evidence-based health promotion, community collaboration and physical therapy

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

6

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?

11

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”

13

This really is all new!

14

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

16

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)

24

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)

25

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 53714608-243-5690info@wihealthyaging.orgwww.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, 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

lschrodt@email.wcu.edu

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

65

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

76

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

tshubert@med.unc.eduLori Schrodt

lschrodt@email.wcu.eduTerry Shea

tshea@uwhealth.org

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