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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 Meeting Chicago, Illinois February 12, 2012. About Us. Lori Schrodt , PT, PhD. Terry Shea, PT, NCS, GCS. Margaret Kaniewski , MPH.

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Evidence-based health promotion, community collaboration and physical therapy

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  1. Evidence-based health promotion, community collaboration and physical therapy Innovative partnerships to maximize client outcomes Combined Sections Meeting Chicago, Illinois February 12, 2012

  2. About Us Lori Schrodt, PT, PhD Terry Shea, PT, NCS, GCS Margaret Kaniewski, MPH Tiffany Shubert, PT, PhD

  3. 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

  4. 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

  5. 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

  6. 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

  7. It’s all about the continuum Discharge Initial Eval PT Evidence–Based Programs

  8. Three + Goals • Understand what an EB program is, and how to complement or integrate programs into practice • Discuss how falls prevention has evolved into evidence-based programs, and the role of PT in these programs • Describe models of PT and Community Partnership to create a continuum of care • Provide a glimpse of the future

  9. What is Evidence-Based Health Promotion

  10. Evidence What? From Dr. Marcia Ory

  11. EBHP: Proven Programs Guarantee Outcomes

  12. 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. Who is funding these things? Why? • 2010-2012: • Implement one type of EBPs in most states • 2006-2010: • Implement one EBP and others from defined list • 2003-2006: • Implement a wide-range of EBPs in disease prevention • 2001: • Develop evidence-based models for seniors

  15. Public Health and Clinical Practice Unintended Consequences When Worlds Collide!

  16. Case Study

  17. 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)

  18. 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)

  19. 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

  20. 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)

  22. 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)

  23. 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. THE CDC? Falls Prevention? The Otago Exercise Program Stepping On falls prevention, EBHP, and Physical Therapy Tai Chi – Moving for Better Balance

  26. Physical Therapy, The Community, Resources for Continuity WA AK ME VT MT ND MN NH MA OR NY SD WI RI ID WY MI CT NJ PA IA NE DE NV OH IL IN MD UT CO WV VA CA KS MO KY NC Hawaii TN OK SC AZ NM AR MS AL GA Northern Marianas TX LA FL Guam States operating or developing Fall Prevention Coalitions (February 2012)

  27. 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

  28. Otago Exercise Program Schedule

  29. 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

  30. 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

  31. 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.”

  32. 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

  33. 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

  34. 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

  35. Otago Certification Program • Deliver program as intended • Ensure participants perform exercises correctly and safely • Monitor and progress • Adapt as necessary • Provide support and motivation

  36. 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

  37. 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

  38. 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)

  39. 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

  40. Stepping On • Master trainers attend 3-day leader training • Implementation Guide • Materials • Support • Site license need to be purchased Wisconsin Institute for Healthy Aging1414 MacArthur Road, Suite BMadison, WI 53714608-243-5690info@wihealthyaging.orgwww.wihealthyaging.org

  41. 24 Local Falls Coalitions = Aging = Public Health = Health Care

  42. 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

  43. 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

  44. 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

  45. 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.

  46. 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

  47. 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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