1. Translating Knowledge to Improve Rehabilitation for Stroke Survivors Experiencing Cognitive Impairment
Michelle Donald
Regional Education Coordinator,
Toronto Stroke Networks
Collaborators: Katelyn Jutzi, Mary Egan, Sara McEwen (Co-PI) , Beth Linkewich (Co-PI)
May 5, 2016
1st National KT Conference, Montreal
Thank you for this opportunity today to share our KT support approach to a research project in Toronto aimed at improving rehabilitation for stroke survivors with cognitive impairment.
Note: The Plenary session is called Engaging Stakeholders to Drive Change

2. Objective
To describe the development of a novel KT support plan and evaluation plan for an interprofessional stroke rehabilitation intervention.

3. Background:
Patients with cognitive impairment have difficulty gaining access to inpatient rehabilitation
Stroke rehabilitation clinicians in Toronto identified a need for better skills and knowledge to foster recovery in persons with cognitive impairments
CIHR – PHSI funding received to implement and evaluate a KT initiative to meet this need
Inpatient stroke rehabilitation teams at 5 Toronto sites will be trained in an evidence-based treatment approach called Cognitive Orientation to daily Occupational Performance (CO-OP)
3 sub-studies planned, at the levels of patient, clinician, and health system.
PHSI – Partnership for Health System Improvement – Engaging stakeholders is embedded in this grant requiring a knowledge user and researcher working together.
and Toronto Stroke Network did some research into access of inpatient rehab. We found that patients with cognitive impairment have difficulty gaining access to inpatient rehab. Best practice is to have 40% of stroke patients admitted to inpatient rehab; reality is that 26% are admitted.
-TSN also did some focus groups with clinicians and found that therapists would like to learn more about how to foster recovery in people with cognitive impairment.
We have funding through Canadian Institute for Health Research to implement and evaluate a new knowledge translation initiative to help patients with post-stroke cognitive impairment.
In this project, our stakeholders are stroke inpatient rehabilitation teams at 5 Toronto sites.
They will be trained in an evidence-based treatment approach called Cognitive Orientation to daily Occupational Performance (CO-OP). I will share with you a brief overview of this approach in a moment.

4. CO-OP?
“CO-OP is a client-centred, performance-based, problem-solving approach that enables skill acquisition through a process of strategy use and guided discovery.”
(Polatajko & Mandich, 2004)
In Ontario, tendancy for OT and PT to fall back on Bobath NDT type techniques (task specific training). Impairment focus vs. function focused.
Tendency to train individual components, e.g. strength, attention etc. rather than on the whole activity et. Dressing, cooking etc.

5. CO-OP KT CO-OP KT is the Workshop + KT Support
CO-OP involves a paradigm shift from an impairment focus approach to function based
CO-OP training workshops exist but trained clinicians do not receive implementation materials or ongoing support
Our interprofessional application of CO-OP is novel
Therefore, there is a need to develop KT support materials for this large scale implementation of the CO-OP approach
CO-OP is relatively complex approach – going into more detail is beyond the scope of the presentation but just to emphasize that it is a paradigm shift…

6. Modifed from: Graham et al. (2006) KTA Framework
Consultants:
knowledge users
clinician team
educators
community engagement specialist
Components of the KTA cycle requiring KT Intervention were identified.
The evaluation component of the project is part of the research protocol and will be described in this presentation as well. The KTA cycle can be viewed as the framework for the entire project – in the parent project, we are working at the top of the cycle.
Modifed from: Graham et al. (2006) KTA Framework

7. Adapt to Local Context CO-OP Implementation Resources Workbook
Provided to each participant at the workshop
Practical tools to help guide clinicians
Includes: case studies, FAQ, decision trees, self-reflection tools, interprofessional collaboration strategies
FAQ (supporting decisions re: time, resources, selection of patients)
The CO-OP Implementation Resources workbook is a KT intervention that addresses several of the components of the KTA cycle as the methods for learning included in this workbook are multi-modal and intended to guide the clinician throughout the 3 month support period.
Site Visits by Implementation Facilitator (IF)
Every 2 weeks for face to face trouble shooting for site specific issues
Observation of CO-OP in action by the Implementation Facilitator (IF)

8. Assess Barriers to Knowledge Use
CO-OP Implementation Resources Workbook
FAQ
Self-Reflection Tool for stroke rehabilitation providers
Barriers and Facilitators Guide
Resource for the IF to prompt identification of potential issues and solutions
The Barriers and Facilitator Guide is a resources for the IF. Tapping into knowledge, organizational, and behavioural barriers, it will be a reference for the IF to use to help the site and individual clinicians to solve issues that arise during implementation.
One such example of a barrier is clinician perception that use of the CO-OP will not lead to improved patient outcomes. There could be several underlying reasons for this that will help in problem solving. Maybe there are concerns about patient levels of frustration, or beliefs that bottom-up approaches lead to better outcomes than top-down approach. Possible suggestions for this barrier might be review CO-OP online module videos, refer to articles posted on the VCoP specific to CO-OP and stroke, designate 15 min. a week to discuss patient outcomes related to CO-OP.
Virtual Community of Practice
A TSNs secure site for stroke rehabilitation providers
CO-OP specific discussion forum with access to CO-OP trainers and opportunity to learn from and support colleagues

9. Select, Tailor, and Implement Interventions
CO-OP Implementation Resources Workbook
Case studies
CO-OP specific decision tree and implementation strategies
Examples of Interprofessional Collaboration (IPC) and process suggestions
Posters & Pocket Guides
Visual cues as reminders for how to implement CO-OP
CO-OP On-Line Learning Module
Provides videos of CO-OP in action as reference
Virtual Community of Practice

10. Example of GPDC prompt – could be pocket card or unit poster.
Tailoring to local context – this actually comes from a head and neck project and we have adapted it for stroke examples.

11. Monitor Knowledge Use CO-OP Implementation Resources Workbook
Self-reflection section for stroke rehabilitation providers to document experience with CO-OP
CO-OP specific decision tree and implementation strategies
IPC examples and process suggestions
Site Visits by Implementation Facilitator (IF)
Observe stroke rehabilitation providers doing CO-OP to improve fidelity
Implementation Journal
Two fold – us monitoring their knowledge us and encouraging self-monitoring.
A notebook provided to stroke rehabilitation providers at the workshop with request to journal experiences implementing CO-OP
This will include a self-administered CO-OP fidelity checklist

12. Sustain Knowledge Use Identification of Site Champions
Leaders in the organizations will help to sustain use of CO-OP after 3 month support period
Virtual Community of Practice
Ongoing access to other teams and CO-OP trainers post intervention
Yearly Support Meetings
Facilitated by CO-OP trainers to allow for collaboration and problem solving among the 5 facilities

13. Proposed Evaluation Plan
Evaluation Tool
Planned Timeframe
Chart Audit Interviews
6 months pre-training
Chart Audits
6 months pre-training, 1 month post-training, 6 months post-training
Self-efficacy rating tool for top-down approaches (SERTA)
Pre- and post-workshop; 1,3, 6, and 12 months post-training
CO-OP multiple choice knowledge questionnaire
Consolidation Session Audio recordings
2-3 months post-workshop
Implementation Journal
Throughout training
Chart-Stimulated Recall
2-3 months post-training
The evaluation plan for study 2 involving clinicians is quite comprehensive involving a number of evaluation methods at designated timeframes as depicted in this slide.
We will be conducting Chart Audits, self-efficacy ratings, a knowledge questionnaire, as well as using audio recordings from the consolidation day to evaluate the use of CO-OP.
In addition, the implementation journal that I spoke about earlier will be evaluated for trends, challenges and successes throughout the training and help to inform adaptation of the approach to local context.
Chart Stimulated Recall are one on one interviews with clinicians using their charts to guide the discussion of why they set the goals and treatment plans that are documented. It is a case-based interviewing
technique used to assess the process and nature of clinical decision making. Predesigned probing questions are used.
I understand that Sara and Katelyn have discussed chart audits with Kathryn Sibley – their thanks to her. So she would be one to connect with about this evaluation method specifically.

14. Where are we now?
Working on the refinement of the KT intervention materials that will be distributed to the stroke rehabilitation providers
Pre-Intervention Chart Audits are underway
CO-OP Workshop to take place in October 2016, followed by the 3 months of KT support
May 18, 2019

15. Email: michelle.donald@sunnybrook.ca
Questions?
Contact info
Michelle Donald
Phone: Ext 7426