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Practical applications in stroke self-management for occupational therapists

Practical applications in stroke self-management for occupational therapists. Riqiea Kitchens, PhD, OTR, BCPR, CSRS TOTA GCED Presentation August 2019. OBJECTIVES. To describe the key components of self-management (SM)

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Practical applications in stroke self-management for occupational therapists

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  1. Practical applications in stroke self-management for occupational therapists Riqiea Kitchens, PhD, OTR, BCPR, CSRS TOTA GCED Presentation August 2019

  2. OBJECTIVES • To describe the key components of self-management (SM) • To identify role of occupational therapy in a stroke specific self-management program (SSMP) • To identify strategies to apply SM principles in group and individual treatment settings

  3. SELF-MANAGEMENT • Responsibility for the day to day management of a condition through engagement in a health promoting activity (Lorig and Holman, 2003)

  4. THEORY • Theory of self-efficacy (Bandura, 1977) • A belief in one’s ability to accomplish a certain task • Performance accomplishments • Vicarious experiences (Modeling) • Verbal persuasions • Emotional arousal

  5. SELF-MANAGEMENT • Self-management is composed of 3 tasks: • Medical management • Maintaining, changing, and creating meaningful behaviors or life roles • Emotional management

  6. SELF-MANAGEMENT PROGRAMS • Chronic Disease Self-Management Program (CDSMP) • Weekly for 6 weeks, 2.5 hours each session • Studied in general and chronic conditions including: arthritis, diabetes, chronic pain, HIV specific programs, stroke*

  7. SELF-MANAGEMENT PROGRAMS • SM Programs address 5 core skills: • Problem solving • Decision making • Finding and utilizing resources • Forming partnerships with health care providers • Making and implementing a plan of action

  8. How is this relevant to OT practice?

  9. OCCUPATIONAL THERAPY PRACTICE FRAMEWORK, 3rd EDITION Occupations (IADLs) Health management and maintenance “Developing, managing, and maintaining routines for health and wellness promotion, such as physical fitness, nutrition, decreased health risk behaviors, and medication routines (AOTA, 2014)”

  10. So, why stroke?

  11. BACKGROUND • Leading cause of long-term disability in the U.S. (American Stroke Association) • 1 in 4 persons who have a stroke will have a recurrent stroke (Roger, et. al 2012) • Persons with multiple risk factors have greater risk of recurrence stroke (Go, et. al 2013) • Estimated costs associated with stroke costs the United States an estimated $36.5 billion annually (Go, et al 2013) • Addressing lifestyle factors can reduce stroke risk (Healthy People 2020)

  12. What does the research say?



  15. ASSESSMENT IN STROKE SELF-MANAGEMENT • Health Education Impact Questionnaire • Quality of Life (QOL) Assessments • Self-report psychological assessments • Generic self-efficacy scales • Stroke Specific QOL scales • Self-management behavioral scales • Client interviews • ADL scales • SF-36 • Stroke Impact Scale • Return to Normal Living Index (RNLI) • Participation Strategies Self-Efficacy Scale • Morinsky Medication Adherence Scale (8)* • Health Promoting Lifestyle Profile II*

  16. ASSESSMENT IN STROKE SELF-MANAGEMENT A standardized assessment tool for self-management in stroke populations has not yet been established


  18. OCCUPATIONAL PROFILE - HANNAH* • 49 y/o Caucasian female • College educated • Divorced • ADL- Mod I • IADL - performed with assistance of friend • Social participation – attending weekly Bible study

  19. PROBLEM AREAS • PMH includes • Type 2 Diabetes • Morbid obesity • Physical Inactivity • Former smoker • 2 prior strokes • Short term memory deficits

  20. OT GOALS • Education on stroke risk factors • Risk factor modification • Medication adherence Example: In 6 weeks client will identify 1 personal risk factor and develop 1 strategy to modify risk factor to decrease risk of recurrent stroke.

  21. PATIENT GOAL To learn how to control diabetes to prevent another stroke

  22. OT ASSESSMENTS • Stroke Risk Score Card • Health Promoting Lifestyle Profile II (HPLP II) • Morinsky Medication Adherence Scale


  24. GROUP PROGRAM • Interdisciplinary 12 week SSMP, cohort format • Weekly 1.5 hr group sessions • 3 Modules: • Building Awareness • Building Knowledge and Making Changes • Building Carryover and Accountability

  25. Weekly log • Goal setting STG and LTG • Group activities included: problem solving and decision making, discussion of coping skills, meal planning, food labels, tailored exercise APPLYING CORE SKILLS

  26. OUTCOMES/RESULTS • 5 stroke risk factors met – High Risk • Increased HPLP II score (2.48 to 3.51) • Improved portion control and food selection • Improved control of Diabetes, decreased insulin medication


  28. OCCUPATIONAL PROFILE- MARTIN* • 63 y/o African American male • Single • PLOF: Independent • Employment: truck driver • Stroke onset: < 2 months

  29. PROBLEM AREAS • High blood pressure • Atrial fibrillation • Tobacco dependence • Diabetes Type 2 – uncontrolled • Express aphasia • Right hemiparesis and ataxia • Limited and inconsistent social support • Emotional distress

  30. OT ASSESSMENT • Standard outpatient evaluation

  31. GOALS • OT goals* • Education on personal stroke risk factors • Risk factor modification • Coping skills Example: In 4 visits Pt. will keep a daily blood sugar log to improve self monitoring of diabetic condition. • Patient goal- to return to PLOF

  32. OT INTERVENTIONS • Weekly 1:1 visits x 8 weeks 45-60 min each session • SM education integrated into rehab plan

  33. APPLYING THE CORE SKILLS • Identifying and utilizing community resources • Communicating with health care providers and caregivers • Problem solving and decision making • Goal setting and health tracking • Emotional management

  34. OUTCOMES/RESULTS • Increased self-monitoring blood sugar levels using daily log • Blood sugars decreased from 200-300s (non fasting) to ~150-180s • Dietary changes • Improved social participation • Improve communication with health care providers • Increase mood and initiative

  35. This is great, but is it billable? Absolutely!

  36. BILLING AND CODING • CPT code 97150: Therapeutic Procedure or Group (2 or more individuals)- Untimed code • CPT code 97535: Self-care/Home management training – Timed code for direct 1:1 treatment • ADL training reasonably and medically necessary to restore or improve the functioning of the patient

  37. POINTS TO CONSIDER • What type of patient is appropriate? • Desire and capability to take an active role in their own healthcare • What type of patient is not appropriate? • When do I start providing stroke self-management interventions?

  38. CONCLUSION • SSMP is beneficial for patients to improve self-efficacy and participation in their own health care in a group or individual • OT is in a unique position to meet this need and can readily incorporate these principles into clinical practice. “an attitude can’t cure chronic illness but a positive attitude and certain SM skills can make it much easier to live with”- Lorig, 2012

  39. Hannah’s Caregiver: “…After the program you thought, well, I can make a difference, I can change some things… made you realize that, you know, you can control some of this…”

  40. AcknowledgementsHarris Health System


  42. REFERENCES American Occupational Therapy Association (2014). Occupational therapy practice framework: Domain and process, 3rd edition. AJOT, 68(Supplemental 1), S1-S551. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. Cadilhac, D. A., Hoffman, S., Kilkenny, M., Lindley, R., Lalor, E., Osborne, R. H., Batterbsy, M. (2011). A phase II multicentered, single-blind, randomized, controlled trial of the stroke self-management program. Stroke, 42, 1673-1679. DOI: 10.1161/STROKEAHA.110.601997 Centers for Disease Control and Prevention (2013). Stroke Facts. Retrieved from http://www.cdc.gov/stroke/facts.htm Damush, T. M., Ofner, S., Yu, Z., Plue, L., Nicholas, G., Williams, L. S. (2011). Implementation of a stroke self-management program: A randomized controlled pilot study of veterans with stroke. Translational Behavioral Medicine, 1, 561-572. DOI: 10.1007/s13142-011-0070-y Editorial: Self-management interventions: Using an occupational lens to rethink and refocus. [Editorial]. (2013). Australian Journal of Occupational Therapy, 60, 1-2. DOI: 10.1111/1440-1630.12032

  43. REFERENCES Lee, D., Fischer, H., Zera, S., Robertson, R. Hammal, J. (2017). Examining a participation-focused stroke self-management intervention in a day rehabilitation setting. Topics in Stroke Rehabilitation. DOI:10.1080/10749357.2017.1375222 Lorig, K., Holman, H. (2003). Self-management education: history, definition, outcomes, and mechanisms. Annals of Behavioral Medicine, 26(1), 1-7. Lorig, K., Holman, H., Sobel, D., Laurent, D., Gonzalez, V., Minor, M. (2012). Living a Healthy Life with Chronic Conditions: Self-management of heart disease, arthritis, emphysema, and other physical and mental health conditions, 4th ed. Bull Publishing: Boulder, CO Parke HL, Epiphaniou E, Pearce G, Taylor SJC, Sheikh A, Griffiths CJ, et al. (2015). Self-management support interventions for stroke survivors: A systematic meta-review. PLoS ONE 10(7): e0131448. doi:10.1371/journal.pone.0131448 Pearce G, Pinnock H, Epiphaniou E, Parke HL, Heavey E, Griffiths CJ, et al. (2015). Experiences of self-management support following a stroke: A meta-review of qualitative systematic reviews. PLoS ONE 10(12): e0141803. doi:10.1371/journal. pone.0141803

  44. CONTACT ME! • E-mail: rikitche@utmb.edu • Twitter: @kitchensOT • Linked in: Riqiea Kitchens

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