Engaging Patients and Providers in Identifying and Addressing Modifiable Risk Factors to Prevent Community-Acquired Ulcers in Veterans with SCI

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The objective of this study is to identify and begin to address the challenges of preventing community- acquired pressure ulcer (CAPrUs) in individuals living with spinal cord injury (SCI) by exploring patient, caregiver, and provider perceived risk factors. We will explore Veteran and caregiver perceptions of CAPrU risk factors using participatory action research [PAR] (photovoice, guided tour) methods and provider perspectives with individual interviews. We will compare SCI providers' perceptions of CAPrU risk factors with those of Veterans and caregivers. We will conduct a Delphi panel with expert panel members to develop, and pilot a risk assessment checklist tool for CAPrUs in an SCI outpatient clinic. Our current health care system is fragmented and well-established HAPrU prevention strategies have not been defined, translated, expanded on or adapted to the outpatient setting, nor have actions and community resources been identified to support ulcer prevention activities in the community. Our study rationale builds on the same logic underlying the U.S. Preventive Services Task Force (USPSTF) recommendations1 and the IOM report, “To Err Is Human” promote developing evidence-based decision support tools to foster meaningful patient-centered productive interactions,2,3 Productive interactions in preventing CAPrUs begin by engaging patient and provider in identifying modifiable risk factors, actions and resources. The proposed checklist is the means for identifying CAPrU risks, actions and resources to stimulate prevention activities in the community. Aims 1 & 2 focus on ensuring the checklist is patient-centered, addresses gaps between the patient and provider perspectives, and is practical and relevant for the community setting. Aim 3 will evaluate whether integrating the checklist into SCI outpatient encounters increases the provision/receipt of CAPrU preventive care and its' impact on new CAPrUs. Our proposed CAPrU checklist is the bridge for patient-provider mutual goal setting in the clinic and for driving prevention activities in the community. We will identify actions and resources needed to operationalize the existing PrU prevention guidelines to community/home settings by: 1) identifying and comparing stakeholder (patient, caregiver, provider) mental models of the challenges in addressing CAPrU risk factors, 2) convening an expert panel of stakeholders (e.g., Veterans, caregivers, providers, and national PrU prevention experts) to develop and validate a risk factor checklist tool that includes specific actions and resources needed to prevent CAPrUs, and 3) evaluating the risk factor checklist tool in an outpatient SCI clinic to determine the feasibility, acceptability, efficacy and integration into work/patient flow in an SCI outpatient clinic. Guided by the USPSTF recommendations and the Wagner Chronic Care Model for improving management of complex chronic conditions, we will create a risk assessment decision support tool to identify risks, actions and resources to promote productive interactions between patients, caregivers and providers. We will use mixed methods to create the tool and conduct a pre-post feasibility trial of that tool in an SCI outpatient clinic. [We will also examine the effect of the tool on new CAPrU incidence at all 3 study sites.] Study products include: 1) an iPad application that automates the risk factor checklist tool and supports provider documentation of risk factors and PrU preventive actions, specific actions and resources needed to prevent CAPrUs for use in the outpatient clinic; 2) a study protocol for implementing the iPad checklist tool during SCI outpatient encounters; and 3) case studies to inform Veterans and SCI providers about risk factors associated with new CAPrUs. This study will create a more consistent approach to CAPrU risk factors and preventive care to be evaluated in a future study.