Wisconsin Star Method

Star icon representing the Wisconsin Star Method

How do you help aging adults with multiple medical problems taking multiple medications and living in difficult or even precarious situations? What do you do when they become severely anxious, discouraged, or irritable? How best to be helpful when they have idiosyncratic values or traits or signs of cognitive impairment that might interfere with their ability to respond to your efforts?

One answer is the Wisconsin Star Method.

1. Why a star?

The Wisconsin Star Method is based upon principles of heuristics, cognitive science, information visualization, ecological interface design, team functioning, and network theory. It consists of a low-tech graphical user interface: a small 5-pointed Star drawn on a clear surface (paper or whiteboard). It enables clinical data about a person to be mapped out onto a single field with five domains: medications, medical, behavioral, personal, and social.

Five pointed star with the words Medication Factors, Medical Factors, Behavioral Factors, Personal Factors, and Social Factors.

2. The 5 star arms

What’s known about the patient is recorded as 5 lists, each corresponding to an arm of the Star. The medication arm includes prescribed, over-the-counter, and “borrowed”. The medical and behavioral arms list diagnoses, functional impairments, and/or symptoms. The personal arm highlights traits, cultural values, and coping styles. The social arm covers interpersonal and environmental problems and assets, such as family support, finances, housing, and transportation.

Five pointed star with the words Medication FactorsPrescribed meds OTC meds Borrowed meds Illicit meds (if any), Medical FactorsDiagnoses Symptoms Physical impairments, Behavioral FactorsCognitive (e.g. dementia, delirium) Organic (i.e. refer medical/medication arms) Mood (e.g. depression, irritability, manic symptoms) Psychotic (e.g. delusions, hallucinations) Anxiety Substance use (e.g. caffeine, alcohol, tobacco, other substances) Somatizing; Sleep, Personal FactorsSituation awareness (e.g. knowledge, experience) Personality traits Values (e.g. personal values, cultural values) Loyalties (e.g. self, family, community, organization) Rules of thumb (e.g. formulations of how to respond to problems), Social FactorsFamily situations Finances Housing Transportation Community support Neighborhood environment Legal (e.g. problems; guardianship/protective placement)

3. The center of the star

Each piece of data listed becomes an element in a network of potentially interacting variables, with the ties between them ranging from very weak to very strong. Each arm of the Star represents a different ecological level where problems are occurring. The primary identifiable clinical challenge (e.g. ability to safely live at home) is written in the center of the Star. In some cases, the primary challenge may not be entirely clear at the onset, but gradually emerges as the situation is reviewed.

Five pointed star with the words Medication FactorsPrescribed meds OTC meds Borrowed meds Illicit meds (if any), Medical FactorsDiagnoses Symptoms Physical impairments, Behavioral FactorsCognitive (e.g. dementia, delirium) Organic (i.e. refer medical/medication arms) Mood (e.g. depression, irritability, manic symptoms) Psychotic (e.g. delusions, hallucinations) Anxiety Substance use (e.g. caffeine, alcohol, tobacco, other substances) Somatizing; Sleep, Personal FactorsSituation awareness (e.g. knowledge, experience) Personality traits Values (e.g. personal values, cultural values) Loyalties (e.g. self, family, community, organization) Rules of thumb (e.g. formulations of how to respond to problems), Social FactorsFamily situations Finances Housing Transportation Community support Neighborhood environment Legal (e.g. problems; guardianship/protective placement), and Primary Identifiable Challenge in the middle

Whether used by individuals or a team, the Star Method produces an extension of care providers’ working memory and thereby enhances their executive functioning for situation awareness and problem-solving. Writing down the elements on an external graphic surface creates a small but significant distance between the user(s) and the problems, providing both a cognitive and affective perspective. The Star Method thereby facilitates the ability to attend to multiple different interacting variables at the same time and to identify which data are most relevant. You simply go around the Star, assessing and highlighting which of the elements listed in each arm might be significantly connected with, and thus contributing to, the challenge in the middle of the Star. You can also determine what potentially relevant data might be missing (e.g. is the person able to manage the process of obtaining refills?).

The Star Method can help to ascertain which problems are multifactorial and thus to avoid the common hazard in complicated situations of coming to premature closure. It can ease shifting sets when considering pairs of problems at different levels that may be linked in linear-causal relationships (e.g. excessive salt intake, hypertension, and an inability to afford medication). Likewise, the Star Method can help to identify the traits and values and to appreciate the anxieties that may underlie puzzling behaviors (e.g. recurrent falls and worry about being seen in public as dependent on a walker). It can also be employed holistically to determine and highlight how multiple problems may be interconnected (e.g. gait instability due to Parkinson’s, falls, loss of usual means for coping, depression, social isolation, and alcohol abuse). The resulting map (the big picture with the strong and weak ties highlighted) can be viewed as the person’s unique ecosystem.