PROJECT INNOVATION 1: COGNITIVE NUDGE

A systems intervention designed to cue providers to include healthcare proxies to compensate for cognitive difficulties or support them in other ways.

THE QUALITY OF CARE GAP

  • Persons experiencing TBI cognitive challenges require assistance with accessing, coordinating, and engaging in healthcare appointments.
  • Specifically, cognitive difficulties result in challenges such as getting to appointments, remembering symptoms, understanding care plans, and implement them to get the full treatment benefit.

  • Prior research has shown that inclusion of someone such as family or trusted friend can help improve the healthcare experience for someone with cognitive difficulties.
  • Because not all persons with cognitive difficulties have a care partner to include, best practices for working with sole individuals are also needed.

  • Healthcare setting including providers must know that a person with cognitive challenges requires a care partner be included in the appointment.
  • Because not all persons with cognitive difficulties have a care partner to include, best practices for working with sole individuals are also needed.
  • An approach to cue the healthcare setting to interact differently with someone who has TBI-related cognitive challenges is needed.

"TBI patients unfortunately forget things, they're not as compliant becasue they don't remember... You have to be cognizant of that when treating TBI patients. It's the patient population. You give them five or ten things (to do), they're probably not going to do any of them."

VA Physician

PROJECT INNOVATION: HOW ARE WE SOLVING THE PROBLEM?

"THE COGNITIVE FLAG INNOVATION"

Developing a cue that someone needs accommodations for their cognitive disability when seeking care is needed. This project's innovation includes the following objectives:

  1. Engage healthcare providers, persons with TBI, and their families to identify content, processes, and procedures to develop a cognitive nudge clinical support tool.
  2. Co-design a cognitive nudge clinical decision support tool with healthcare providers, persons with TBI, and their families.
  3. Pilot implementation and evaluate outcomes of the cognitive nudge at a major VA medical and polytrauma rehabilitation center.
Image 1

The I-HEAL Team will develop and validate a medical record flag (cognitive nudge) that will identify someone who requires cognitive accommodation because they are at risk for not remembering important healthcare information.

Image 2

The team will partner with all individuals that would be impacted or implement the cognitive nudge via stakeholder engagement activities, focus groups, and surveys to gather relevant input for designing the nudge.

Image 3

We will develop products for a toolkit to help healthcare systems implement the cognitive nudge. We will pilot the toolkit and seek future opportunities to refine for adoption across different healthcare settings.

Meet I-HEAL's First Innovation Team

Photograph of Dr. Dams-O'Connor

Kristen Dams-O’Connor, PhD

Principal Investigator

Clinical Neuropsychologist and Neurotraumatologist, Subject Matter Expert incivilian and Veteran/Service Members TBI, prognostic modeling and chronic TBI outcomes; comorbid disease management in chronic TBI; cognitive assessment and neurorehabilitation interventions; research translation.

Photograph of Dr. Silva.

Marc A. Silva, PhD

Principal Investigator

Rehabilitation Neuropsychologist, Subject Matter Expert in Veteran/Service Members TBI, chronic rehabilitation needs; health and behavioral interventions that accommodate TBI impairments; cognitive and neurobehavioral assessment; pilot study and feasibility designs.

photograph or Dr. Richardson

Risa Nakase-Richardson, PhD, FACRM, FNAN

Co-Principal Investigator

Dr Richardson has published extensively on the neurobehavioral consequences of TBI resulting in two position statements defining clinical phenotypes at risk for maladaptive behaviors and competency standards for inpatient rehabilitation teams. She developed team-based learning programs for managing maladaptive behaviors after brain injury and has mentored early career professionals in collaborative projects examining patient and healthcare system impacts of maladaptive behaviors including access to care.

Photograph of Ms. Coulter.

Jill Coulter, Lived Experience Partner

Principal Investigator

Subject Matter Expert in lived experience as a health care proxy for her spouse, a retired Navy Veteran who sustained a severe TBI in 2010; navigating military and civilian health systems, chronic care management, peer support in caregiving, disability support for those with TBI.

INDIVIDUAL ENGAGEMENT PARTNERS

I-HEAL's Individual Engagement Partners (IEP) ensure our work is relevant for healthcare settings. Each project has its own set of IEPs that engage with the I-HEAL project's team throughout the grant. Project 1's IEP are:

  1. Colleen Jakey, M.D.
  2. Steven Scott, D.O.
  3. Doug Bidelspach, Program Manager, Lead for PMNR Integration
  4. Joe Lezama, M.D., FACP, MACP
  5. Ronald Gironda, Ph.D.

I-HEAL CORE PARTNERS

  1. Dr. Rebecca Campbell-Montalvo | Data and Communcation Core
  2. Dr. Deveney Ching | Operations Core
  3. Cassandra Decker | Data and Communication Core, Operations Core
  4. Dr. Natalie Gilmore | Community Engagement Core
  5. Dr. Jessica Ryan | Data and Communcation Core

PROJECT INNOVATION 1'S INDIVIDUAL EXPERIENCE PARTNERS

Person 1

Former Hospital Administration Chief of Staff, Dr. Colleen E. Jakey, was named Chief of Staff at James. A. Haley Veterans’ Hospital in May 2018.

In this role as the Chief Medical Officer/Hospital Administrator, Dr. Jakey oversaw the medical care provided within the Tampa VA system. Dr. Jakey was responsible for the hospital organizational leadership including reviewing and updating policies and procedures related to the delivery of health care for veterans. James A. Haley Veterans’ Hospital and Clinics is one of the 5 polytrauma centers within the VA. As such, Traumatic Brain Injury care is one of the main priorities of the Tampa VA. This is considered throughout the spectrum of care provided and directly impacts the approach to care. Tampa VA, under Dr. Jakey’s leadership, fostered and expanded specialty inpatient and outpatient programs for those with TBI, from screening and diagnosis through recovery and rehabilitation.

Associate Chief of Staff of Physical Medicine and Rehabilitation. Steven G. Scott, DO, is a pioneer in the treatment of traumatic brain injuries (TBI). Dr. Scott is an originator of the U.S. Department of Veterans’ Affairs (VA) polytrauma system of care and a leading researcher into issues affecting those serving in our nation’s armed services, such as treatment and costs of combat-related blast injuries. He serves as Chief of Physical Medicine & Rehabilitation, Medical Director of the Polytrauma Rehabilitation Center, and Medical Director of the Inpatient Pain Program at James A. Haley’s Veterans’ Hospital (Haley) in Tampa, Florida. A committed educator, Dr. Scott is training new generations of physicians in polytrauma medicine. He established the first sports rehabilitation fellowship program in the United States at Mayo Clinic in 1987 and the first spinal cord injury fellowship and PM&R residency in Florida in 2001. He also holds an appointmen as Assistant Professor in the Department of Neurology and Division Director of Physical Medicine & Rehabilitation at the University of South Florida's Morsani College of Medicine in Tampa. During his distinguished career, Dr. Scott has received a Letter of Appreciation from the VA Under Secretary for Health, a Certificate of Appreciation from the State of Florida Department of Veterans Affairs, and was named the 2021 Physician of the Year, an award that is among the American Osteopathic Foundation’s highest honors. It recognizes one DO each year whose extraordinary accomplishments, integrity, commitment to service and patient health are unmatched. Dr. Scott has overseen the clinical services addressed by this program’s submission. His input will be highly valuable for maximizing acceptability of innovations addressed in the submission.

Person 2
Person 1

VA Electronic Medical Record Partner. Douglas Bidelspach is a Physical Therapist by training who serves VA National PMR Program Coordinator for Rehabilitation and Prosthetic Services in VA Central Office. He began his current role in 2005 with primary responsibilities in database development and reporting in support of planning, executing, and administering VHA system-wide rehabilitation programs and systems of care. His position also calls for collaborative oversight and development of clinical program areas that include specialized clinical services for patient populations such as stroke, amputations, and traumatic brain injury. Mr. Bidelspach is currently responsible for implementation of rehabilitation-relevant elements in the VA electronic medical record and dashboards for monitoring outcomes to inform a learning healthcare system approach in VA.

Hospital Administration Chief of Medicine. Dr. Joe Lezama is the Associate Chief of Staff for Medicine and Specialty Care at the James Haley Veterans Hospital and continues to serve in that role formerly known as “Chief of Medicine” since February 2006. He also serves as the Vice Chair for Education and Academic Affairs and the Senior Vice Chair for the Department of Internal Medicine where he is also Professor of Medicine. He is a “double Gator” having graduated from the University of Florida in 1993 for microbiology and cell science and 1997 for his medical degree. He completed his Internal Medicine residency at USF in 2000 and joined the James Haley VA and USF College of Medicine as a faculty member the day after he finished his training and he has remained there ever since. He has won over 30 teaching and patient care awards at the university, state of Florida, and national level. He was recognized as a top 10 internal medicine physician for the 2010 year by the American College of Physicians. Dr. Lezama helped to establish one of the first VA Patient Safety and Quality Improvement fellowships nearly fifteen years ago (and one of the first in the nation in any setting as well). This residency has graduated close to 20 trainees that have gone on to take leadership roles inside and outside the VA and has had numerous site visits over the years from institutions VA and non-VA with national recognition of his group from the Institute for Safe Medication Practices in 2014. Dr. Lezama also was recognized for his leadership in VHA emergency management stemming from his role as Medical Director of the Federal Coordinating Center Tampa VA for Operation Haiti Relief with recognition from the State Surgeon General for his community leadership. He was inducted into the University of Florida College of Medicine Wall of Fame in 2020 celebrating his accomplishments in Medicine in the fields of education, humanism, leadership and emergency management, and subsequently he was given the highest national recognition with the national Laureate Award by the American College of Physicians last fall.

Person 2
Person 1

Deputy Associate Chief of Staff for Mental Health and Behavioral Sciences. Ronald Gironda, Ph.D. is a clinical psychologist who has served as the Chief of Psychology and Assistant Chief of Mental Health & Behavioral Sciences Service of the James A. Haley Veteran’s since 2008. He has overseen the growth of one of the largest workforces of mental health providers for Veterans in VISN 8. Dr. Gironda has administratively overseen management of the providers impacted by many of the TBI-morbidity challenges addressed in this proposal. He served as a stakeholder in preliminary meetings to guide the focus of this submission. As a former VA Career Development Award grantee, he is familiar with the research process. His clinical expertise lies in the field of chronic pain assessment, treatment, and research. He was a member of the Chronic Pain Rehabilitation Program interdisciplinary team that was awarded the VA’s Olin Teague Award for Excellence in Rehabilitation and the American Pain Society’s Clinical Program of Excellence designation. He is a former VA RR&D Associate Investigator and Career Development awardee, and he was named the James J. Peters Scholarship recipient in 2002. More recently he has served as a Site Visitor for the Department of Veterans Affairs Office of Mental Health Operations and as the President of Association of VA Psychology Leaders. His clinical specialty, chronic pain, is highly relevant for Projects 2 and 4.

PROJECT INNOVATION "COGNITIVE NUDGE:" PROGRESS & PRODUCTS

Progress and Achievements

  • Developed a Project 1 overview presentation and focus group guide for providers treating patients with TBI that was reviewed for understanding by the Community Engagement Council’s Lived Experience Partners and Professional and Policy Partners.
  • Presented on an I-HEAL symposium at the annual meeting of the American Congress of Rehabilitation Medicine (ACRM), to disseminate information on I-HEAL P1 to the scientific and rehabilitation provider community, an interdisciplinary audience.
  • Currently executing focus groups with providers on the topic of including caregivers in appointments. Preparing to execute focus groups with caregivers of and patients with traumatic brain injuries after participating in a reciprocal engagement process with I-HEAL’s Lived Experience Partners to strengthen and refine the focus group guide.

Products Supporting the "Cognitive Nudge Innovation"

Introduction to the Cognitive Nudge Innovation: aims, methods, and people.

Partner identified best practices for attending appointments.

SOP developed on cognitive nudge and EMRs.

Guide on how to train staff to engage caregivers in appointments.

The views expressed are those of the authors and do not necessarily represent the official policy or position of the Department of Veterans Affairs or any other U.S. government agency. This work is funded by DOD CDMRP Award Number HT9425-23-1-0621 for Improving Health Care Access and Engagement for Veterans and Service Members with TBI Morbidity (I-HEAL). This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital. The administering institution for this work is the Tampa VA Research and Education Foundation.