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: T eaching O thers tO L ive with S troke (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.
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.
Table 3
Type and location of provider interviews and indication of the number of providers (by type) that commented on each theme, n = 44.
Indianapolis, IN
|
MD | 2 | 2 | 1 | 1 | 1 | 2 | 0 | 2 | 0 | 0 | 2 | 1 | 0 | 1 | 1 | 2 |
Res | 3 | 3 | 0 | 1 | 1 | 0 | 3 | 2 | 3 | 0 | 2 | 3 | 1 | 0 | 3 | 2 |
RN | 4 | 4 | 1 | 1 | 4 | 0 | 2 | 1 | 3 | 0 | 1 | 2 | 0 | 0 | 0 | 1 |
OT | 5 | 5 | 5 | 0 | 5 | 0 | 3 | 2 | 1 | 0 | 5 | 5 | 1 | 1 | 1 | 1 |
PT | 4 | 4 | 4 | 0 | 4 | 0 | 3 | 3 | 2 | 0 | 3 | 3 | 1 | 0 | 2 | 3 |
RT | 2 | 2 | 2 | 0 | 2 | 0 | 2 | 0 | 0 | 0 | 1 | 2 | 0 | 0 | 1 | 1 |
SW | 6 | 1 | 1 | 1 | 5 | 0 | 4 | 1 | 1 | 0 | 5 | 3 | 1 | 1 | 2 | 0 |
Total | 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 | 1 |
PA | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 |
Res | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 1 |
NP | 3 | 3 | 3 | 0 | 3 | 0 | 0 | 1 | 1 | 1 | 2 | 2 | 0 | 0 | 1 | 0 |
RN | 4 | 4 | 2 | 2 | 3 | 2 | 1 | 2 | 2 | 3 | 2 | 3 | 2 | 1 | 2 | 3 |
LVN | 2 | 2 | 0 | 0 | 2 | 1 | 1 | 2 | 0 | 0 | 1 | 1 | 0 | 0 | 1 | 1 |
OT | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 1 |
PT | 1 | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 0 | 1 | 0 | 1 | 0 | 0 | 0 | 1 |
SW | 3 | 2 | 1 | 0 | 1 | 0 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 0 | 1 |
Total | 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%) |
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.
Table 4
Summary of emergent themes from the needs assessment
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% |
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.'
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 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 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 self-management of stroke risk factors. We again trained the providers to use the prescription pad to refer veterans 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 goal-setting 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 self-management 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.