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?
The answer is the Wisconsin STAR Method
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.
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.
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.
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 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.
- The Wisconsin STAR Method. Timothy Howell, MD, MA. 4-page PDF.
- Addressing Complexity in the Face of Scarcity: Results of the Wisconsin Geriatric Psychiatry Initiative after 7+ Years. Timothy Howell, MD, MA. 98-slide PDF.
- The Wisconsin Star Method: Understanding and Addressing Complexity in Geriatrics. Timothy Howell, MD, MA. 8-page PDF.
- Wisconsin STAR Method Template. 1-page PDF.
- Wisconsin STAR Method Patient Checklist. Timothy Howell, MD, MA. 6-page PDF.
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