evidence-based health promotion, community collaboration and physical therapy
DESCRIPTION
Evidence-based health promotion, community collaboration and physical therapy. Innovative partnerships to maximize client outcomes Combined Sections Meeting Chicago, Illinois February 12, 2012. About Us. Lori Schrodt , PT, PhD. Terry Shea, PT, NCS, GCS. Margaret Kaniewski , MPH. - PowerPoint PPT PresentationTRANSCRIPT
Evidence-based health promotion, community collaboration and
physical therapy
Innovative partnerships to maximize client outcomes
Combined Sections MeetingChicago, Illinois
February 12, 2012 1
About Us
2
Lori Schrodt, PT, PhD
Margaret Kaniewski, MPH Tiffany Shubert, PT, PhD
Terry Shea, PT, NCS, GCS
Speakers
• Tiffany E. Shubert, MPT, PhD• Scientist – UNC Chapel Hill, Center for Aging and Health
• Lori A. Schrodt, PT, MS, PhD• Associate Professor - Department of Physical Therapy,
Western Carolina University • Terry Shea, PT, GCS, NCS
• Physical Therapist – U of Wisconsin Hospital & Clinics
• Margaret Kaniewski, MPH• Project Officer – CDC National Center for Injury Prevention and
Control3
Acknowledgements
• Carolinas Geriatric Education Center, Center for Aging and Health, University of North Carolina at Chapel Hill School of Medicine
• Western Carolina University• Centers for Disease Control Injury
Prevention Center• University of Wisconsin Hospital and Clinics
4
Objectives
• Define evidence-based health promotion programs
• Discuss the role of the physical therapist in evidence-based health promotion programming and creating a continuum of care
• Describe the evolution of falls prevention into a public health issue, and the role of EBHP in falls prevention efforts at the state and national level
5
Objectives
• Describe initiatives and resources at the national, state, and local level to disseminate evidence-based falls prevention programs
• Discuss effective models for physical therapy clinicians to partner with community providers to create a continuum of care
• Develop an action plan to create a continuum of care using EBHP or other partnership models into physical therapy practice
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7
It’s all about the continuum
8
PT
Discharge
Evidence–Based Programs
Initial Eval
Three + Goals
1. Understand what an EB program is, and how to complement or integrate programs into practice
2. Discuss how falls prevention has evolved into evidence-based programs, and the role of PT in these programs
3. Describe models of PT and Community Partnership to create a continuum of care
4. Provide a glimpse of the future
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WHAT IS EVIDENCE-BASED HEALTH PROMOTION
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Evidence What?
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Evidence-based Medicine
Use of current best evidence in making decisions about the care of individual patients
Evidence-based Public Health Evidence to inform public health decisions
Evidence-based Behavioral Medicine
Evidence-based interventions for health promotion and disease prevention
Evidence-based Health
Promotion
Evidence-based programs and policies adapted from behavioral sciences, public health, aging services sectors
From Dr. Marcia Ory
EBHP: Proven Programs Guarantee Outcomes
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Target Population: Those with chronic conditions
Measureable Goals: Improve outcomes, decrease utilization
Rationale: Based on behavior change principles
Benefits: Proven in randomized controlled trials
Program Structure & Timeframe: 6 wks/2.5 hr/wk
Staffing: Certification process
Facility & Equipment: Workshop space
Program Evaluation: On Stanford Website
Fidelity Checklist: Identified health measures
Evidence-Based vs. Best Practice
• Evidence-based (www.noca.org)
• Scripted program• Program tested in randomized controlled trials and
proven highly effective• Results based on if delivered as intended• Matter of Balance, Healthy Ideas, etc.
• Best practice (www.ncoa.org)
• Program based on evidence-based components• Not tested (as yet) in RCT• “Fallproof”, “Get Some Balance in Your Life”
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This really is all new!
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2001:• Develop
evidence-based models for seniors
2003-2006:• Implement a
wide-range of EBPs in disease prevention
2006-2010:• Implement one
EBP and others from defined list
2010-2012:• Implement
one type of EBPs in most states
Who is funding these things? Why?
Public Health and Clinical Practice
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Unintended Consequences When Worlds Collide!
Case Study
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Case Study
• Ms T - 70-years-old with diabetes, diabetic neuropathy, hypertension, and knee O/A
• Referral for knee pain• Therapist screens for falls risk using
STEADI tool (released in 2012, www.cdc.gov)
• “Stopping Elderly Accidents, Deaths, Injuries”
• Translation of AGS Falls Prevention Guidelines (AGS, 2011)
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STEADI Falls Risk Screen
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• Have you fallen in the past year?• Yes
• Do you feel unsteady when standing or walking?• Yes
• Are you worried about falling?• Yes
• Score of 4+ on Stay Independent Brochure
(Rubenstein, 2011)
STEADI Falls Risk Screen
• Evaluate Gait and Balance• Timed Up and Go
• 11 Seconds
• 30 Second Chair Stand• Can only do 3
• 4 Stage Balance Test• Unable to hold tandem stance for 10 seconds
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Case Study
• Evaluate and treat knee pain• Multifactorial falls risk assessment• Refer to Diabetes Self-Management
Program (DSMP)• Led by 2 former patients trained as lay leaders• Series offered monthly in-house
21
Falls Risk Assessment
• Postural hypotension • Cognitive screening• Medication screening• Functional assessment• Vision screening• Feet & Footwear• Use of mobility aids
(STEADI, 2012)
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EBHP and Falls Risk Management
• Ms T at risk for falls based on functional assessment
• Secondary referral to treat gait and balance
• Use of V-code 15.88 to justify treatment• Refer patient to Stepping On at local
senior center (Clemson, 2004)
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Case Study
• 8 weeks later• Blood sugars better managed
• Less pain
• 15 chair rises, 10 second tandem hold
• Wants to keep exercising
• Improvements in balance confidence
• Refer to YMCA to attend Tai Chi – Moving for Better Balance Program (Li, 2005; 2008)
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Injury, Falls, and Prevention
• 35% of older adults fall each year• Leading cause of unintentional death• $24 Billion (direct + indirect medical costs)• Effective programs validated• No mechanism for broad dissemination
(CDC, 2011)
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FALLS PREVENTION, EBHP, AND PHYSICAL THERAPY
The Otago Exercise Program
Stepping On
Tai Chi – Moving for Better Balance
THE CDC? Falls Prevention?
Physical Therapy, The Community, Resources for Continuity
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Hawaii
AKMT
ID
WA
CO
WY
NV
CA
NMAZ
MN
KS
TX
IA
WI
IL
KY
TN
IN OH
MI
ALMSAR
LA
GA
FL
SC
WV VA
NC
PA
VT
RI
ME
NHOR
UT
SD
ND
MO
OK
NE
NY
CTNJ
MDDE
NorthernMarianas
Guam
MA
States operating or developing Fall Prevention Coalitions (February 2012)
What is the Otago Exercise Program?
• An in-home exercise program delivered by physical therapists (Campbell, 1999)
• Tailored balance and strength program and walking plan
• Exercises are progressed
• Minimum of 7 home visits and 7 phone calls over 12 months
• Reimbursement• Medicare A + B
• Medicare B
Otago Exercise Program Schedule
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Month 1 2 3 4 5 6 7 8 9 10 11 12
Week 1 2
Home Exercise Visits
X X X X X X X
Telephone Follow-up X X X X X X X
Monitoring of Exercises Completed
X X X X X X X X X X X X
Monitoring of any Falls X X X X X X X X X X X X
Who benefits from Otago?
• Adults 80 years and older with moderate strength and balance deficits (Thomas, 2010)
• Participants should be living in the community (not institutionalized)
• Able to walk independently in home with or without a walking aid
Who Doesn’t Benefit From Otago?
• Older adults < 80 years of age• Older adults too frail to do standing exercises • Older adults who fall due to syncope, vertigo,
severely impaired vision, some neurologic conditions, or with significant cognitive impairment (Campbell, 2005)
• Older adults with mild deficits may need a more challenging program • May benefit from other evidence-based fall prevention programs
such as Tai chi: Moving for Better Balance
Evidence for Otago
• Meta-analysis (Robertson, 2002)
• 1,016 participants aged 65-97 • High risk of falling per physician assessment
• 35% reduction in falls, RR = 0.65 (0.57-0.75).• 35% reduction in fall-related injuries, RR = 0.65
(0.53-0.81)• Improved balance and strength at 6 months
“This exercise program was most effective in reducing fall-related injuries in those aged 80 and older and resulted in a higher absolute reduction in injurious falls when offered to those with a history of a previous fall.”
Pros of Otago and Clinical Practice• Buy In (evidence-based, effective falls prevention)
• Providers• Patients
• Patient Choice • Home based exercise program• Individual program
• Medicare reimbursement• Home Health Quality Initiative• Physician Quality Reporting Initiative (PQRI)
• Feedback from patients
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Cons of Otago and Clinical Practice
• Length of program (12 months)
• Models• Homebound and transition: Med A transition to
Med B delivered in the home• Not homebound: Med B delivered in the home
Cons of Otago and Clinical Practice
• Medicare reimbursement Part B• Travel for PT not covered• Special Rules for Hospitals
• Patient only seen in home if medically unable to come to the hospital
• Home Health Agencies• Best choice for seeing patient in the home• Many do not provide part B
• Phone calls not covered under Part A or B
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Otago Certification Program
• Deliver program as intended• Ensure participants perform exercises
correctly and safely • Monitor and progress• Adapt as necessary • Provide support and motivation
Want to be certified?
• Webinar certification for grantee states (Colorado, New York, Oregon)
• APTA National Meeting• Tampa, June 6-9 2012
• Bring trainings to your regions• Collaboration with state chapters to present
at state meetings• One-day workshops organized and sponsored
by state agencies
Want to be certified?
• Online training – August 2012• 60 minute interactive online training program• Partnership between CDC, UNC Center for
Geriatric Education Consortium, APTA• Links at APTA Learning Center and on CDC
Falls Dissemination page• Free until 2013 then minimal charge• CEUs available
Stepping On
• 7 two-hour weekly classes + 1 home OT visit + 1 booster class at 3 months
• Facilitated by an OT and content experts• Focus on balance and strength exercises,
improving home and community environmental safety, behavioral changes, encouraging vision screen and medication review
• Randomized Controlled Trial results 31% reduction in falls; RR = 0.69
(Clemson, 2004)
Stepping On1 – Overview, PT introduces balance and strength exercises2 – Exercises and safety3 – Exercises and home hazards4 – Vision, community safety, footwear5 – Medication management, bone health6 – Getting out and about7 – Review and plan ahead
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Stepping On• Master trainers attend 3-day leader training
• Implementation Guide• Materials• Support
• Site license need to be purchasedWisconsin Institute for Healthy Aging1414 MacArthur Road, Suite BMadison, WI [email protected]
24 Local Falls Coalitions
= Aging
= Public Health
= Health Care
Falls Prevention in Wisconsin
• 2000 Wisconsin Falls Prevention Initiative • Members: Health care practitioners, educators,
researchers, organizations serving older adults, social service professionals and staff members from the Divisions of Long Term Care and Public Health.
• Mission Statement: Reduce falls and fall-related complications and deaths among Wisconsin’s older adults through the integration of community based and medical prevention approaches
Stepping On Since 2005:
• Over 2000 older adults enrolled
• 50% reduction in falls pre-post
• PTs• Invited expert at
3 of 7 classes• 2011 19 active
PT SO leaders
Otago Exercise Program
• 6 workshops in Wisconsin 2007-2011 (241 PTs)
• Models & Issues• Home Health transition to Outpatient
• Poor transition to OP• Outpatient only• Reimbursement with Medicare A or B
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Dane County, WisconsinSafe Communities Falls Prevention Task Force
• 2006 County Falls Summit: task force formed • Broad and active representation from health care providers,
community organizations, first responders and aging network• 47 organizations including business organizations
• 2009 Madison/Dane County became the 6th US-designated community in the WHO Safe Communities America network, and the first such community in Wisconsin.
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Dane County Work Plan
• Health care provider education• Expanding availability of community-based exercise
classes to reduce falls risk• Providing Home Safety Assessments• Enhancing coordination of services between health care
organizations, community organizations, and the ageing network
• Developing and implementing a Falls Helpline via United Way 2-1-1
• Implementing a public awareness campaign to highlight the significance of falls and ways to reduce falls
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Falls Prevention Among Older Adults: An Action Plan for Wisconsin: 2010-2015
• Four main goals of the plan:• Shape systems and policies to support fall prevention
• Increase public awareness about fall prevention
• Improve fall prevention where people live
• Improve fall prevention in healthcare settings• http://www.dhs.wisconsin.gov/health/InjuryPrevention/FallPrevention/
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Western North Carolina InitiativesLori Schrodt, PT, PhDWestern Carolina University
Acknowledgements:WNC Partnership for Public Heath
Jackson County Health DepartmentWNC Fall Prevention CoalitionNC Center for Healthy Aging
Carolina Geriatric Education Consortium51
Older Adult Population
The average for NC is 12.0%.
The range is from 6.3% to 23.6%
12% or less
12.1% to 13.0%
13.1% to 14.4%
14.5% to 15.9%
More than 16%
Western NC
Western NC: Falls “Hot Spot”
North Carolina
• North Carolina Falls Prevention Coalition
Western North Carolina
• WNC Partnership for Public Health• Senior Health Initiative: What is Public
Health’s Role?• WNC Fall Prevention Coalition 55
Transyl
vania
Anson
Beaufort
Bertie
Brunswick
Camden
Carteret
Columbus
Craven
Currituck
Duplin
Edgecombe
Gaston
Gates
Greene
Halifax
Harnett
Hertford
Hoke
HydeJohnston
Jones
Lee
Lenoir
Lincoln
Martin
Moore
Nash
Northampton
Onslow
Pamlico
Pasquotank
Pender
Perquimans
Pitt
Rich
mon
dRobeson
Sampson
Scotland
Tyrrell
Union
Washington
Wayne
Wilson
Alamance
Alexander
AlleghanyAshe
Caldwell
Caswell
CatawbaChatham
Davidson
Davie
ForsythFranklinGuilford
Gran
vil le
Iredell
Person
Randolph
RockinghamStokesSurry
Vanc
e Warren
Watauga WilkesYadkin
Wake
Avery
CherokeeClay
Graham
Hende
rson
BuncombeMcDowell
Macon
Mitchell
Polk
RutherfordSwain
Madison
Haywood
Yancey
New
Hanover
Chowan
Cum
berla
nd
Mon
tgom
ery
Stanly
Mecklenburg
Cabarrus
Rowan
Cleveland
Burke
Orange
Durham
Jackson
Bladen
Dare
Asheville
Winston-Salem Raleigh
Charlotte
Falls Prevention Coalitions
Region A Health Promotion
Western NC
FP Regional
Piedmont Area
Metrolina
Guilford County Chapter of the NC FP Coalition
Eastern NC
Greensboro
NC Local and Regional Falls Prevention Coalitions
Senior Health Initiative
• Fall prevention programming Jackson County, NC• Healthy Aging 101 for health department staff and
community providers
• Awareness through local media
• Community educational sessions
• Multi-disciplinary fall risk screening clinic
• 2 Matter of Balance master trainers
• “Get Some Balance in Your Life” exercise program
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Community-Clinician Models:Fall Risk Screening Clinic
• Multi-agency partnership• Health department, senior center, hospital,
university, pharmacies
• Risk factor screening
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Fall history Gait and balanceVision Home safetyPostural hypotension FootwearMedications Mobility aids
(AGS, 2011)
Community-Clinician Models:Fall Risk Screening Clinic
• Offered 6 times a year• Referrals to physician, PT, and/or
community programs• E.g. Matter of Balance, Get Some Balance in
Your Life, Arthritis Foundation Tai Chi and Exercise Program, etc.
• Similar model now in Macon County, NC initiated by outpatient PT practice
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• Get Some Balance in Your Life• PT does screenings and pre/post testing• PT students assist with class• Two 12-wk sessions a year offered by
senior center• Improvements in balance and mobility • Very positive feedback from participants
and instructors
Community-Clinician Models:Best Practice Program
Clinical CaseEd, 85 y.o. man referred to physical therapy for rotator cuff tear
• Mild-moderate balance impairments noted• Home program for shoulder and balance
exercises• PT also suggested Get Some Balance in Your
Life program for post-discharge• Ed completed 2 sessions of the 12- week
program, positive outcomes, decreased fall risk
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Community CaseShirley, a 73 y.o. woman, attended fall risk screening clinic after seeing newspaper ad• No history of falls• Mild balance impairments noted• No other significant risk factors for falls• Currently sedentary• PT recommended a general exercise class at
the senior center before Get Some Balance in Your Life
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Role in Clinical Practice
• Continuum of care• Adjunct to therapy• Discharge planning• Community service
and visibility• Fee-for-service
programs• Host or become
trained
WNC Fall Prevention Coalition
Fall Preventi
on
Community Awareness &
Education
Provider EducationScreening & Risk Assessment
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WNC Fall Prevention Coalition
• Goal: maximize reach of a fall risk screening program• Community sites• Underserved areas
• Collaboration with NC Center for Healthy Aging
• Research Question: Will community providers be able to conduct a brief fall risk screening with fidelity?
Community-Clinician Models:Community Provider Outreach
• Provider education and training session• Knowledge and skills
• Providers conduct screening• Questions:
• In the past 12 months have you had a fall?• Do you have any difficulties with walking
or balance?• Timed Up & Go
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Community-Clinician Models:Community Provider Outreach
• Screening recommendations • Discuss results with physician• Consider participation in community-based
program if at lower risk of falls• WNC Coalition developed county-specific
resource lists for participants and providers• Rehab professionals, home safety programs,
medication screening, low vision programs, community-based fall prevention programs, etc.
Community-Clinician Models:Community Provider Outreach
Training Session
Knowledge &
Skills Assessment
Onsite Skills Assessment• Coalition arranged for 16 screening events to
be held in 7 WNC counties• Screeners and other volunteers• Marketing• Forms and equipment
Community-Clinician Models:Community Provider Outreach
Outreach• Over 300 older adults
screened• 50% underserved sites
• Positive feedback from those screened
• Positive feedback from those trained
Community Providers• Able to conduct
screenings with guidance
• Build infrastructure• Excited about
engagement and playing a role in fall prevention
Community Health and Mobility Partnership (CHAMP)
• Community-based program to improve balance and mobility and reduce falls In McDowell County, NC
• 11 organizations led by Vicki Mercer, PT, PhD from UNC• Academic institutions, health department,
EMS, social services, local hospital• Comprehensive fall risk assessments and
follow up at community sites
Community Health and Mobility Partnership (CHAMP)
• 179 participants over 2 years• 136 at increased risk for falls and provided
individualized exercise recommendations with follow up (based on Otago) and/or referrals to healthcare providers
• Exercise participants showed improved balance and strength
• Program received a 2010 Outstanding County Program Award from NC Association of County Commissioners
Where to Look for Programs and Partnership Opportunities
• Falls prevention and health promotion coalitions
• Senior and community centers• Health education and wellness centers• YMCA/YWCA and fitness centers• Local parks and recreation departments• Local and state health departments• Area Agencies on Aging• Retirement communities
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So many models, so little time
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So many models, so little time
• Chose what works best for your patients and your practice• Partner with the community
• Wellness• Evidence-based health promotion programs• Tai Chi
• Deliver a program within your practice• Otago, Stepping On, Best Practices
• Others
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Innovative Partnerships
• Connect the dots however you want!(just use EVIDENCE!)
• Wellness centers• Work with wellness staff to offer EBHP• Work with wellness staff to create referral systems for
patients to attend classes
• Recreational therapy • Educate about EBHP• Evaluate exercise classes, determine if an E-B
curriculum is appropriate
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Innovative Partnerships
• Physical therapy satellite clinics in senior centers• Potential to build the infrastructure for a
continuum• Streamline patients into exercise classes• Streamline patients into evidence-based
programs (Shubert, 2011)
• Follow patients after discharge
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…. Make it so!
• Public Health initiatives need participants• Public Health has disseminated programs
our patients need• Physical therapists need programs to
complement and enhance outcomes• We are strategically positioned to integrate
these programs into our practices and have a positive impact on patient health!
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