Using Clinical Decision Support Tools to Implement Patient Self-management

1. Using Clinical Decision Support Toolsto Implement Patient Self-management Jane Anderson, PhD, RN, FNP-BC Associate Director, Stroke Center Michael E. DeBakey VA Medical Center

2. Translating and Documenting Evidence Based Care Evidence-based practice Information Systems STOP Stroke Tool STOP Stroke Clinic Performance Improvement Self-management Support

3. QUERI’s Six Step Process Implementation Pipeline (B Mittman) Step 1 Steps 4/5/6 Step C Step 2 Clinical Research / Guideline Development Implementation Research Improved quality/health Mainstream Health Services Research Step M Step 3 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 .

4. Pilot Project • Two specific aims: • Test the functionality of each component of the tool in simulation • Determine overall usability of the tool among a sample of multidisciplinary clinicians. • A pre-experimental before/after design • Documentation of CPGs was compared among a sample of multidisciplinary providers (N=15) using test case scenarios and two documentation systems, standard CPRS vs. the STOP Stroke Tool. • Usability was evaluated with a questionnaire

5. Clinical Management Patient Education Patient Self-management

6. Embedded Guidelines Patient specific information Medication Algorithm

7. Hyperlink to Education Materials Automates Documentation of guideline based actions – providing supporting evidence of JC regulations

8. Joint Commission Standardsfor Self-Management • Joint Commission Standards for Primary Stroke Center Certification • Supporting Evidence (SE) • SE 1 - Patients are involved in the decision-making process for managing their disease or condition • SE 2 – Recommended lifestyle changes support patient self-management actions • SE 3 - Patient’s educational needs are addressed in the context of self-management

9. Supporting Self-Management with Information Systems • The STOP Stroke Tool • Guides clinicians in an evidence-based self-management intervention • Collaborative action plan • Facilitates documentation of supportive evidence for self-management • Stores supportive evidence data for outcomes monitoring and JC reporting

10. Patient selects an action to reduce stroke risk Action needs to be something the patient wants to do Provider steps patient through specifics of their stated goal

11. Confidence level is established by the patient and indicates how much they believe they will accomplish their stated goal. Needs to be at least 7 or more. If not 7 – provider helps patient rework their action plan until the patient has a higher confidence level. Automates Documentation of action plan– providing supporting evidence of JC regulations Health Factor

12. 3 Clinic visits 6 Self-management classes Implementing Self-management in the STOP Stroke Clinic

13. STOP Stroke Clinic – Care Delivery 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

14. Implementation Barriers Clinic Structure • Time required to participate in SM Class • 30% participants completed all 6 visits • Most frequent participant recommendations • – fewer visits and shorter class time • Geographic constraints • 48% patients > 50 miles from main facility • Most common reason for not participating in course • - I live too far from the VA

15. Implementation Barriers Care Delivery • Heavy burned for staff resources • NP students made possible multiple simultaneous clinic visits and served as course facilitators • 1 NP faculty and 3 NP students for clinic visits • 1 NP faculty and 2 NP students for Self-management course • NP Students only available during Spring and Summer • Elective course

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

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

19. What’s Next ? • Application of Lessons Learned • Restructure STOP Stroke Clinic • Test implementation of STOP Stroke Tool • Multiple Clinic Settings

20. Possible 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 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

21. Beta TestingImplementation of the STOP Stroke Tool in Clinical Practice • Beta test the STOP Stroke Tool in primary care and other practice setting where veterans receive follow-up care for stroke and TIA • Test components of the tool • Primary Care Clinics • Rehabilitation Medicine Clinics • Neurology Clinics