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Evidence-based health promotion,
community collaboration and
physical therapy
Innovative partnerships to maximize
client outcomes
Combined Sections Meeting
Chicago, Illinois
February 12, 2012
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About Us
Lori Schrodt, PT, PhD
Margaret Kaniewski, MPH
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Terry Shea, PT, NCS, GCS
Tiffany Shubert, PT, PhD
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
Control
3
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
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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
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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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It’s all about the continuum
Discharge
Initial Eval
PT
Evidence–Based Programs
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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?
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
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EBHP: Proven Programs Guarantee
Outcomes
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
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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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Who is funding these things? Why?
2001:
2003-2006:
• Implement a
wide-range of
EBPs in disease
prevention
• Develop
evidence-based
models for seniors
2006-2010:
• Implement one
EBP and others
from defined
list
2010-2012:
• Implement
one type of
EBPs in most
states
Public Health and Clinical Practice
Unintended Consequences
When Worlds Collide!
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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
• 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)
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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
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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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THE CDC? Falls Prevention?
The Otago Exercise Program
Stepping On
FALLS PREVENTION, EBHP,
AND PHYSICAL THERAPY
Tai Chi – Moving for Better Balance
Physical Therapy, The Community,
Resources for Continuity
WA
AK
ME
VT
MT
ND
MN
OR
ID
SD
NY
WI
WY
PA
IA
IL
OH
IN
CO
CA
RI
MI
NE
NV
NH MA
KS
WV VA
MO
KY
Hawaii
CT
NJ
DE
MD
NC
TN
AZ
OK
NM
SC
AR
MS
Northern
Marianas
AL
GA
TX
LA
FL
Guam
States operating or developing Fall Prevention Coalitions
(February 2012)
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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
Month
Week
Home
Exercise
Visits
Telephone
Follow-up
Monitoring
of Exercises
Completed
Monitoring
of any Falls
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2
X
X
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8
X
X
X
X
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10
11
X
X
X
12
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
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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 On
1 – Overview, PT introduces balance and
strength exercises
2 – Exercises and safety
3 – Exercises and home hazards
4 – Vision, community safety, footwear
5 – Medication management, bone health
6 – Getting out and about
7 – 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 purchased
Wisconsin Institute for Healthy Aging
1414 MacArthur Road, Suite B
Madison, WI 53714
608-243-5690
[email protected]
www.wihealthyaging.org
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, Wisconsin
Safe 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 Initiatives
Lori Schrodt, PT, PhD
Western Carolina University
[email protected]
Acknowledgements:
WNC Partnership for Public Heath
Jackson County Health Department
WNC Fall Prevention Coalition
NC Center for Healthy Aging
Carolina Geriatric Education Consortium
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Older Adult Population
12% or less
12.1% to 13.0%
13.1% to 14.4%
14.5% to 15.9%
The average for NC is 12.0%.
More than 16%
The range is from 6.3% to 23.6%
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
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NC Local and Regional Falls
Prevention Coalitions
Winston-Salem
Asheville
Raleigh
Greensboro
Alleghany
Ashe
Surry
Stokes
Rockingham
Northampton
Warren
Caswell
Gates
Person
Hertford
Watauga
Halifax
Wilkes
Davie
Madison
Buncombe
Iredell
McDowell
Swain
Graham
Polk
Lincoln
Nash
Martin
Chatham
Randolph
Catawba
Bertie
Franklin
Wake
Davidson
Burke
Rutherford
Guilford
Durham
Caldwell
Orange
Forsyth
Alamance
Yadkin
Avery
Wilson
Rowan
Pitt
Harnett
Stanly
Gaston
Johnston
Lee
Cabarrus
Tyrrell
Beaufort
Hyde
Greene
Wayne
Moore
Lenoir
Craven
Macon
Cherokee
Clay
Union
Falls Prevention
Coalitions
Hoke
Anson
Jones
Sampson
Duplin
Scot
land
Onslow
Robeson
Region A Health
Promotion
Western NC
Charlotte
Bladen
Pender
Columbus
FP Regional
Brunswick
Piedmont Area
Metrolina
Guilford County
Chapter of the NC
FP Coalition
Eastern NC
Carteret
Dare
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
Fall history
Vision
Postural hypotension
Medications
Gait and balance
Home safety
Footwear
Mobility aids
(AGS, 2011)
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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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Community-Clinician Models:
Best Practice Program
• 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
Clinical Case
Ed, 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 Case
Shirley, 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
Provider
Education
Community
Awareness
& Education
Screening &
Risk
Assessment
Fall
Prevention
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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
Community Providers
• Able to conduct
screenings with
guidance
• 50% underserved sites
• Build infrastructure
• Positive feedback
• Excited about
from those screened
engagement and
• Positive feedback
playing
a
role
in
fall
from those trained
prevention
• Over 300 older adults
screened
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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Thank You!!
Questions?
Tiffany Shubert
[email protected]
Lori Schrodt
[email protected]
Terry Shea
[email protected]
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