Stroke Self-Management Program: Implementation Challenges

1. QUERI National Meeting 2008The Implementation of A Stroke Self-Management Program: Process Challenges Teresa Damush, Ph.D., Laurie Plue MA, Gloria Nicholas, RN, Linda S. Williams, MD VA Stroke QUERI Center, HSRD Center of Excellence on Implementing Evidence-Based Practices, Roudebush VAMC, Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN Funded by VA HSRD IIR –IMV #04-096

2. Objectives • Challenges encountered and modifications made to a small scale demonstration of a stroke self management program at 2 VA Centers (Indy & GV) • Points for Group Discussion

3. QUERI’s Six Step Process Implementation Pipeline (B Mittman) Step 1 Step C Step 2 Steps 4/5/6 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”

4. Study design System/provider intervention Indy (N = 56) System/provider intervention GV (N = 84) 28 28 42 42 Social Control Patient self-management intervention Social Control

5. Development of Stroke Self-Management Program • Formative Developmental Evaluation • Began with the Stanford Arthritis and Chronic Disease Self-Management format (Lorig et al) • Key informant survey of structure of patient education and self-management resources • Received stakeholder input and preferences • Stroke Survivors • Caregivers • Neurologists • General Internists

6. Self-Efficacy Theoretical Concepts & Program Applications • 1. Verbal Persuasions • Staff explanations • Promotion of physician and therapeutic recommendations • 2. Social Modeling/ Vicarious Experiences • Staff demonstration of all strategies and new behaviors • Peers practice behavior in group meetings and share vicarious experiences • View material of stroke patients similar to them 3. Past Achievements • Set realistic, achievable goals • Gain an understanding of the course of stroke rehabilitation and realistic expectations • Tackle one stroke risk factor at a time • 4. Reinterpretation of Sensations/physical state • Discuss symptoms and how to diminish • Distraction – Mental Imagery • Relaxation

7. Expectations after stroke – What is normal? Negative/Positive thinking Addressing Fears Another stroke Falling Having Something to do Creating a weekly routine Follow – Up Medical Visits Communication Provider caregivers Adapting/coping with disabilities-Rehabilitation Finding a buddy Meds for Mood Relaxation Distraction – Mental Imagery Move to improve Mood & Energy Following PT guide Community Resources Management of Stroke Risk Factors Stroke Self-Management Menu

8. Goal Setting Behavioral Planning Problem-solving Feedback Social Support Build Self-Efficacy

9. Intervention - RCT • Self-Management • 6 sessions • Phone • Face to face • Booster call • Fidelity measurement of session contents • Database for action plans/checklist • Social Control • 6 calls • How are you doing? • Refer ? To MD • Booster call

10. Patient Recruitment • Staff monitored admissions and received approval from neurology to approach pt • Staff introduced program during hospitalization and followed up after discharge • Initially attempted to deliver while hospitalized • Patients were overwhelmed with clinical experience • What is the best method to recruit pts? • Do pts have right to join program directly?

11. Social Marketing • What materials are used to invite patients to participate in self-management programs? • Program brochures, pictures, logos • Contents of invitation • How are these programs marketed to facility providers? • Do pt self-management programs assist providers? • Do providers value these programs?

12. Patient Functioning • Cognitive -Screen with Short Portable Mental Status Questionnaire (SPMSQ) • Dx of Dementia – pass SPMSQ then eligible • Language Functioning • National Institutes of Health (NIH) Stroke Scale How do we include patients with mild cognitive impairment? Large % GV patients

13. Patient Discharged to Rehabilitation Facility from VA • Followed patient through rehabilitation • Recruited, conduct baseline assessment and consent within 2 weeks of discharge from rehab to home ---the beginning of self care. • Randomization blocked on discharged to rehabilitation facility

14. Behavioral Action Plans • Goal setting to increase self-efficacy • Use a paper based action plan • Experienced reading and writing problems among some stroke patients • Modified action plan to a behavioral checklist

15. Secondary Stroke Prevention and Risk Factor Management • Many Risk Factors • Multiple behavior change is challenging • Facilitate pt negotiation to start with one risk factor – staff training • Challenge • Focus on one before moving on to another • When to move onto next behavior • Simultaneous preferences – realistic goals • Patient choice may not be the most pressing risk factor

16. Delivery of Intervention • Individual session vs group meeting • Sufficient number of pts for clinical group on regular schedule • In person vs telephone • Hearing or speech problems • Telehealth tools - videophones • Cell phones • Best use of personnel time to deliver • Nurse, rehab professional, social worker, other

17. Geographic Coverage –VAMC • Indy - Patients drive up to 2 hours to facility • Follow up care at CBOCs • Pt geographic mobility during the year • Snow birds, • visit relatives out of state • Gainesville – covers North Florida from Ocala to Tallahassee to South Georgia • Follow up care at CBOCs • Pt geographic mobility during the year

18. Quality Control/Fidelity: Use of Telephone Conferencing • Used Teleconference system to listen to self-management sessions at secondary site. • Patient agreed to call in and participate in the session while the quality control listened. • Worked very well = potential resource for future program delivery

19. Summary • Variation in functional status among patients with a stroke is challenging for logistical planning • Addressing multiple stroke risk factor management may be overwhelming to patients attempting to self-manage • Telehealth tools may increase reach of programs into Veteran population

20. National QUERI MeetingThe Implementation of Self-Management Programs in VA Workshop • WORKING GROUP GOALS • To share knowledge across QUERI and generate specific ideas for follow-up activities to improve QUERI methods • To brainstorm about solutions to improve QUERI processes, both internal and in collaborations with operations • To generate ideas for collaboration across QUERI groups on research projects • To generate specific ideas for collaborating with operations on implementation and implementation research • To generate specific ideas for strengthening QUERI impact on VA healthcare

21. Points of Discussion Operations Collaborations Program/Research Issues Disease Specific vs Global Program Multiple behavior change Technology Reach into Veteran population Caregivers Program fidelity • VA Personnel • Site champions • Training/Delivery of programs • Workflow integration • CPRS • Software • Patient Referrals • Self • Providers • Social Marketing