Pressure Ulcer Prevention Program Using Principles of Lifestyle Redesign® PREPARED AND PRESENTED BY: JANA LA MARCA, OTD, OTR/L ALISON COGAN, MA, OTR/L JANICE KIM, OTR/L, ATP
Disclosure This presentation will describe ongoing work that is occurring under a contract between the VA Long Beach and the University of Southern California (USC). The term "Lifestyle Redesign®" is an occupational therapy intervention approach. The name was registered for quality control purposes in order to prevent other entities from using the same name to describe similar programs without the consent of USC. The following presentation will describe the elements of the intervention approach in the context of how it is being applied to the Pressure Ulcer Prevention Program currently being implemented at the VA. The presenters have no product to promote during this presentation. The presenters have no financial interest in this presentation.
Acknowledgements Paralyzed Veterans of America ® UNIVERSITY OF SOUTHERN CALIFORNIA
VA LONG BEACH
Dr. Florence Clark, PhD, OTR/L, FAOTA
Dr. Sophia Chun, MD
Dr. Erna Blanche, PhD, OTR/L, FAOTA
Maureen Jennings, DPT Maria Lim, OTR/L, ATP
Jesus Diaz, OTD, OTR/L
Kristin Pressler, MA, OTR/L
Jane Baumgarten, OTR/L
Dr. Peter Cody Hunt, PhD
Celso Delgado Jr, OTD, OTR/L
Ted Holmquist Brad Luke, RN, MN and the entire rural health care SCI team Judy Lim, BSN, RN, WCC, OMS Dr. Mark Bachman, PhD – University of California, Irvine Ryan Smith – University of California, Irvine
Overview of Presentation Background of Pressure Ulcer Prevention Program Description of how program exists in clinical practice Challenges and Successes Case studies Next steps Questions/ Discussion
Background of Pressure Ulcer Prevention Program PUPP-VA
Lifestyle Redesign® Lifestyle Redesign® is the process of infusing healthy and meaningful activities into day-to-day routines through maximizing contextual resources Preventive occupational therapy
Focused on lifestyle Activity based
Beginnings of Lifestyle Redesign® The USC Well Elderly 1 Study (1994-1997)
◦National Institutes of Health (R01 AG11810-01S1) ◦NIA, AHCPR, NCMRR ◦American Occupational Therapy Foundation ◦PI: Florence Clark, PhD, OTR/L, FAOTA ◦Purpose: To assess whether a type of preventive occupational therapy, which we now call Lifestyle Redesign®, leads to improved health and well-being in older people.
The USC Well Elderly 2 Study (2004-2008)
◦National Institute on Aging (R01 AG 021108-01A3) ◦PI: Florence Clark, PhD, OTR/L, FAOTA ◦Purposes: Examine the mediating mechanisms responsible for its positive effects; Replicate our previous results on the positive effects of the Lifestyle Redesign® intervention; Extend focus from efficacy to effectiveness
Results Well Elderly Study 1 demonstrated the efficacy of a Lifestyle Redesign® intervention (Clark et al., 1997) Well Elderly Study 2 documented the effectiveness of a Lifestyle Redesign® intervention (Clark et al., 2012) ◦ Applied to a sample of older adults at higher risk for experiencing health disparities ◦ Implemented in diverse community settings ◦ Delivered within a shorter time interval
Cost-Effective
How is Lifestyle Redesign® unique? Select personalized healthy activity options Make changes in routines Practice habits and routines
Other applications of the Lifestyle Redesign® approach Current programs at the USC Occupational Therapy Faculty Practice ◦ Weight management ◦ Diabetes control ◦ Smoking cessation
Research ◦ Pressure ulcer prevention
The USC-Rancho Pressure Ulcer Prevention Study (PUPS) NCMRR #R01HD056267 PI: Florence Clark
Aims ◦ Determine the efficacy of the intervention in preventing medically serious pressure ulcers in people with SCI ◦ Reduce pressure ulcer-related surgeries ◦ Lower medical costs ◦ Improve quality of life
(Clark et al., 2014)
RCT Intervention Manual Data-based models of pressure ulcer risk episodes (Clark et al., 2006)
Focus on prevention principles through all areas of life (Jackson et al., 2010)
Feasibility test completed prior to RCT (Blanche et al., 2011)
Inclusion of motivational interviewing approach
PUPP RCT Manual Modules
Fixed Topics
Variable (Optional) Topics
Module 1 Understanding Lifestyle and Pressure Ulcer Risk
Importance of Lifestyle Prevention Practices in Daily Life Personal Risk Profile Development of Personal Prevention Plan
Activity vs. Health; Life Events; Exercise; Nutrition & Weight; Smoking; Alcohol/Substance Abuse; Prevention Techniques; Pressure Reliefs; Pressure & Shearing; Stages of Pressure Ulcers; Response to Emerging Ulcers
Module 2 Advocacy
Attendant Care Partnering with Your Healthcare Professional Self-Advocacy Fine-Tuning of Personal Prevention Plan
Access to Health Care; Medical Treatments; Medical Administration Issues; Medical Complications; Selecting/Managing Care Attendants; Emotions, Attitudes, & Self-Efficacy; Decision Making
Module 3 Equipment and the Physical Environment
Equipment Transportation and Use of Environmental Options Further Refinement of Personal Prevention Plan
Personally Relevant Transportation Options; Overcoming Environmental Barriers; Detail on Specific Equipment Options; Living Situations; Safety In and Outside the Home
Module 4 Social Support
Social Support Family and Intimate Relationships Review of Current Use of Personal Prevention Plan
Developing Friendships; Social Networking; E-Mailing; Dealing with Family Problems; Job Issues; Social Contact and Ulcer Risk; Overcoming Loneliness
Module 5 Happiness and Personal Well-Being
Accomplishing a Sense of Well-Being Relation of Mental Health to Ulcer Risk Further Refinement of Personal Prevention Plan
Coping Strategies; Managing Pain; Depression; Stress; Risk Taking; Alcohol & Drugs; Healthy Activity; Maintaining a Positive Outlook
Module 6 Planning the Future
Successfully Anticipating Change Making Healthy Habits Permanent Review of Personal Prevention Plan
Aging Skin; Finances; Strategizing for Continued Success; Personal Organization Skills; Aging and SCI
(Clark et al., 2014)
Collaboration between USC and VA Performance improvement project
Changes required to program ◦ ◦ ◦ ◦
Focus on rural Veterans with SCI Implementation via telehealth Increased flexibility of intervention No limitations on number of sessions
Timeline Summer 2012
Project Planning
March 2013
June 2013
Version 1 of PUPPVA Manual
Version 1.1 of PUPPVA Manual
October 2012
April-June 2013
Needs Assessmen t
Therapist Training in Intervention
March-May 2014 Initial Video Filming and Editing
July 2013 Initial implementation
May 2014 Implementation of tracking database
Qualitative Needs Assessment Interviews with 8 Veterans with SCI (6 rural, 2 non-rural)
Focus group with Veterans and VA staff members
Ongoing meetings with VA occupational therapists
Different Populations PUPS RCT SAMPLE (PYATAK ET AL., 2013)
PUPP-VA
Urban
Rural
80% identify as African American or Latino
46% identify as African American or Latino
50% have income < $1000 per month
37% have income below poverty line of $24,000 per year
Limited healthcare resources
Access to VA benefits and healthcare Outdoor, high risk activities
Themes Access to care
High intensity/high risk activities
Independence
Manual Changes Access to care ◦ Less emphasis on accessing quality care since comprehensive services available through VA ◦ Inclusion of VA resources, e.g. home modification services
Emphases of intervention on high risk activities and independence ◦ Falls and Accident Prevention ◦ Nutrition and Weight Management ◦ Skin care during high risk activities
Format changes ◦ Most modules optional depending on client needs
PUPP-VA Manual Fixed Modules
Evaluation
Prevention Practices in Daily Life
Variable Modules Attendant Care Fall and Accident Prevention Managing Pain
Equipment
Mental Health and Well-Being Navigating the Home and Community Environment Nutrition and Weight Management
Successfully Anticipating Change
Self-advocacy Social Support
Re-evaluation
Pressure Ulcer Prevention in Clinical Practice STAND-ALONE PROGRAM INTEGRATED PROGRAM
Stand-Alone Program ◦ Inpatients and outpatients with history of pressure ulcers or current pressure ulcer (Stage 3 or 4) ◦ Client factors ◦ Physical, socio-emotional, financial, political, etc. ◦ Role performance ◦ In all aspects of life ◦ Examining current equipment functions and needs ◦ Custom Seating Systems ◦ Assistive technology ◦ Regaining control of modifiable lifestyle factors ◦ Directing care ◦ Diet and nutrition ◦ Building self-confidence and self-efficacy in health care management
Integrated Program Veterans have the opportunity to receive elements of the Pressure Ulcer Prevention Program through: ◦ Primary Care ◦ Education and needs assessment of Veterans with new injuries ◦ Outpatient services for other rehabilitation goals ◦ Can incorporate ways to minimize risk of pressure ulcers during periods of change or stress (i.e. illness of family member)
◦ Weight loss/ Diabetes management program to compliment PUPP-VA
Encounters 12 Veterans have participated in stand-alone program Veterans are referred from physicians or wound care team Encounters occur in: ◦ Hospital Rooms ◦ Outpatient Setting ◦ Telehealth
Questions ◦ Time use in typical day ◦ Knowledge questionnaire
Setting of SMART (Specific, Measurable, Attainable, Realistic and Timely) goals ◦ Led by Veteran
Use of Motivational Interviewing ◦ Connect behaviors that effect skin integrity to deeper reasons that may be unrelated to skin care
Professional Rewards and Benefits Bring practice into the realm of wellness and health promotion Discharge planning using tools from intervention including the life balance wheel and typical day form to plan for life after discharge
Further involvement in seating interventions – opportunities for training abound from regular inservices regarding new products and technology to courses in custom seating system and assistive technology
Professional Rewards and Benefits Share in success of Veterans who are able to sustain good skin care habits for longer periods of time and avoid lengthy hospital stays Moving away from view of patient with reoccurring pressure ulcers as non-compliant and towards holistic view of patient, seeking to use patient’s own desires and needs to influence change Emergence of weight loss/diabetes prevention program Expansion of SCI/D therapy telehealth services and interdisciplinary home evaluations
Challenges in Implementation Identifying appropriate candidates for intervention ◦ Learning who is ready for change
Learning how to use motivational interviewing effectively ◦ Practice
Finding time for phone conferences biweekly meetings and special documentation in addition to previously existing caseload and treatment plans
Many other Performance Improvement projects and changes to health care group being made at the same time as this project Lack of personnel in comparison to USC-Rancho PUPS RCT
Case Study 1 ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦
Background information Mother of 5 children High level of injury (C5 Level of Injury) Injured in motorcycle accident Slightly over 1 year since injury Completed initial rehabilitation at Long Beach VA Continued to see occupational therapy and psychology at Long Beach VA Participated in kinesiotherapy at Sepulveda VA Hospitalized with pressure ulcer at time of intervention
Case Study 1 Motivating Factors ◦ Upcoming family trip to Philippines ◦ Desire to find ways to regain control of household/ childcare ◦ Willingness to try new equipment or techniques
Barriers to Achievement ◦ Passive member of household ◦ Difficulty with acceptance of injury ◦ No plan of care in place for airplane ride or travel while in Philippines ◦ Difficulties with bladder care
Case Study 1 Treatment ◦ Occupational Therapist helped patient to link motivation for upcoming trip with healthy habit formation in order to prevent future pressure ulcers ◦ OT and Veteran planned out each step of trip from arrival at airport to accessing buildings and sites across the Philipines (Taking Charge) ◦ Veteran was paired with peer mentor with similar level of injury who traveled extensively ◦ Equipment needs assessed and met
Case Study 1 Post-Intervention Patient has not experienced any new pressure ulcers She has also taken steps to become a more active participant in her household and her role as a parent
Case Study 2 ◦ ◦ ◦ ◦ ◦
Background Information Husband Student at local university in graduate program T11, ASIA A Level of Injury secondary to spinal ischemia Repeated hospitalizations since injury occurred in 2010 Issued PWC with power seating options to help with pressure relief program
Case Study 2 MOTIVATING FACTORS
BARRIERS TO ACHIEVEMENT
Desire to return to school
External locus of control
Supportive wife
Low self-efficacy in management of pressure ulcers
Desire to socialize outside of hospital High degree of health literacy Desire to be successful with managing skin
Remorse over lack of spontaneity Trouble remembering to pressure relieve while completing school work Fear of attracting attention from peers in class or in the community
Case Study 2 Treatment ◦ Initially, Veteran would say he was interested in intervention, but actions spoke otherwise ◦ Veteran able to find easy habits to incorporate into daily routine in order to relieve pressure effectively and still maintain semblance of spontaneity ◦ Veteran decided to educate wife on how best to help him prevent pressure ulcers ◦ Self-efficacy in management of chronic conditions was emphasized
Case Study 2 Post-intervention Veteran returned to school and was able to attend class in-person and completed internship No hospital readmissions Searches out OT to share successes when visiting Long Beach for other needs
Next Directions Creating an interactive video training program and computer application to provide pressure ulcer prevention education to staff working in spoke sites Collaboration between VAMC Long Beach, USC, and UCI
3 Veterans and Caregivers were recruited to participate in training videos in own homes Filmed by professional film crew with professional equipment and editing software Interveners in videos were highly experienced members of USC-Rancho PUPS RCT team Film is edited into clips with interactive learning components
Video Example
References Blanche, E. I., Fogelberg, D., Diaz, J., Carlson, M., & Clark, F. (2011). Manualization of Occupational Therapy Interventions: Illustrations From the Pressure Ulcer Prevention Research Program. American Journal of Occupational Therapy, 65(6), 711-719. doi:10.5014/ajot.2011.001172 Clark, F. A., Azen, S., Zemke, R., Jackson, J., Carlson, M., Mandel, D., … Lipson, L. (1997). Occupational therapy for independent-living older adults: A randomized controlled trial. Journal of the American Medical Association, 278, 1321-1326. Clark, F. A., Jackson, J. M., Carlson, M., Chou, C., Cherry, B., Jordan-Marsh, M.,… Azen, S. (2012). Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: Results of the Well Elderly 2 randomized controlled trial. Journal of Epidemiology and Community Health, 66, 782-790. Clark, F. A., Jackson, J. M., Scott, M. D., Carlson, M. E., Atkins, M. S., Uhles-Tanaka, D., & Rubayi, S. (2006). Data-based models of how pressure ulcers develop in daily-living contexts of adults with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 87(11), 1516-1525. doi: 10.1016/j.apmr.2006.08.329 Clark, F. A., Pyatak, E. A., Carlson, M., Blanche, E. I., Vigen, C., Hay, J., … Azen, S. P. (2014). Implementing trials of complex interventions in community settings: The USC-Rancho Los Amigos Pressure Ulcer Prevention Studs (PUPS). Clinical Trials. Advance online publication. DOI: 10.1177/1740774514521904.
Pyatak, E. A., Blanche, E. I., Garber, S. L., Diaz, J., Blanchard, J., Florindez, L., & Clark, F. A. (2013). Conducting intervention research among underserved populations: lessons learned and recommendations for researchers. Archives of Physical Medicine and Rehabilitation, 94(6), 11901198. doi: 10.1016/j.apmr.2012.12.009 Jackson, J., Carlson, M., Rubayi, S., Scott, M. D., Atkins, M. S., Blanche, E. I., Saunders-Newton, C., Mielke, S., Wolfe, M. K., & Clark, F. A. (2010). Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury. Disability and Rehabilitation, 32(7), 567-578.
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