Title: Using Clinical Decision Support Tools to Implement Patient Self-management
1Using Clinical Decision Support Toolsto
Implement Patient Self-management
- Jane Anderson, PhD, RN, FNP-BC
- Associate Director, Stroke Center
- Michael E. DeBakey VA Medical Center
2Translating and Documenting Evidence Based Care
Evidence-based practice
Information Systems
STOP Stroke Clinic
STOP Stroke Tool
Performance Improvement
Self-management Support
3QUERIs Six Step Process Implementation Pipeline
(B Mittman)
Step 1
Steps 4/5/6
Step 2
Step C
Clinical Research / Guideline Development
Implementation Research
Improved quality/health
Mainstream Health Services Research
Step 3
Step M
Phase 1 Pilot Projects
Phase 2 Small-Scale Demonstrations
Phase 3 Regional Demonstrations
Phase 4 National Rollout
Step 4 in the Development or adaptation of
educational materials or decision support
tools. Phase 1 as a pilot project Alpha stage
development and testing was recently completed to
develop the STOP Stroke Tool .
4Pilot Project
- Two specific aims
- Test the functionality of each component of the
tool in simulation - Determine overall usability of the tool among a
sample of multidisciplinary clinicians. - A pre-experimental before/after design
- Documentation of CPGs was compared among a sample
of multidisciplinary providers (N15) using test
case scenarios and two documentation systems,
standard CPRS vs. the STOP Stroke Tool. - Usability was evaluated with a questionnaire
5(No Transcript)
6Embedded Guidelines
Patient specific information
Medication Algorithm
7Hyperlink to Education Materials
Automates Documentation of guideline based
actions providing supporting evidence of JC
regulations
8Joint Commission Standardsfor Self-Management
- Joint Commission Standards for Primary Stroke
Center Certification - Supporting Evidence (SE)
- SE 1 - Patients are involved in the
decision-making process for managing their
disease or condition - SE 2 Recommended lifestyle changes support
patient self-management actions - SE 3 - Patients educational needs are addressed
in the context of self-management
9Supporting Self-Management with Information
Systems
- The STOP Stroke Tool
- Guides clinicians in an evidence-based
self-management intervention - Collaborative action plan
- Facilitates documentation of supportive evidence
for self-management - Stores supportive evidence data for outcomes
monitoring and JC reporting
10Patient selects an action to reduce stroke risk
Action needs to be something the patient wants to
do
Provider steps patient through specifics of their
stated goal
11Confidence level is established by the patient
and indicates how much they believe they will
accomplish their stated goal. Needs to be at
least 7 or more. If not 7 provider helps
patient rework their action plan until the
patient has a higher confidence level.
Automates Documentation of action plan providing
supporting evidence of JC regulations
Health Factor
12Implementing Self-management in the STOP Stroke
Clinic
- 6 Self-management classes
13STOP Stroke Clinic Care Delivery
Initial Clinic Visit
Group SM Course
Group SM Course
Group SM Course
Clinic Follow-up
Group SM Course
Group SM Course
Group SM Course
Final Clinic Follow-up
Stroke secondary prevention risk factor profile
20 minutes
Self-management course Stanford CDSM Program -
6 group sessions 2 hours duration
Clinical management follow-up, RF education,
Reinforce action planning
Self-management course continued
Final clinical management visit, RF education,
Reinforce action planning
14Implementation Barriers Clinic Structure
- Time required to participate in SM Class
- 30 participants completed all 6 visits
- Most frequent participant recommendations
- fewer visits and shorter class time
- Geographic constraints
- 48 patients gt 50 miles from main facility
- Most common reason for not participating in
course - - I live too far from the VA
15Implementation Barriers Care Delivery
- Heavy burned for staff resources
- NP students made possible multiple simultaneous
clinic visits and served as course facilitators - 1 NP faculty and 3 NP students for clinic visits
- 1 NP faculty and 2 NP students for
Self-management course - NP Students only available during Spring and
Summer - Elective course
16Implementation Facilitators
- STOP Stroke Tool is Effective in
- Prompting Guideline-based care
- Increases documentation
- Clinical Practice Guidelines
- Patient Education
- Patient Self-management
17Stroke Etiology Risk Factor AHA/ASA Stroke Secondary Prevention CPGs Outcome Measures
NonCardioEmbolic/Cardioembolic Stroke Antiplatelet/ Anticoagulation Therapy Prescribed Aspirin, Plavix, Aggrenox or Warfarin
Hypertension Hypertension Diabetes Hypertension Medications Prescribed Angiotensin Converting Enzyme Inhibitor-Thiazide Diuretic Angiotensin-Receptor Blockers
Diabetes Oral hypoglycemic agents/Insulin Prescribed
Diabetes Dietary Counseling Provided
Hypercholesterolemia Statin Agent Prescribed
Smoking Smoking cessation recommended Pharmacologic support offered/prescribed
Overweight/Obesity BMI Dietary Counseling and/or Exercise Training Recommended
Physical Inactivity Exercise Training Recommended
Heavy Alcohol Consumption Reduced alcohol consumption recommended Referral to alcohol dependency counseling
Patient specific risk factors Patient Education Materials Provided
Behavioral risk factors Patient Self-management -Action Plan Completed
18Number of Providers that Changed Documentation of
Clinical Practice Guidelines Using the STOP
Stroke Tool Compared to CPRS
CPG Intervention Documented CPRS Documented STOP-ST Documentation Change p value
Anti-platelet/coag 14 15 1 1.0
HTN medications 13 15 2 .50
DM medications 9 15 6 .031
DM diet counseling 8 15 7 .016
HCL/Statin agent 6 15 9 .004
Smoking cessation 13 15 2 .50
Reduce alcohol 13 15 2 .50
BMI -diet/exercise 7 15 8 .008
PI/Exercise program 12 15 3 .25
Education materials 0 15 15 .000
Self-management 0 15 15 .000
CPG clinical practice guideline, CPRS computerized patient record system, STOP-ST STOP Stroke Tool, HTN hypertension, DM diabetes, HCL high cholesterol, BMI body mass index, PI physical inactivity CPG clinical practice guideline, CPRS computerized patient record system, STOP-ST STOP Stroke Tool, HTN hypertension, DM diabetes, HCL high cholesterol, BMI body mass index, PI physical inactivity CPG clinical practice guideline, CPRS computerized patient record system, STOP-ST STOP Stroke Tool, HTN hypertension, DM diabetes, HCL high cholesterol, BMI body mass index, PI physical inactivity CPG clinical practice guideline, CPRS computerized patient record system, STOP-ST STOP Stroke Tool, HTN hypertension, DM diabetes, HCL high cholesterol, BMI body mass index, PI physical inactivity CPG clinical practice guideline, CPRS computerized patient record system, STOP-ST STOP Stroke Tool, HTN hypertension, DM diabetes, HCL high cholesterol, BMI body mass index, PI physical inactivity
19Whats Next ?
- Application of Lessons Learned
- Restructure STOP Stroke Clinic
- Test implementation of STOP Stroke Tool
- Multiple Clinic Settings
20Possible Clinic Restructure -
Clinical management provided during individual
clinic visit followed by Initial group clinic
Group session for self-management counseling,
action planning and problem solving
Individual Clinic
Initial Group Clinic
Video Phone 1
Video Phone 2
Video Phone 3
Video Phone 4
Final Group Clinic
Individual Clinic
Staff Nurse Practitioner
4 video phone follow-up sessions provided to
reinforce. Specific risk factor management,
patient self-management, action planning, and
problem solving
Staff Registered Nurse
Final follow up clinic provide during individual
clinic visit followed by Final group encounter
to review patient self-management, action
planning and problem solving skills
Staff Nurse Practitioner
21Beta TestingImplementation of the STOP Stroke
Tool in Clinical Practice
- Beta test the STOP Stroke Tool in primary care
and other practice setting where veterans receive
follow-up care for stroke and TIA - Test components of the tool
- Primary Care Clinics
- Rehabilitation Medicine Clinics
- Neurology Clinics