Implementing Evidenced-Based Programs

1. Implementing Evidenced-BasedPrograms Lindsey Myers, MPH Injury, Suicide and Violence Prevention Branch Colorado Department of Public Health and Environment

2. Discussion Topics

3. What are Evidence-based Programs? Slide adapted from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)

4. Why use Evidence-based or Best Practices? • Spend limited resources efficiently • Funders require it • Agencies want proven results • Implementers like “packaged” programs • Participants want programs that work • Easier to spread the adoption of programs

5. The Evidence-based PublicHealth Framework Slide adopted from presentation by Ross Brownson, PhD (2011)

6. Identify the Problem: Older Adult Falls Prevention • Falls are the leading cause of injury death among Coloradans ages 65 and older. • Falls are also the leading cause of injury hospitalization for Coloradans age 65 and older. • Each year, the hospitalization charges for older adults hospitalized for fall-related injuries in Colorado total more than $391 million.

7. The Evidence-based PublicHealth Framework Slide adopted from presentation by Ross Brownson, PhD (2011)

8. Types of Evidence-based Programs Packaged Programs Guidelines

9. Packaged programs Pros Cons • Shelf ready • Often has implementation guidelines • May not require extensive evaluation • Proven track record helps with funders • Technical support often available • Level of evidence may not be clear • Expenses due to licenses and material costs • Limited flexibility • Not always a good fit • May conflict with other existing programs

10. Guideline-based Pros Cons • Based on evaluated programs • Often provides guidelines on key elements • Adaptable to local situation • Technical support may be available • Not all programs are evaluated at the level of RCT • Key elements are not always clarified • Time/effort/skills need to design the actual program • Needs more rigorous evaluation

11. Evidence-based policies • May be able to prove laws lead to positive behavior or positive outcomes • Few evaluation studies for policy strategies; emerging science • Not always easy/possible to evaluate

12. Evidence-based Programs for Older Adult Falls Prevention • Centers for Disease Control and Prevention http://www.cdc.gov/HomeandRecreationalSafety/Falls/pubs.html • National Council on Aging http://www.ncoa.org/improve-health/center-for-healthy-aging/where-to-find-evidence-based.html • Administration On Aging http://www.aoa.gov/AoARoot/AoA_Programs/HPW/Title_IIID/index.aspx

13. Compendium of Effective Fall Interventions • Provide public health practitioners and others with detailed information about rigorously-tested, effective interventions

14. The Evidence-based PublicHealth Framework Slide adopted from presentation by Ross Brownson, PhD (2011)

15. Intervention Priority Considerations • Data • Momentum • Political Will • Funding • Partner Priorities • Availability of evidence-based programs

16. Deciding which program is best for your community? • Community readiness • Goal alignment • Capacity to deliver programs • Target audience • Ability to implement • Ability to sustain • Appropriate approach (e.g. individual vs. group)

17. Choosing an intervention Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)

18. Selecting EB Falls Programs in Colorado • Colorado Injury Prevention Winnable Battle • By 2016, decrease the rate of fall-related hospitalization among adults ages 65 and older in Colorado by 10 percent (from 1818/100,000 to 1636/100,000) • CDC Core VIPP Falls Component FOA • Tri-County Health Department Colorado Trust Grant • Falls Prevention Network • State Unit on Aging Matter of Balance Program

19. Core VIPP Falls Component Stepping On Fall Prevention Program STEADI Toolkit (Clinical Integration) TaiChi Moving for Better Balance Otago Exercise Program Policy Changes at Multiple Levels (Local, organizational, reimbursement, legislation)

20. The Evidence-based PublicHealth Framework Slide adopted from presentation by Ross Brownson, PhD (2011)

21. Translation of EBP to Practice Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)

22. Translation of EBP to Practice Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)

23. Build in Sustainability from the Beginning Elements of a sustainable infrastructure and delivery system Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)

24. Stepping On • Group class designed to prevent falls • Exercise and progression of exercise is key • Seven weekly 2 hour program sessions • Led by health professional • Access to team of experts that are guest presenters (PT, pharmacist, community safety expert) • Evidence: 30% reduction in falls

25. Stepping On- Pros • Training and implementation assistance available • Evidence-based makes it easy to sell to partners • Technical assistance available • Key elements/requirements are spelled out

26. Stepping On- Challenges • Training and implementation requirements are a significant expense • Key elements requirements are not so easy (Led by health professional; access to specific guest presenters (PT, pharmacist, community safety expert) • Overlapping niche with Matter of Balance

27. Colorado Approach to Stepping On • Build infrastructure within hospital systems • Access to professional disciplines required for program • Locating programs where there are fewer Matter of Balance programs • Ability to spread across the state • Build sustainable training infrastructure • Consortium for Older Adult Wellness Training Academy • Train Colorado-based master trainers • Master trainers conduct fidelity checks per program guidelines • Support trainers by supplying weights as needed • Require evaluation data to be collected from the beginning • Help promote Matter of Balance

28. Tai Chi: Moving for Better Balance • Group exercise program • Focused on increasing balance and physical function • One hour classes delivered by an instructor • Total program time: 36 hours over 12 weeks • For older adults aged 60 and older, who can walk easily with or without assistive devices • Evidence: 55% reduction of fall risk

29. Tai Chi: Moving for Better Balance –Pros • Easy to sell the program to partners • Effectiveness evaluation supports maintaining the key elements of the program (program dose, reach and instructor training) • YMCA has funding to develop complementary program • Training available • Implementation Guide and technical support available • Outcome evaluation can be manageable

30. Tai Chi: Moving for Better Balance - Challenges • Time and money needed to develop infrastructure • Instructor prerequisites not always easy to meet • Expensive to develop local training program • Required schedule does not always fit into existing organizations (Parks and Rec like drop-in classes for < 12 weeks) • Not clear how to integrate with other established Tai Chi classes

31. Colorado Approach to Tai Chi: Moving for Better Balance • Bring master trainer from Oregon • Work with the YMCA training structure • Pay for instructor training • Train on evaluation data collection from the beginning • Allow instructors to charge for classes • Build relationships with senior centers, churches, and rec centers • Use previous experience to inform class recruitment • Developing: Colorado-based master trainer, fidelity plan, instructor quality check system

32. Otago Exercise Program • One-on-one exercise program delivered by Physical Therapist • 7 home visits and 7 phone calls over a year • In home exercises and walking plan (Med A and B) • For older adults that live at home, with or without a walking aid • Most effective for age 80+ or those that have fallen with moderate to severe strength and balance impairments • Evidence: 35% reduction in falls

33. Otago–Pros • Delivered by trained Physical Therapists • 2-hour webinar-based training for PTs available • Built-in reimbursement strategy • Reaches older adults that may not access community classes • Most effective for age 80+ or those that have fallen in the last year, with moderate to severe strength and balance impairments

34. Otago- Challenges • Medicare only covers home-based physical therapy • Under Med A when provided through a home health agency and patient meets homebound criteria • Under Med B if provided by a PT not affiliated with a hospital • May need to facilitate Med A and B partnerships • Medicare Advantage and supplemental insurance carriers typically follow what is covered by Medicare • Possibly difficult to assess fidelity and track which PTs are using Otago with their patients

35. Colorado Approach to Otago • Work with home health agencies • Start with home health agencies that are Medicare Part A and Part B providers • Pilot test the transition from Medicare Part A and Part B to provide guidance to other PTs • Advertise the availability of the web-based Otago training • Incorporate evaluation data collection from the beginning • Partner with physical therapy school

36. Evidence-Based Clinical Guidelines The STEADI Tool Kit is Based on American Geriatric Society (AGS) and British Geriatric Society (BGS) clinical guideline in addition to input from healthcare providers AGS, Clinical Practice Guidelines, 2010

37. STEADI • Preventing Falls in Older Patients: A Provider Toolkit • Provider resources • Training materials • Assessment tools • Patient education

38. STEADI Implementation Pros • Tool Kit based on strong clinical guidelines and provider input • Evidence-based strategies for interacting with clinical care around public health issues • Tobacco • Obesity • Research from Tinetti et al provides implementation guidance • Technical assistance available • HealthTeam Works’ experience working with providers in target area on other health issues

39. STEADI Implementation Challenges • Do not have adequate resources to implement program in the same way Tinetti et al did • Evidence-based tools may not be practical and easy to apply in the primary care setting • Lack electronic tools • May not have the optimal space to perform the TUG in the practice setting, etc • Low levels of staff participation can hinder success • Algorithms are still complex, requires multiple steps and a lot of time. • Every primary care practice is different.  What works for one may not work for others. • Determining what changes have occurred and sustaining those changes in a real-world settings is difficult.

40. Colorado Approach to STEADI • Reach 66% of PCP’s (Family/General/Internal Medicine) in Adams and Arapahoe counties • Contract with HealthTeam Works • Engage practices using academic detailing • Provide STEADI, a comprehensive toolkit to help healthcare providers incorporate fall risk assessment and proven interventions into their clinical practice • Explore adapting the STEADI Tool Kit to be used in electronic medical records *Arapahoe county data consolidated from Peregrine and Colorado Medical Society. Adams county extracted from Peregrine and estimated based on assumption that 1/3 of physicians do not accept or limit # of Medicare patients.

41. Putting It All Together

42. The Evidence-based PublicHealth Framework Slide adopted from presentation by Ross Brownson, PhD (2011)

43. Pilot and Evaluate Slide from presentation by Marcia Ory, PhD, MPH and Ashley Wilson, MPH, (2012)

44. Resources for Implementation Science • National Implementation Research Network: http://nirn.fpg.unc.edu/ • The Community Tool Box : http://ctb.ku.edu

45. Conclusion • There are different types of evidence-based programs, each with their own set of implementation challenges • Successful implementation of an evidence based program takes careful planning • Think about evaluation, fidelity and sustainability from the beginning • Partnerships are key to success • External factors outside the project can contribute or hinder success

46. THANK YOU! Contact Information: Lindsey Myers 303-692-2589 lindsey.myers@state.co.us