery

system at discharge and follow up care; decision support

during hospitalization; and discharge and follow up visits

[38]. A team of healthcare providers and researchers first

reviewed and critiqued the interview questions. We then

pilot tested the interview questions with four providers

and made modifications based on their recommendations.

We included probes throughout the interviews to

delve into the research topics: current knowledge and

practices to prevent a second stroke; needs to support

providers in providing secondary stroke prevention to

secondary stroke prevention; and resources necessary to

provide enhanced secondary stroke prevention. In addition, the interviews were specific to disciplines and the

Table 1 Steps of Intervention Mapping (IM) 2

Step Tasks

0 Needs assessment Specify needs of providers

Specify needs of patients

1 Creation of a matrix of proximal program objectives Specify the performance objectives

Specify important, changeable determinants

Differentiate the target population

Create matrices of proximal program objectives

2 Selection of theory based intervention methodologies practical

strategies and suggestions from targeted users

Brainstorm methods to achieve proximal program objectives

Use the theoretical and empirical literature to further delineate the methods

Translate methods into strategies

3 Design and organization of the program Operationalize the strategies into plans considering implementers and sites

Design instruction materials

Pretest instruction materials with the target group

Produce the materials

4 Adoption and implementation of the program Develop a linkage system

Specify adoption and implementation performance objectives

Specify determinants of adoption and implementation

Write and implementation plan

5 Monitoring and program evaluation Develop an evaluation model using information from the previous Steps of IM

and information from the needs assessment

Develop effect evaluation questions, referring to the matrices of proximal

program objectives as blueprints for instrument development

Develop process evaluation questions from the needs assessment and

intervention map

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role responsibilities of each provider type. For example,

rehabilitation therapists were not asked about prescribing medications to manage BP. A sample interview

guide is available from the authors upon request.

The interviews were completed in both Houston and

in Indianapolis by four experienced research staff

trained by the investigator (TD) on interviewing techniques, including how to probe based upon given

responses. The interviewers practiced administering the

interview on study staff. In total, there were 26 completed interviews in Indianapolis and 18 in Houston. All

interviews were audiotaped and transcribed into word

processing files for data analysis. All provider identifiers

were removed.

Findings of needs assessment

We interviewed 44 providers; 26 in Indianapolis and

18 in Houston (Table 3). Most importantly, almost all

providers endorsed the idea that they have a role in secondary stroke risk factor management (81% in Indianapolis and 100% in Houston). However, there was a

disparity in the extent and delivery manner of this role.

Some consistent themes that emerged from our needs

assessment that guided our IM included a need for:

improved patient and caregiver compliance; standardized clinical reminders or prevention checklist; training

regarding stroke risk factors and warning signs; stroke

support groups; and provision of pamphlets and written

information. These topics and emergent themes were

used to support IM Steps and are described below.

Identified needs included: improved patient and caregiver compliance; standardization of a stroke risk factor

reminder, checklist, or approach; a way to refer to

resources and services within the VA; better education

to the providers regarding risk factors and warning

signs; and improved administrative support. A summary

of the emergent themes is available in Table 4.

The majority of providers at both facilities (Indianapolis, 85% and Houston 82%) endorsed the fact that

improved patient and caregiver compliance is important

in managing health after stroke. Providers discussed less

then optimal patient compliance and motivation to

change as well as reasons for decreased compliance:

depression; cognition; stroke severity; reading ability;

transportation; and family relationships. An occupational

therapist (OT) talked specifically about lack of compliance in following rehabilitation and diet recommendations once the patients are discharged into the home:

’... I feel like [diet] is a big component. It seems that

if they...are not too compliant...what I’ve recommended does not make that big of an impact. In

OT, we try to remind them how to incorporate their

good diet, say when we do cooking and we turn to

what they are going to be doing at home. We try

to remind them and to incorporate their good diet

into their selection, but they’re still selecting the

things that are bad for them despite what we’ve

talked about.’

Multiple providers from different fields along the continuum of care suggested a need of a more standardized

approach to secondary stroke prevention, including a

systematic check-off list in the electronic medical

records during the hospitalization. Specifically, a nurse

was asked about provider training regarding stroke risk

factors and stated:

‘Standardization...it shouldn’t be up to the physicians, like recognition, skills, knowledge ... because

we get new doctors all the time...Everybody documents everything a little bit differently...but it should

be like a math equation. It shouldn’t be up to

coincidence.’

Table 2 Summarization of the recommendations and next actions for the TOOLS intervention

Enhance provider practices in secondary stroke

risk factor management

Address the needs to support

providers in secondary stroke risk

factor management

Implement advice from providers to enhance

secondary stroke risk factor management

throughout the continuum of care

Educate all types of providers regarding stroke

warning signs, stroke risk factors, and stroke risk

factor management

Tailor the self-management aspect of

the TOOLS intervention to each veteran

using self-management concepts

Address secondary stroke prevention prior to

discharge - we are providing this through training

of all providers

Teach rehabilitation therapists to include a stroke

risk factor management goal for every patient with

stroke or TIA

Develop and issue rehabilitation specific

information handouts and pamphlets for

addressing stroke risk factors

Send pamphlets and information home with each

patient - we are addressing this through nursing

discharge

Incorporate (through nursing) secondary stroke risk

factor management information and training into

the discharge process for every patient with stroke

or TIA

Develop and issue a self-management

prescription pad for risk factors - this will

provide information for clinics, etc

Need to establish a gatekeeper (or champion) at

each facility, we feel that this person may be found

in rehabilitation due to the relationships that are

often built

Develop a discharge template

Initiate peer to peer programming and facility

stroke support groups

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Table 3 Type and location of provider interviews and indication of the number of providers (by type) that commented on each theme, n = 44

Provider

type

n Current provider practices in secondary

stroke risk factor management

Barriers and supports to risk factor management Advice or needs to enhance secondary stroke prevention

The provider is

providing

secondary stroke

prevention

Works

with

other

providers/

referrals

Works

with pt,

family,

caregiver

Adherence

and

motivation

Provider

lacks

knowledge

Lack of

admin

support

Other* Pt

cognition/

education

Transportation Wants education Wants handouts Wants check

off list

Wants

support

groups

How to

refer

to

what?

Other^

Indianapolis, IN

MD 2 2 1 1 1 2 0 2 0 0 2 1 0 1 1 2Res 3 3 0 1 1 0 3 2 3 0 2 3 1 0 3 2RN 4 4 1 1 4 0 2 1 3 0 1 2 0 0 0 1OT 5 5 5 0 5 0 3 2 1 0 5 5 1 1 1 1PT 4 4 4 0 4 0 3 3 2 0 3 3 1 0 2 3RT 2 2 2 0 2 0 2 0 0 0 1 2 0 0 1 1SW 6 1 1 1 5 0 4 1 1 0 5 3 1 1 2 0Total 26 21

(81%)

14

(54%)

4

(15%)

22 (85%) 2

(8%)

17

(65%)

11

(42%)

10 (38%) 0 19 (73%) 19 (73%) 4

(15%)

3

(12%)

10

(38%)

10

(38%)

Houston, TX

MD 2 2 2 2 2 0 1 0 1 1 2 0 0 0 0 1PA 1 1 1 0 1 0 0 1 1 0 1 0 0 0 0 0Res 1 1 1 0 1 0 0 1 1 0 1 0 0 0 0 1NP 3 3 3 0 3 0 0 1 1 1 2 2 0 0 1 0RN 4 4 2 2 3 2 1 2 2 3 2 3 2 1 2 3LVN 2 2 0 0 2 1 1 2 0 0 1 1 0 0 1 1OT 1 1 1 0 1 0 0 1 0 1 0 0 0 1 0 1PT 1 1 1 0 1 1 0 1 0 1 0 1 0 0 0 1SW 3 2 1 0 1 0 1 1 1 0 1 1 1 1 0 1Total 18 17

(94%)

12

(66%)

4

(22%)

15 (83%) 4

(22%)

4

(22%)

10

(56%)

7

(39%)

7

(39%)

10 (56%) 8

(44%)

3

(17%)

3

(17%)

4

(22%)

9

(50%)

Total 44 38

(86%)

26

(59%)

8

(18%)

37 (84%) 6

(14%)

21

(48%)

21

(48%)

17 (39%) 7

(16%)

29 (66%) 27 (61%) 7

(16%)

6

(14%)

14

(32%)

19

(43%)

* ‘other’ includes: patient depression, decreased function, lack of provider time, no place to exercise, wait time for care, no caregiver, patient or caregiver denial, problems with drug seeking behaviors

^ ‘other’ includes: patients need to be encouraged and empowered, anger management, work on self-esteem and confidence, need to distribute BP machines and pedometers, educate family members, allow for

nursing follow up after dischargeMD, Medical DoctorPA, Physicians AssistantRes, ResidentNP, Nurse PractitionerRN, Registered NurseLVN, Licensed Vocational NurseOT, Occupational TherapistPT, Physical TherapistRT, Recreation TherapistSW, Social Worker

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Additionally, providers indicated that they worked

with others in the VA facility or referred patients to

other local community services or programs to assist

in risk factor management (Indianapolis, 52%, and

Houston, 68%). However, providers at both facilities

discussed making patient referrals to highly visual VA

services that cover common risk factors of smoking and

diabetes; but many commented on needing to know

about other available services and how to officially refer a

patient to such services. For example, a resident was

asked about the MOVE program (a VA nationally implemented exercise and nutrition program) and stated:

‘No. I don’t even know what that is. Why, why don’t I

know about this? It’s frustrating to me that I don’t

know about this...But if I knew about them, I would be

much more inclined and willing to use them. I just

don’t know about them. And I’m embarrassed that I

don’t, but I just don’t have time to come into a place as

a resident and say, ‘Ok, I need to go do my homework,

and find out exactly what my options right now.’’

Thus, providers suggested a need to be educated on

all locally available programming that addresses stroke

risk factors. They need to know how they and patients

can access it. Multiple providers also discussed needing

some education regarding stroke risk factors and warning signs. Some providers talked about wanting to be

more comfortable in talking about some risk factors,

such as patient obesity. One doctor discussed discomfort

with talking about obesity, but also provided a solution:

‘...They don’t like to talk about weight, [so] you

avoid it. Then, they are not going to lose weight...I

thought it was too sensitive to talk about weight...I

found out that it took longer for them to lose the

weight... So now I’ve found an indirect way to overcome it, by printing out weight graphs, and then use

it to discuss with them. I give them BMI charts, so

they are able to see for themselves. In fact, I’ve had

patients tell me ‘based on this weight, I’m obese.’ Or

‘based on this weight, I’m morbidly obese.’ It

becomes easier to then discuss. But when I used to

avoid discussing this, it took a long time, and we

failed quite a lot.’

Some providers discussed a need for additional administrative support to be able to implement a stroke

Table 4 Summary of emergent themes from the needs assessment

Interview Topics Supporting Themes Indy

N = 28

Houston

N = 19

Current Provider Roles Current roles of the provider to prevent a second stroke 81% 94%

Working with or referring to other professionals or VA

programs to prevent a second stroke

54% 66%

Working with the patient, family, or caregiver to prevent a

second stroke

15% 22%

Barriers and Supports to Secondary Stroke Risk

Factor Management

Patient adherence/motivation/or set in their ways 85% 83%

Provider lacks the knowledge or training to assist in

secondary stroke risk factor management

8% 22%

Level of support from the administration (barrier/support) 65%/15% 22%/41%

Other: factors and characteristics such as poor adherence,

decreased motivation, patients not wanting to change,

and patients not taking responsibility for their self,

depression, cognition, stroke severity, reading/education

level, family relationships

42% 56%

Patient lacks the cognition, education, knowledge, training,

comfort to assist with prevention of a second stroke

38% 39%

Patient transportation 0% 39%

Suggestions on how to Enhance Secondary

Stroke Risk Factor Management Throughout the

Continuum of Care

Desired resources: staff/provider education, handouts and

pamphlets, standard training and discharge list, videos,

support groups

93% 70%

Training about what resources are available in the VA

system, how to refer

38% 41%

Timing of stroke risk factor management is important 30% 41%

Other: important aspects of care: empowerment and

encouragement of the patient, blood pressure machines,

increased time with patient specifically for secondary

stroke prevention information and training, and time to

work with the family.

38% 65%

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prevention program. Many providers reported a lack of

time to do as much as they would have liked to with

patients to prevent a second stroke. Others felt that they

needed resources, such as handouts and pamphlets, to

best educate patients. However, others reported that

stroke prevention had not been made enough of a priority in the hospital or a specific service and this barrier differed by site where providers in Indianapolis were more

likely to endorse the idea that they did not receive the

necessary support from administration (65% versus 35%).

We used the results of this needs assessment to plan

the TOOLS program.

Step 1: Matrix of proximal program objectives

The planned intervention focused on adapting local

tools to enable providers to systematically deliver secondary stroke prevention. We used the evidence-based

guidelines of secondary stroke prevention to operationalize the components of secondary stroke prevention.

Using these guidelines, we created proximal program

objectives at the provider and organizational level and

completed Step 1 of IM.

Step one of IM is to develop proximal program objectives, illustrated in a matrix of cells that include the

intersection of behavioral or environmental proximal

performance objectives (rows of table) with specified

determinants (columns of table) (tables found in Additional File 1 Step 1) [2]. Determinants are personal and

external factors that may influence outcomes. Each cell

typically contains a statement, or a learning or change

objective, regarding what needs to be learned related to

this determinant to achieve the proximal performance

objective.

Specifically, our proximal performance objectives were

based upon the secondary stroke guidelines and included

the following: assess patient stroke risk factors during

hospitalization for stroke; order lab tests as needed; prescribe appropriate medications to manage risk factors;

educate patients about stroke risk factor education; refer

patient to local programs that address stroke risk factors;

and motivate patient to modify lifestyle. These proximal

performance objectives were crossed in the matrix with

secondary stroke prevention delivery determinants. The

determinants are based on the chronic care model and

include: community resources for stroke risk management; patient self-management; health system organizational promotion of stroke risk factor management;

delivery system design; decision support; and clinical

information systems. Finally, change objective statements

(i.e., the expected changes in the behavior and environment) were identified and added. The change objective

statements were then used to guide us in the development of the TOOLS program. The proximal performance

objectives, determinants, and subsequent change

objective statements for the TOOLS program can be

found in Additional File 1 Step 1.

Step 2: Selection of theory-based intervention

methodologies

Bartholomew states that the goal of IM Step 2 is to use

a conceptual model or theory to guide the identification

of appropriate intervention methods and delivery strategies of these methods that are matched to the objectives

stated in Step 1 [2]. A theoretical framework or model

can be thought of as a supporting technique or process

that influences change in the determinants identified in

Step 1. We then used the components of the model to

operationalize intervention components and implementation strategies.

For the TOOLS program, we reviewed the literature

and chose the elements of the chronic care model [35]

that fosters high-quality chronic disease care and applied

them to secondary stroke prevention care. Given that

secondary stroke care spanned inpatient and outpatient

care services and targeted both the providers and

patients, we believed the chronic care model elements

were comprehensive. The elements are: clinical information systems support, delivery system design, decision

support, self-management, and community resource

access. For the implementation strategies, we incorporated the components of the theory of planned behavior

[36] and specifically utilized strategies involving subjective norms/social persuasion for provider change strategies; and perceived behavior control/self-efficacy and

goal setting facilitation for patient change strategies. In

Additional File 1 Step 2, we identify both practical strategies to reach the objectives of Step 1 and suggestions

that were derived from the provider semi-structured

interviews completed with the needs assessment. An

example of a provider suggestion that is supported by

our conceptual model is that providers at both facilities

suggested the development of a standardized checklist

to ensure that each stroke survivor received the proper

information and training to prevent a second stroke at

discharge. This is supported through the model component of system design. See Additional File 1 Step 2 for

additional examples.

Step 3: Design and organization of the TOOLS program

Step 3 of IM includes designing and organizing the program to be implemented. Following Bartholomew’s

recommendations, we used the results of the needs

assessment, the generation of theoretical-based and

practical strategies from the literature and the targeted

users (IM Steps 1 and 2) to design and organize the

TOOLS program in Step 3 (See Additional File 1 Step

3). We used the interviews to determine needs, as well

as to discuss proposed strategies to assess the acceptability of the program, and to gain provider suggestions

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for implementation of the program. Main themes that

emerged from the interviews included the need or desire

for the following programs and strategies: standardized

provider check-off list or discharge check-off list and

clinical reminders; training and education regarding

local resources and referral to such resources; provider

stroke risk factor and prevention education; stroke support groups; peer programs; materials for patient education; and administration support. The resultant program

included programming for both providers and veterans

with stroke. See Table 2 and Additional File 1 Step 3 for

a summarization of the recommendations and next

action Steps that were derived from the interviews and

IM. We specifically address some of the activities below.

Patient and caregivers factors, characteristics, and

compliance impact prevention and lifestyle choices.

Because prevention includes lifestyle change, some providers discussed the need to work with the patient,

family members, and caregivers to best facilitate patient

secondary stroke prevention. A doctor talked about the

benefits of including family members into risk factor

management:

’I found out that involving family helps a lot, because

I found out some of the patients don’t tell family. By

family, I mean close family, the spouse, and the children. The children don’t even know that the father

is diabetic or has cholesterol problem. So when I

involve them, some of the children, I find that they

are more aware of the medical relationship between

smoking and cholesterol.’

We implemented multiple activities to help provide a

standardized approach to secondary stroke prevention.

For example, we helped to develop a standard information packet that included handouts and pamphlets

addressing the risk factor modification that is now given

to all patients with stroke or TIA by a specified nurse

prior to hospital discharge.

Interestingly, providers from both facilities (Indianapolis, 15%, and Houston, 24%) were interested in the

development of a discharge template or check-off to

ensure completion of secondary stroke prevention education and training. Due to this need, we developed a

stroke risk factor checklist poster based on the guidelines that were placed in the neurology workstations at

both sites and has been requested in an electronic format that is in progress.

An important concept arose when talking about available VA support and resources. Many providers were

not aware of existing services and programs, and often

did not know how to refer patients to risk factor management programs at their local facility, such as the

MOVE (VA weight loss) program or stress management

clinics. In order to address this important issue, and

because people discussed the need for a more systematic

approach to risk factor management at the facility level,

we created a stroke risk factor ‘prescription pad’ (see

Additional File 2). This prescription pad can be used by

any VA provider to identify and ‘prescribe’ appropriate

resources for each of the stroke risk factors and contact

information at their local facility. For example, if someone is diagnosed with high BP, they can be sent to the

VA hypertension clinic (phone number, day, and room

information are provided), and/or they can receive

home monitoring instructions and recommendations. If

they are noted as having weight control issues (or

obese), they are referred to the MOVE weight loss program (coordinator, phone number, and room number

are provided). We have received positive feedback from

the clinicians on this prescription pad and providers

have subsequently requested the pad be transferred into

an electronic order and that is a work in progress.

Because many providers discussed not necessarily having the knowledge or training to address the stroke risk

factor modification, we provided standard training and

education regarding patient motivational interviewing

and goal setting to foster behavior change and support.

We included role playing as part of this training (script

available upon request). We also distributed materials

and handouts for these providers to disseminate to

patients and caregivers.

Because stroke support groups were mentioned by

multiple providers at each facility, we have commenced

with a monthly local stroke support group. Activities

have included yoga, nutrition, stress management,

finances after stroke, and caregiver support. Others

talked about the importance of empowering the patient,

teaching them to ask questions and encouraging them

to make lifestyle changes and to be proactive. Multiple

other providers talked about the need for BP machines.

Previously, BP machines were easily issued to veterans

who needed to control their hypertension, this is no

longer the case and many providers would like to see

this benefit returned. However, to fulfill this need

through the TOOLS program, we are able to issue BP

machines on site for teaching purposes and provided

information to the patients for purchasing if interested.

Additionally, we are able to provide pedometers, ergometers, resistance exercise bands, and/or a 10-minute

relaxation CD for patient education and risk factor

modification..

As self-management is an integral piece of the chronic

care model [35] and discussed in our patient focus

groups [37], we also planned program components with

both the provider and the veterans to enhance selfmanagement of stroke risk factors. We again trained the

providers to use the prescription pad to refer veterans

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to community resources, but we also taught providers

motivation interviewing and goal-setting techniques.

This was to prepare the provider to begin discussions

about stroke risk factor management. Additionally, we

included training for the rehabilitation therapists to

incorporate a stroke risk factor management goal for

every patient with stroke or TIA. We also implemented

self-management training for veterans to learn goalsetting techniques to modify his stroke risk factors to

reduce his risk for secondary strokes.

Finally, we also specifically asked stroke survivors about

existing programs for secondary stroke prevention. We

asked care providers about the American Heart Association ‘peer to peer’ program, where a volunteer who has

survived a stroke works with a patient with a new stroke.

Both patients and their caregivers were excited about the

support and guidance a fellow stroke survivor could provide. Stroke survivors repeatedly reported the desire to

be around other stroke survivors who could relate to the

functional limitations and role-functioning changes. The

peer volunteer is a fellow stroke survivor and used as a

support network to help guide the new stroke survivor

through the process of stroke recovery. The majority of

providers (65%) encouraged the use of this program and

talked about how veterans often feel a connection to one

another and that we should try to use this connection to

enhance care. Thus we have included this in the TOOLS

programming.

Step 4: Adoption and implementation of the TOOLS

program

Prior to adoption and implementation of the TOOLS

program, we locally tailored the intervention as per local

needs and interests. For example, each site utilized a different self-management program with a local delivery

schedule that fit into their healthcare system. We then

fed back the program to a panel of local experts (i.e.,

chiefs of neurology), leaders from different clinical services, and some levels of administration at each facility

to gain feedback prior to implementation. We also

secured a ‘clinical champion’ at each facility to help

assist with the implementation of the TOOLS program,

and importantly to help sustain it after the end of the

study funding.

Step 4 of IM includes the adoption and implementation

plan for the program in the prescribed setting and is vital

to ensure delivery of the program [2]. Step 4 includes

complex tracking of each aspect of the program and

working with providers and administration to address

any issues prior to roll out of the program. For TOOLS,

this includes complex tracking of how each of the intervention components are delivered and used by the

veteran or the provider, where they are used, and the

delivery format (via group, individual, face, telephone, or

electronic). We also include our patient self-management

checklist where we are able to document which selfmanagement activities the patient engaged in to manage

their stroke risk factors. (Additional File 1 Step 4).

Step 5: Monitoring and program evaluation

Monitoring and evaluation of the program is the last

Step of IM. This evaluation uses the planned products

of other IM Steps to evaluate the process and the effect

of the program [2]. It is necessary to plan for the evaluation of the program, and it should include reflection on

the determinants, provider and patient behaviors, and

health outcomes. Bartholomew and colleagues indicate

that IM allows for thoughtful formative evaluation to

best evaluate both process and effect of the program

and whether changes need to be made [2].

Our program monitoring and evaluation can be found in

Additional File 1 Step 5. It includes primary and secondary

outcomes, evaluation of change both at the provider and

patient level, utilized measures, the time it takes to

complete the individual assessments, and a schedule of

assessments at baseline, three months, and six months

post-intervention. At the provider level, we were interested

in determining whether there was lifestyle or medication

management counseling, or specific stroke prevention

goals in the rehabilitation notes. This will all be completed

through medical record reviews. At the patient level, we

will assess stroke quality of life, stroke severity, physical

functioning, depression, self-efficacy, knowledge of stroke

signs and risk factors, and outcome expectations through

self-report and medical record review.

Discussion

Similar to previous health promotion programs, we used

IM to guide the development and implementation plan

of an evidence-based intervention targeting secondary

stroke prevention. IM provides a planning template for

incorporating theoretical components, practical strategies, evidence-based components from the literature,

and direct input from the targeted user groups. By conducting a needs assessment at both sites, we found that

most VA health providers are interested in engaging in

secondary stroke prevention; however, they needed better resources, training, and implementation guidance.

Moreover, their needs were different at each facility and

IM allowed us to tailor the intervention to each.

While this paper is not reporting the performance rate

on secondary stroke indicators of care, we did query

clinical providers on their current practices according to

the VA/DoD and the American Stroke Association

guidelines related to secondary stroke risk factor management and prevention to identify best practices and

gaps. While the majority of our interviewed providers

indicated that they participated in secondary stroke

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prevention at some level, many talked about referring to

other healthcare providers or not being competent to

provide such information. This parallels a recent study

we completed where we surveyed all occupational and

physical therapists in the Midwest region. Therapists

often indicated that they were likely to refer patients to

other healthcare providers, or that secondary stroke prevention was not part of their role as a therapist [40].

We also found that therapists were not aware of VA

stroke rehabilitation guidelines, indicating that part of

the TOOLS intervention will need to be basic education

regarding guideline compliance and education about

stroke prevention, risk factors, and stroke warning signs.

From our interviews, the rehabilitation therapists specifically discussed interest in learning about how to include

secondary stroke prevention in goal writing. This is

important because goal writing has been called the

‘essence of rehabilitation,’ and we believe it may be used

as a modality to change rehabilitation practice as it is

related to risk factor management [41].

Our study also identified provider needs to better support secondary stroke prevention. Multiple providers discussed patient adherence with medication, physical

activity, and lifestyle change. Rimmer et al. assessed the

barriers to physical activity for people with stroke and

found that the four most common barriers included: cost

of programming, not knowing about a local fitness center

or where to exercise, lack of transportation, and not

knowing how to exercise [42]. Therefore, to enhance

adherence in the TOOLS study, it is essential for us to

tailor the intervention to each individual patient to best

accommodate their needs and enhance secondary stroke

prevention outcomes. Thus, we are encompassing selfmanagement strategies to modify stroke risk factors [43].

Once we have completed the TOOLS program at both

sites, we will complete the evaluations of Step 5 and

focus groups of veterans and providers. We will use

these focus groups to better understand how the

TOOLs program altered care and self-management of

stroke risk factors. We will also seek information on

how to better adapt it for both veterans and providers

for future implementation.

Summary

We completed IM to develop an evidence-based program to systematically deliver at two different facilities.

The use of IM has allowed us to determine our goals,

the determinants, change objectives, practical strategies,

evaluation of the program, and the program itself. This

will guide us as we implement the program into the two

pre-determined facilities but also as we move forward

into different settings.

Additional material

Additional file 1: TOOLS Secondary Stroke Prevention, Intervention

Mapping, Steps 1-5. The additional file includes specific information for

each of the Intervention Mapping Steps. All steps are included in table

format. Specifically we include: Intervention Mapping, Step 1: Secondary

stroke prevention program matrix of proximal program objectives at the

provider and organizational level. Intervention Mapping, Step 2:

Theoretical and practical strategies to systematically deliver secondary

stroke prevention matched to proximal program objectives. Intervention

Mapping, Step 3: Program design to tailor a stroke secondary prevention

program - implementation intervention Intervention Mapping, Step 4,

Adoption and implementation plans. Intervention Mapping, Step 5,

Evaluation of intervention impact.

Additional file 2: Prescription Pad. The additional file includes an

example of the ‘prescription pad’ we used to help management of

stroke risk factors for our specific VA hospital.

Acknowledgements

We thank Angela Harris, Danielle Sager, Barbara Kimmel, Christi Murphy, and

Ellen Matthiesen for conducting the provider interviews at the Indianapolis

and Houston VAMC. We are grateful for the time and effort provided by the

clinical providers of both the Indianapolis and Houston VAMC to complete

these interviews. Support was provided by VA HSR&D funding IIR-05-297-2

‘Adapting Tools to Implement Stroke Risk Management to Veterans’ to Dr.

Damush and in part by VA RR&D funding CDA D6174W to Dr. Schmid.

Author details

1

Roudebush Veterans Administration Medical Center; Health Services

Research and Development (HSR&D) Center on Implementing EvidenceBased Practice, 1481 W. 10th Street, 11 H, Indianapolis, Indiana 46202-5199,

USA. 2

VA Stroke Quality Enhancement Research Initiative (QUERI), 1481 W.

10th Street, 11 H, Indianapolis, Indiana 46202-5199, USA. 3

Indiana University

School of Health and Rehabilitation Science, Department of Occupational

Therapy, 1140 W. Michigan Street CF 311, Indianapolis, Indiana 46202-5199,

USA. 4

Indiana University Center for Aging Research 1001 West 10th Street,

Indianapolis, Indiana 46202-5199, USA. 5

Michael E. DeBakey Veterans

Administration Medical Center, 2002 Holcombe BlvdHouston, TX, USA.

6

Regenstrief Institute, 1001 West 10th Street, Indianapolis, Indiana 46202-

5199, USA. 7

Indiana University School of Medicine, Department of

Neurology, 1001 West 10th Street, Indianapolis, Indiana 46202-5199, USA.

8

Indiana University School of Medicine, Department of General Internal and

Geriatrics, 1001 West 10th Street, Indianapolis, Indiana 46202-5199, USA.

Authors’ contributions

All authors were involved with drafting and reviewing the manuscript.

Specifically, AS drafted the manuscript as the primary author, completed

revisions with TD, helped complete study participant interviews, and

participated in the design of the study and the development of the

interviews. JA participated in the conception and design of the study, data

collection, and made substantial contributions to the manuscript. TK

participated in the conception and design of the study and is the attending

neurologist for the study at Houston site. LW is the attending neurologist for

the study at the Indianapolis site and participated in the conception and

design of the study. TD is the PI of the study, participated in the conception

and design of the study, helped with data collection and development of

interviews, and made substantial contributions to the manuscript and

revisions and developed the matrix. All authors read and approved the final

draft.

Competing interests

The authors declare that they have no competing interests.

Received: 23 June 2009 Accepted: 15 December 2010

Published: 15 December 2010

Schmid et al. Implementation Science 2010, 5:97

http://www.implementationscience.com/content/5/1/97

Page 10 of 11
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doi:10.1186/1748-5908-5-97

Cite this article as: Schmid et al.: Using intervention mapping to

develop and adapt a secondary stroke prevention program in Veterans

Health Administration medical centers. Implementation Science 2010 5:97.

Schmid et al. Implementation Science 2010, 5:97

http://www.implementationscience.com/content/5/1/97

Page 11 of 11
Additional file

TOOLS Secondary Stroke Prevention (Damush et al. from HSRD IIR Adapting Tools for Secondary Stroke Prevention In V

Intervention Mapping, Step 1: Secondary stroke prevention program matrix of proximal program objectives at the prov

organizational level

Secondary stroke prevention delivery determinants based upon chronic care model

ProviderPerformanceObjectives

CommunityResources for Stroke

Risk Management

Patient Self‐Management

Health SystemOrganizational

Promotion ofStroke Risk FactorManagement

Delivery SystemDesign Decision S

Assesses patient

stroke risk factors

during

hospitalization for

stroke

Access to localresources availableto assess stroke risk

factors

Communicates thepatient’s risk

factors for stroke to

patient

Neurology serviceat facility

promotes stroke

risk factorassessment

Work flow of

dischargeplanning includesthe systematicdelivery of stroke

risk factorassessment

Practices w

the guideli

the JointCommissio

VA/DoD an

American S

Association assess stro

factors

Orders lab tests as

needed

Access to patientmaterials on

laboratory tests and

interpretation of

results

Communicates with

patient on need for

tests and on

patient results

Neurology serviceat facility orders

lab tests perguideline care and

prescribestreatment tomodify risk factors

based on results

Orders lab tests

per guidelinecare; System

alerts provider of

lab results;Providerprescribestherapy based on

results

Practices w

the guideli

the JointCommissioVA/DoD anAmerican S

Association order labs

Prescribes

appropriate

medications to

manage risk factors

Accesses and

provides patienteducation materials

on medications

Educates the

patient on the

benefits of themedication

Healthcare system

providesmedicationprescribed to

Medicationreconciliationprior to hospital

discharge is

Accesses calgorithmscards base

guideline c
Secondary stroke prevention delivery determinants based upon chronic care model

ProviderPerformanceObjectives

CommunityResources for Stroke

Risk Management

Patient Self‐Management

Health SystemOrganizational

Promotion ofStroke Risk FactorManagement

Delivery SystemDesign Decision S

prescribed for stroke

risk factormanagement

prescribed,prescribed dosage,

medicationadherence, andpotential sideeffects

veterans withstroke

standard practice

with pharmacistfor veterans

hospitalized with

stroke

patients w

stroke

Educates patient

about stroke risk

factor reduction

Accesses and

provides patient with

appropriate and

relevant stroke risk

factor education

materials

Discusses goalsetting to modifystroke risk factors;

provides feedback

on patient efforts

to modify risk

factors

Dedicated staff

members are

assigned theresponsibility of

patient education

on stroke risk

factors

Neurologists and

nurses documenteducation

provided on thespecific risk

factors present inthe patient prior

to discharge

Clinical remand suppomaterials aavailable fo

Refers patient to

local programs that

address stroke risk

factors

Recommends MOVE

program; smokingcessation classes andsupport; nutritionalcounseling; dietclasses; angermanagement classes;physical activity inthe community;diabetesmanagement;

Refers patient to

diabetes self

managementcourses; refer to

local andcommunity support

groups;

Health care

system providessupport programs

to reduce riskfactors; Providers

are aware of how

to access

programs for theirpatients

Access to localprograms is

readily availablefor patients;

Patientinformatioavailable oMyhealthe
Secondary stroke prevention delivery determinants based upon chronic care model

ProviderPerformanceObjectives

CommunityResources for Stroke

Risk Management

Patient Self‐Management

Health SystemOrganizational

Promotion ofStroke Risk FactorManagement

Delivery SystemDesign Decision S

Motivates patient

to modify lifestyle

Writes orders forhome equipment to

support patient

lifestyle changes(e.g., pedometers,blood pressure

machines); accesses

information on local

programs

Appliesmotivationalinterviewing tomotivate patient tomodify lifestyle;

negotiates lifestylechange efforts with

patient

The organization

culture supports

the providers time

to spend on

patient lifestyle

modification

Patient lifestyle

modification is

part of the stroke

discharge process

Utilizes po

cards/grapdisplays tomotivate plifestylemodificatio
Intervention Mapping, Step 2: Theoretical and practical strategies to systematically deliver secondary stroke preventio

program objectives

Theoretical Strategies Practical Strategies Provider S

Stru

Provider Performance Objectives

Theory of Planned Behavior

Assesses patient stroke risk

factors during hospitalization for

stroke

Perceived Social Norms ‐ clinical

champion promotes; added into

annual competency evaluation

Attitudes, Beliefs, Values ‐ training

Self‐efficacy/control ‐ role playing

to improve skills; vicarious/peer

modelingBehavioral intentions ‐ assess

intentions/commitment toperform

In the discharge planningtemplate, a stroke risk factor

assessment template is included;

A computer reminder for stroke

risk factor assessment is alerted

at time of stroke discharge

planning

Suggest sy

check off l

records du

Orders lab tests as needed

Perceived Social Norms ‐ clinical

champion promotes; added into

annual competency evaluation

Attitudes, Beliefs, Values ‐ training

Self‐efficacy/control ‐ role playing

to improve skills; vicarious/peer

modelingBehavioral intentions – assess

intentions/commitment toperform

Provider receives a clinical

reminder to order specific labtests upon patient admission for

stroke; Provider systematically

accesses clinical templates toorder lab tests; Provider receives

clinical alert of lab tests results

Providers a

medical re

Prescribes appropriate

medications to manage risk

factors

Perceived Social Norms ‐ clinical

champion promotes; added into

annual competency evaluation

Attitudes, Beliefs, Values ‐ training

Self‐efficacy/control‐ role playing

to improve skills; vicarious/peer

modeling

Provider systematically accesses

clinical templates to prescribe

appropriate medications per

clinical guideline care and results

of lab tests; Accesses decision

support on appropriate

prescriptions available and

Providers a

medical re
Theoretical Strategies Practical Strategies Provider S

Stru

Provider Performance Objectives

Theory of Planned Behavior

Behavioral intentions – assess

intentions/commitment toperform

potential interactions

Educates patient about stroke

risk factor reduction

Self‐efficacy to motivate patients

to change their lifestyles –

training, role playing to improve

skills; vicarious/peer modeling

through follow up sessions

Provider provides on demand

patient education materials about

specific risk factor relevant to the

patient; Provider answers patient

questions; Pharmacists providesmedicine reconciliation prior to

hospital discharge to review all

prescribed medications and

educate patient about side effectsand answer patient questions

Provide clieducationa

handouts fthe caregiv

Refers patient to local programs

that address stroke risk factors

Perceived social norms – clinical

champions promotes referrals

Self‐efficacy – improve the MD

confidence to make appropriate

referrals in VA and the

community.

Provider discusses local programoptions available for the patient

to modify risk factors and

communicates his/her

recommendation for the patient

to participate

Provide cli

informatio

available p

stroke risk 

patients m

a stroke sutheir patie

support

Motivates patient to modify

lifestyle

Self‐efficacy to motivate patients

to change their lifestyles –

training, role playing to improve

skills; vicarious/peer modeling

through follow up sessions

Provider is trained in motivational

interviewing and goal setting;

Provider applies motivational

interviewing principles to assist

patient plan lifestylemodifications; Providercollaborates with patient to setgoals to change health behaviors;

Providers n

starting th

their patie

modificatiotheir patie

support fo

change. Re

importanc

their patie
Intervention Mapping, Step 3: Program design to tailor a stroke secondary prevention program – clinical intervention

Provider

Performance

Objectives

Community

Resources for

Stroke RiskManagement

Patient Self‐

Management

Health System

OrganizationalPromotion ofStroke RiskFactorManagement

Delivery

System Design

Decision

Support

Clinical

InformatiSystems

Assesses patient

stroke risk

factors during

hospitalization

for stroke

Provider accesseslocal resources

available to assesspatient stroke risk

factors

Communicates

patient’s

specific stroke

risk factors

and begins the

conversationon how to

modify and

conveys its

importance

Neurologyserviceendorsesstroke risk

factorassessmentduringhospitalizationfor stroke as

usual practice

Nursesystematicallyassessespatient strokerisk factors

duringhospitalizationanddocuments in

electronicmedicalrecords

Guidelinecare for

stroke riskfactormanagementprovided onposters andplaced atneurologyworkstations

Electronicmedical re

templatescreated

Orders lab tests

as needed

Access to patient

education materials

on lab tests results

Providercommunicateslab test results

with patient

Neurologyserviceendorses labtests orders

duringhospitalizationfor stroke as

usual practice

Neurologyelectronicmedical recordtemplatessystematicallyinclude ordersfor lab tests for

stroke patients

Guidelinecare for

stroke riskfactor

managementprovided onposters andplaced atneurologyworkstations

Utilizes ex

electronicmedical retemplates
Provider

Performance

Objectives

Community

Resources for

Stroke RiskManagement

Patient Self‐

Management

Health System

OrganizationalPromotion ofStroke RiskFactorManagement

Delivery

System Design

Decision

Support

Clinical

InformatiSystems

Prescribes

appropriate

medications to

manage risk

factors

Access to patient

education materials

on medications

Includesexistingpractice of

Pharmacistprovidingmedicinereconciliationprior todischarge toreview allmedicines

prescribed,theirinstructions,side effects

and answer

patientquestions

Neurologyserviceendorses theprescription of

medicationsdesigned toreduce stroke

risk upon

discharge for

stroke as usual

practice

Neurologyelectronicmedical recordtemplatessystematicallyinclude ordersforprescriptionsfor stroke risk

factormanagement

Guidelinecare for

stroke riskfactormanagement

provided on

posters andplaced atneurologyworkstations

Utilizes ex

electronicmedical re

templates

Educates patient

about stroke risk

factor reduction

Materials/Handouts

provided forproviders to deliverto patients on

specific risk factors

AmericanStrokeAssociationPeer VisitorProgramimplementedto supportveteran with

stroke;

Nurses areassigned the

responsibility

of patient

education on

stroke risk

factormanagement

Thedocumentationof nurse risk

factoreducation is

required priorto hospital

discharge

On demandeducation isavailable forstaff

Modifiedexisting paeducation 

template documentspecific ris

factoreducationdelivereddocument
Provider

Performance

Objectives

Community

Resources for

Stroke RiskManagement

Patient Self‐

Management

Health System

OrganizationalPromotion ofStroke RiskFactorManagement

Delivery

System Design

Decision

Support

Clinical

InformatiSystems

Refers patient to

local programs

that address

stroke risk

factors

Prescription padcreated for localprograms for each

stroke risk factor

with instructions on

how patients may

access

Stroke Self

Managementprogramprovided for

patients inhospital/afterdischarge;

Healthcareorganizationprovidessupportprograms toreduce stroke

risk factors

(e.g., smoking

cessation; diet

modification)

Prescription

pad madeavailable at

neurology

residentworkstation

Prescriptionpad outlinesappropriateprograms by

stroke riskfactor

Createdelectronicversion of 

factorprescriptio

Motivates

patient to

modify lifestyle

Provided Providertraining on

communityresources available

ProvidedProvidertraining on

motivationalinterviewingand goalsetting

Healthcareorganizationprovidessupportdevices forlifestylemodification(e.g.,pedometersfromprosthetics)

Incorporateslifestylemodification

into patient

clinical goals

AccessesinformationonMyhealthEvet

Created p

goal settinchecklist fstroke self

managem
Intervention Mapping, Step 3: Program design to tailor a stroke secondary prevention program – implementation inter

Theoretical Strategies Implementation Strategies

Provider Performance Objectives

Theory of Planned Behavior Operationalized

Assesses patient stroke risk

factors during hospitalization for

stroke

Perceived Social Norms ‐ clinical champion

promotes stroke risk factor assessment;

added into annual competency evaluation

Attitudes, Beliefs, Values ‐ training

Self‐efficacy/control‐ role playing to

improve skills; vicarious/peer modeling

Behavioral intentions – assess

intentions/commitment to perform

Chief of Neurology assigns neurology 

to assess stroke risk factors of all patie

admitted with stroke, document resu

electronic discharge planning templat

provide a education packet that addre

the stroke risk factor prior to discharg

Research team provides training, role

playing and support materials to clinic

Assesses attitudes and intentions to

perform in next 90 days. Post perform

objectives and guideline care at neuro

workstations where discharge plannin

occurs.

Orders lab tests as needed

Perceived Social Norms ‐ clinical champion

promotes; added into annual competency

evaluation, provides feedback on

performanceAttitudes, Beliefs, Values ‐ training

Self‐efficacy/control‐ role playing to

improve skills; vicarious/peer modeling

Behavioral intentions – assess

intentions/commitment to perform

Measures performance and provides

regular feedback on quality of perform

to providers. Provides training to cliniand assesses behavioral intentions.

Prescribes appropriate

medications to manage risk

factors

Perceived Social Norms ‐ clinical champion

promotes; added into annual competency

evaluationAttitudes, Beliefs, Values ‐ training

Self‐efficacy/control‐ role playing to

improve skills; vicarious/peer modeling

Behavioral intentions – assess

Provider systematically accesses clinic

templates to prescribe appropriate

medications per clinical guideline care 

results of lab tests; Accesses decision

support on appropriate prescriptions

available and potential interactions.

Measures performance and provides
Theoretical Strategies Implementation Strategies

Provider Performance Objectives

Theory of Planned Behavior Operationalized

intentions/commitment to perform regular feedback on quality of perform

Provides training, and evaluates inten

to perform over next 90 days

Educates patient about stroke

risk factor reduction

Self‐efficacy to motivate patients to change

their lifestyles – training, role playing to

improve skills; vicarious/peer modeling

through follow up sessions

Provides on demand patient educatio

materials about specific risk factor rel

to the patient; Provides training on ta

to patients about stroke risk factors a

social influence of the provider. Provi

training and role playing on addressin

objections and barriers. Pharmacists

(practical strategy) provide medicine

reconciliation prior to hospital dischar

review all prescribed medications and

educate patients about side effects an

answer patient questions.

Refers patient to local programs

that address stroke risk factors

Perceived social norms – clinical champions

promotes referralsSelf‐efficacy – improve the MD confidence

to make appropriate referrals in VA and the

community.

Provider is familiar with an update on 

programs that address pt risk factors;

discusses local program options availa

for the patient to modify risk factors a

communicates his/her recommendati

the patient to participate; provides ris

factor referral Rx pad to use with pati

Motivates patient to modify

lifestyle

Self‐efficacy to motivate patients to change

their lifestyles – training, role playing to

improve skills; vicarious/peer modeling

through follow up sessions

Provider is trained in motivationalinterviewing and goal setting –educat

role playing/social modeling; Provider

applies motivational interviewing prin

to assist patient plan lifestyle modifica

Provider collaborates with patient to 
Theoretical Strategies Implementation Strategies

Provider Performance Objectives

Theory of Planned Behavior Operationalized

goals to change health behaviors;
Intervention Mapping, Step 4, Adoption and implementation plans

Chronic Care

Model Factor

InterventionComponent

Fidelity Date(s) Provider/

Instructor

PlaceHouston/IndianapolisClinic/Dept/Floor

Contents Me

ForGroInd

Oth

1. Community

Resources forstroke risk

management

Provider gaveparticipant

educational

materials from

community

resources (e.g.,AHA/ASA)

Notes inelectronicmedical records

Yes  

No  

Houston 

Indianapolis Clinic Department Floor 

GroInd

Oth

Participantobtained

community

resources (e.g.,AHA/ASAmaterials)

Self‐reportYes  

No 

Houston 

Indianapolis Clinic Department Floor 

GroInd

Oth

Participant utilized

communityexercise programs

(YMCA, other)

Sef‐reportYesNo

Houston 

Indianapolis Clinic Department Floor 

GroInd

Oth

Participantenrolled in VA

support program

(e.g., MOVE,smoking cessation,

others)

Program logs;Medical records

Houston 

Indianapolis Clinic Department Floor 

GroInd

Oth

2. Health

System

JCAHO Guidelines

promoted

Yes  

No 

Houston 

Indianapolis 

 

 
promotion of

stroke risk

management

Clinic



Department



Floor



  ___

VA/DoD Guidelines

promoted

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



 

   ___

AHA/ASAguidelinespromoted

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



 

   ___

3. Patient Self‐

Managementfor stroke risk

reduction

ASA Peer Stroke

SupportOther:_______

ResearchdatabaseTreatmentDeliveryParticipantinvited to attend

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



1st meeting Yes  

No 

2nd meeting Yes  

No 

3rd meeting Yes  
No  

4th meeting Yes  

No 

5th meeting Yes  

No 

6th meeting Yes  

No 

Additionalmeetings

Yes  

No 

Providercounseling

Counsel on

smoking cessation

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Counsel on AHA

diet

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Counsel on

exercise

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Discuss

medications‐Statins‐ACE inhibitor

‐Antithrombotics

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor


‐Antiplatets

Case‐management

Referral to existingnurse/social

worker program

CPRS

– medical

records

Houston



Indianapolis



Clinic



Department



Floor



Telehealth devicemonitoring

CPRS

– medical

records

Houston



Indianapolis



Clinic



Department



Floor



4. Delivery

System

Local champion

exists for stroke

risk reduction

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Referrals made by

providers to VA

resources

Yes  

No 

 Rehab

 MOVE PERC

 Nutrition Smoking

Cessation Other

________

Staff training for

patient lifestylecounseling

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



 

   ___

Nurse standing

order for

Yes  

No 

Houston



Indianapolis


medication

management forstroke risk

reduction

Clinic



Department



Floor



Dedicated clinic

forms to flag

stroke patients

Yes  

No 

5. Decision

Support

Pocket cardsprovided

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Preprinted/electronic

admission order

sheets with

checked boxes

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Checked fastinglipids

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Checked fastingglucose

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Checkedhemoglobin A1c

values

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Checkedhypertension

Yes  

No 

Houston



Indianapolis


status Clinic



Department



Floor



Calculated BMI Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Medication

Algorithms

Provided

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Prescribedhypertension medsas appropriate

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Prescribed

Antithromboticmeds as

appropriate

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Prescribed Statinsas needed

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



Educated patienton Stroke

information –signs,

symptoms, call 911

Yes  

No 

Houston



Indianapolis



Clinic



Department



Floor



6. Clinical Electronic Yes  Houston


(Step 4 Continued) Patient Self‐Management Checklist

Stroke Self‐Management Course Overview Week 1 Week 

M T W R F Sa Su M T W R 

DATE OF SESSION________

Talked to my doctor about receiving physical or speech or

occupational therapy

Attended my rehabilitation therapy appointmentsLearned the warning signs of strokeDiscussed my fears about recoveryTalked to my doctor about depressionPracticed Rehab Exercises from therapistPracticed Personal Exercise Program in handoutPracticed problem‐solvingUsed a pill box to keep track of medicationsTook pills as my doctor recommendedContacted a community resource:____________Became Active around the Home:____________Practiced Exercises from the Exercise and Daily Activity

Book

InformationSystem

reminder forstroke guideline

care in CPRS

No  Indianapolis 

Developed localautomatedidentifiers for

stroke patients

Yes  

No 

Houston 

Indianapolis 

Developedautomated clinicalform to monitor

performance

Yes  

No 

Houston 

Indianapolis 
Walked the dog

Walked in the communityPracticed Other Physical Activity:_____________Practiced Deep BreathingListened to Relaxation CDPracticed Progressive Muscle RelaxationPracticed Changing Negative thoughts to PositiveAte healthy foodsEliminated unhealthy foods from dietAttended Smoking Cessation classesUsed smoking cessation aidesStopped smokingReduced alcohol consumptionStopped consuming alcoholTested my sugar level for diabetesUsed a salt substitute in my mealsReduced salt in my mealsStopped using salt in my mealsBrought my doctor a list of my health concernsAsked my doctor questionsAsked my doctor for explanationsMeasured my blood pressureWeighed myselfOTHER:OTHER:OTHER:OTHER:

(Step 4 Continued) Stroke Peer Visitor MonitoringTRACKING YOUR PEER VISITS Name of Patient, date of visit, place of visit, length of time of visit 
Patient Name Visit Date Place of Visit Length of time 

of visit 

Any special requests/needs 
Intervention Mapping, Step 5, Evaluation of intervention impact

Outcome assessment protocol: Measures and schedule of administration

Domain Source Measure Items Time (min) Sched

BL 3 MO 

PRIMARY OUTCOMESStroke Risk FactorManagement Provided

by Staff/Providers

Medical

Records

Medication ManagementLifestyle counseling/referral

[treat yes/no: dose, duration]

CPRS

Abstract X X 

Stroke Risk FactorManagement Behaviors Survey

Lifestyle Behaviors

‐Physical Activity‐ Diet

‐Smoking‐Alcohol‐Medication Adherence

20 15 X X 

SECONDARY OUTCOMESStroke Quality of Life Survey SSQoL – stroke specific, health‐related quality of life 27 10 X X Stroke Outcomes Survey Rankin 1 1 X X Physical Functioning Survey SF‐36V subscale floor effect 10 3 X X Depression Survey PHQ9 9 3 X X Self‐efficacy Survey Self‐Efficacy 9 3 X X Outcome Expectations Survey Outcome Expectations 9 3 X X Knowledge of StrokeSigns Survey Warning Signs/Plan for Stroke 2 1 X X Demographics Survey

Age, race, income, education,

marital status, Mini‐Mental

Screener

5 1 X

Stage of Change Survey

Stage of Change for Physical

Activity; Diet, Cigarettes

Smoking

4 1 X X 

Blood Pressure CPRS Systolic/Diastolic

Abstracted

X X 

Body Composition CPRS Weight X X 
Outcome assessment protocol: Measures and schedule of administration

CPRS Height From Medical

Record

X X 

Clinical Data CPRS Comorbidity; Cholesterol; smoking status; X X