Using Clinical Decision Support Tools to Implement Patient Self-management

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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

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Translating and Documenting Evidence Based Care
Evidence-based practice
Information Systems
STOP Stroke Clinic
STOP Stroke Tool
Performance Improvement
Self-management Support
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QUERIs 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 .
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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 (N15) using test
  case scenarios and two documentation systems,
  standard CPRS vs. the STOP Stroke Tool.
• Usability was evaluated with a questionnaire

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Embedded Guidelines
Patient specific information
Medication Algorithm
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Hyperlink to Education Materials
Automates Documentation of guideline based
actions providing supporting evidence of JC
regulations
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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 - Patients educational needs are addressed
  in the context of self-management

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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

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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
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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
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Implementing Self-management in the STOP Stroke
Clinic

• 3 Clinic visits

• 6 Self-management classes

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STOP Stroke Clinic Care Delivery
Initial Clinic Visit
Group SM Course
Group SM Course
Group SM Course
Clinic Follow-up
Group SM Course
Group SM Course
Group SM Course
Final Clinic Follow-up
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
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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 gt 50 miles from main facility
• Most common reason for not participating in
  course
• - I live too far from the VA

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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

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Implementation Facilitators

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

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Stroke Etiology Risk Factor AHA/ASA Stroke Secondary Prevention CPGs Outcome Measures
NonCardioEmbolic/Cardioembolic Stroke Antiplatelet/ Anticoagulation Therapy Prescribed Aspirin, Plavix, Aggrenox or Warfarin
Hypertension Hypertension Diabetes Hypertension Medications Prescribed Angiotensin Converting Enzyme Inhibitor-Thiazide Diuretic Angiotensin-Receptor Blockers
Diabetes Oral hypoglycemic agents/Insulin Prescribed
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
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Number of Providers that Changed Documentation of
Clinical Practice Guidelines Using the STOP
Stroke Tool Compared to CPRS
CPG Intervention Documented CPRS Documented STOP-ST Documentation Change p value
Anti-platelet/coag 14 15 1 1.0
HTN medications 13 15 2 .50
DM medications 9 15 6 .031
DM diet counseling 8 15 7 .016
HCL/Statin agent 6 15 9 .004
Smoking cessation 13 15 2 .50
Reduce alcohol 13 15 2 .50
BMI -diet/exercise 7 15 8 .008
PI/Exercise program 12 15 3 .25
Education materials 0 15 15 .000
Self-management 0 15 15 .000
CPG clinical practice guideline, CPRS computerized patient record system, STOP-ST STOP Stroke Tool, HTN hypertension, DM diabetes, HCL high cholesterol, BMI body mass index, PI physical inactivity 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
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Whats Next ?

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

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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
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
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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