Reflections on a System-wide, Interprofessional CO-OP Implementation Initiative: 10 Years of Collective Problem Solving in Stroke Rehabilitation

Reflections on a System-wide, Interprofessional CO-OP Implementation Initiative: 10 Years of Collective Problem Solving in Stroke Rehabilitation

This blog is provided by: Jackie Gilpin (TSN Regional Education Coordinator), Nesanet (Nes) Girma (CO-OP Champion*) and Sara McEwen (CO-OP instructor and researcher) respond to questions about the ongoing initiative and their experiences with it.

* in international contexts sometimes called ‘knowledge broker’

Context

A decade ago, a team of researchers and knowledge users implemented a knowledge translation project to train interprofessional teams working on inpatient stroke rehabilitation units in the Toronto Stroke Networks (TSN; learn more about the TSN at tostroke.com). The external funding is long gone, papers are published, and many team members have moved on to other roles. Despite that, the initiative has spread to train clinicians in acute care and outpatient/community roles, and carries on to this day. 

Implementation Model

What is the structure of the initiative as it is currently implemented?

Jackie: The TSN use a champion model to guide this initiative. One or two stroke care clinicians at each participating site are trained in the CO-OP Approach and are responsible for leading local implementation. Using a champion model ensures there are clinicians at each organization to advocate for and support the initiative. Their role includes promoting awareness of educational opportunities and resources, providing practice support, gathering feedback and building clinician engagement. The CO-OP Approach Introductory Workshop Series is offered annually for all stroke care clinicians, and supplementary workshops have been developed to meet clinician needs. We maintain open lines of communication and ensure that at least one site visit is scheduled each year with each participating program. This allows us to gain insights into the use of the approach and better understand the needs and gaps experienced by staff. We leveraged this knowledge to develop various additional resources, including:

  • Supplementary workshops, such as Maximizing CO-OP Effectiveness with Family, Care Partner and Health Care Provider Support; Strategies for Working with Persons with Complex
    Communication and Cognitive Impairments, and Considerations of an Individual’s Values
  • Tip sheets on documentation, CO-OP essential elements, and guided discovery
  • Clinician videos 

CO-OP Value Over Time

How have you seen CO-OP evolve over time within the TSN?

Jackie: Over time, we have observed a shift in the baseline level of understanding among clinicians attending the workshops. Previously, many clinicians attending had little to no familiarity with the CO-OP Approach. As a result of the dedicated efforts of champions and increased number of trained clinicians who use the approach in practice, staff members who are attending the introductory workshop have more knowledge and an increased appreciation of the approach. Over the years, it has also become easier to fill the workshop seats. We believe that part of this can be attributed to clinicians seeing value in the approach and encouraging their colleagues to sign-up. We regularly receive emails from clinicians new to the TSN asking about upcoming workshops and resources. We anticipate that as this awareness continues to grow, it will lead to even greater success in implementing the CO-OP approach across our organization.

Educating and Advocating

You are a CO-OP Champion on your acute care unit. What is involved in this role?

Nes: So far, my role as CO-OP Champion has really been educating colleagues about the existence of the CO-OP Approach and recruiting colleagues to take the courses. There has been high turnover of staff as of late so it will be important to have all interested current staff educated in the CO-OP Approach so we can use the terminology in rounds and in our reports. In addition, I have been meeting with another CO-OP champion, Lyndsey De Souza, to discuss ways to make it easier to remember to use the CO-OP Approach, and to educate our staff nurses on what CO-OP is and how to incorporate it in their daily routine.

Becoming an Active Partner

What are some of the benefits of using CO-OP in acute care?

Nes: The benefits of using the CO-OP Approach in acute care are that patients become familiar with the idea of setting their own goals and to become an active partner in problem solving around their issues. This allows patients some control over their own progress and recovery even in the acute phase of their hospital stay. The CO-OP Approach has also allowed me a framework and methodology on how to work with more chronic patients who are deemed “not ready for rehab”, “unsafe for home” and whose repatriation or placement time is extended for whatever reason. I often struggled with these patients because I did not have an approach on how to work with them. CO-OP has helped me by providing a structure in the way I approach these patients both in goal setting and providing therapy within the acute care setting. 

Guided Discovery as Speech Language Pathologist (SLP)

CO-OP has mainly been used by OTs and PTs, and there is less known about using the approach as an SLP. Can you provide your perspective on that? 

Nes: The challenge as an SLP is the innate aspiration risk that is present while SLPs assess swallowing, and the communication challenges that our patients have that necessitate our involvement in the first place.  For example, trying to incorporate the guided discovery aspect of CO-OP, where we are instructed to “ask, don’t tell” is a difficulty during an initial swallowing assessment.  I cannot refrain from prompting a patient to “swallow” quite urgently if the patient is holding food or liquid in their mouth in order for the patient to clear the food/liquid in a timely manner, thereby reducing the risk of aspiration. In the moment, then I will tell and I won’t ask for safety reasons. However, after the fact, when debriefing about the swallowing assessment and providing strategies, I will use this time to use the guided discovery methods. If the patient is alert and communicating or if there are family members present, I will then ask them questions in order to come up with safer swallow strategies. For example, rather than leaving the room and typing up the safer swallow strategies on my own, I will make the risky aspects of the patient’s swallow obvious to the patient or family and ask them what could be done to reduce risk. For a patient with a lot of residue in their weaker right side of mouth, for instance, I would ask: (a) “What do you notice is remaining in the right side of your mouth?”, (b) “How do you think we could reduce the amount remaining in your mouth?”, (c) “How could we avoid having food stuck there?”. Then I’ll write down possible safer swallow strategies such as: “Place food and liquid on the left side of the mouth”, and “Use your tongue or finger to remove residue remaining on the right side of your mouth”. This has led to a greater understanding of why these strategies are important and to a greater adherence to the instructions.

Creating Understanding

What would you say to a clinician who says they don’t have enough time to use CO-OP in acute care? 

Nes: In my experience, during communication assessments, I don’t tend to use the guided discovery methods as some of the communication assessments require use of standardized instructions and level of prompting. However, I am now understanding that the assessment portion is congruent with the dynamic performance analysis portion of CO-OP and can be used to inform guided discovery when problem solving around communication strategies that may be useful to the patient, and to teach how to complete the Goal-Plan-Do-Check worksheets for goals that could be potentially worked on later in rehab or now, in acute care, if the patient is to stay for a prolonged amount of time. The Goal-Plan-Do-Check process is rarely accomplished for a single goal let alone multiple goals within acute care due to the short stay of a typical patient. However, it has sometimes helped in completing rehab applications with information that is more meaningful to the patient and has been a way to provide hopeful care in a rather challenging period in a patient's life.  

I agree that there is minimal time during a patient’s stay in acute care to use CO-OP as patients move on so quickly to the next portion of the continuum of care. However, with multiple exposures to the CO-OP Approach and strategies, watching videos or taking CO-OP courses (e.g. refreshers), it is possible to be primed to use increasing portions of the CO-OP Approach, little by little, over time with more patients.

An Example

Can you describe a CO-OP success story?

Nes: I recently used aspects of CO-OP with a patient who had been participating minimally in her care and recovery to the point she was deemed incompetent. By using the CO-OP Approach, the patient was able to show her true interest in getting better when she identified and wrote the following goals:

  • Not drooling out of the corner (of the mouth)
  • Drinking from a straw
  • Talking more
  • Getting out of hospital

 I then used the global cognitive strategy Goal-Plan-Do-Check worksheet to address the first of these goals. This helped the family understand how to complete the worksheets for any of the other, smaller goals that the patient had.

Overall Reflection on the Process

What do you think all of this means for system-wide, interprofessional implementation of CO-OP?

Sara: The reflections from Jackie and Nes, along with my own experiences in teaching CO-OP to new groups of clinicians from the TSN each year, leave me very optimistic about the potential for system-wide use of CO-OP, by multiple disciplines, along the full continuum of a condition-specific care pathway.

We implemented CO-OP with a multi-faceted, evidence-based knowledge translation approach in five high-intensity inpatient rehabilitation units, and had good outcomes from the initiative at client,5 provider,7 and system levels.1 We also had challenges and some obvious opportunities for improvements. A focus group was conducted with the initial group of champions three months after formal research-funded support for CO-OP implementation ended. This led to a number of recommendations,3,4 many of which were incorporated into the TSN sustain and spread plans.

Now that we are a decade into the project, I see the impact of staying the course:

  • System-wide implementation of a complex intervention is possible
  • Individual clinicians and teams adapt CO-OP for their specific practice contexts

I have learned that change of this magnitude takes time, organizational support, and multi-faceted continuing professional development practices. Further, on-site clinical support, such as a champion, is important.  

Contributors

Nesanet Girma, MSc., S-LP, Reg. CASLPO
Krembil Neuroscience Program, Toronto Western Hospital, University Health Network
Adjunct Lecturer Academic Appointment, Department of Speech Language Pathology, University of Toronto

Jaclyn Gilpin, OT Reg. (Ont.)
Regional Education Coordinator, Toronto West Stroke Network, University Health Network

Sara McEwen, PhD
Regional Research and Evaluation Lead, North East Specialized Geriatric Centre, Health Sciences North

Acknowledgements

The original work was supported by a Canadian Institutes for Health Research grant, co-led by Elizabeth Linkewich. The authors would like to thank TSN Regional Education Coordinators and CO-OP champions who have been instrumental in sustaining and spreading the use of CO-OP since the research project ended.

Publications Related to This Work

  1. Linkewich E, Rios J, Allen KA, Avery L, Dawson DR, Donald M, Egan M, Hunt A, Jutzi K, McEwen S. The impact of an integrated, interprofessional knowledge translation intervention on access to inpatient rehabilitation for persons with cognitive impairment. PLoS One. 2022 Sep 1;17(9)
  2. Rios J, Linkewich E, Allen KA, Egan M, Dawson DR, Godleski M, Hunt A, Jutzi K, Quant S, McEwen SE. Lessons learned and functional outcomes following multifaceted team training in a cognitive strategy-based approach to stroke rehabilitation. JBI Evid Implement. 2022 Feb 14;20(1):33-43.
  3. Hunt AW, Allen KA, Dittmann K, Linkewich E, Donald M, Hutter J*, Patel A, McEwen S. Clinician perspectives on implementing a team-based metacognitive strategy training approach to stroke rehabilitation. J Eval Clin Pract. 2022 Apr;28(2):201-207.
  4. Allan KA, Dittmann KR, Hutter J*, Chuang C, Donald ML, Enns A, Hovanec N, Hunt AW, Kellowan RS, Linkewich EA, Patel A, Rehmtulla A, McEwen SE. Implementing a shared decision-making and cognitive strategy-based intervention: Knowledge user perspectives and recommendations. J Eval Clin Pract. 2020 April 26 (2): 575-581.
  5. Linkewich E, Avery L, Rios J, McEwen SE. Minimally clinical important differences in functional independence following a knowledge translation intervention. Arch Phys Med Rehabil. 2020 April 101 (4): 587-591. Senior Responsible Author.
  6. Jutzi KSR, Linkewich E, Hunt A, McEwen SE. Does training in a top-down treatment approach influence recorded goals and treatment plans? Can J Occup Ther. 2019 Jun 6:8417419848291. doi: 10.1177/0008417419848291.
  7. McEwen SE, Donald M, Jutzi K, Allen KA, Avery L, Dawson DR, Egan M, Dittmann K, Hunt A, Hutter J, Quant S, Rios J, Linkewich E. Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice. PLoS One. 2019 Mar 11;14(3)
  8. McEwen SE, Linkewich E, Donald M, Dawson D, Egan M, Hunt A, Quant S, Runions S. A Multi-faceted, knowledge translation approach to support persons with stroke and cognitive impairment: Evaluation protocol. Implementation Science 2015 Nov 5;10:157.
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