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

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

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 3

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 4

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 5

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 6

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

8. 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 8

9. WHAT IS EVIDENCE-BASED HEALTH PROMOTION 9

10. Evidence What? 10 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

11. EBHP: Proven Programs Guarantee Outcomes 11 Target Population: Those with chronic conditionsMeasureable Goals: Improve outcomes, decrease utilizationRationale: Based on behavior change principlesBenefits: Proven in randomized controlled trialsProgram Structure & Timeframe: 6 wks/2.5 hr/wkStaffing: Certification processFacility & Equipment: Workshop spaceProgram Evaluation: On Stanford WebsiteFidelity Checklist: Identified health measures

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” 12

13. This really is all new! 13

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?

15. Case Study 15

16. 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) 16

17. STEADI Falls Risk Screen 17 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)

18. 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 18

19. 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 19

20. Falls Risk Assessment Postural hypotension Cognitive screening Medication screening Functional assessment Vision screening Feet & Footwear Use of mobility aids (STEADI, 2012) 20

21. 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) 21

22. 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) 22

23. 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) 23

24. FALLS PREVENTION, EBHP, AND PHYSICAL THERAPY The Otago Exercise Program Stepping On Tai Chi – Moving for Better Balance THE CDC? Falls Prevention?

25. Physical Therapy, The Community, Resources for Continuity 25 www.ncoa.org

26. 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

27. Otago Exercise Program Schedule 27 Month123456789101112 Week12 Home Exercise Visits XXXXXXX Telephone Follow-up XXXXXXX Monitoring of Exercises Completed XXXXXXXXXXXX Monitoring of any Falls XXXXXXXXXXXX

28. 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

29. 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

30. 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.”

31. 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 31

32. 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

33. 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 33

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

35. 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

36. 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

37. 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 39

40. 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 info@wihealthyaging.org www.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 44

45. 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. 45

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 46

47. 47

48. 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/ 48

49. Western North Carolina Initiatives Lori Schrodt, PT, PhD Western Carolina University lschrodt@email.wcu.edu Acknowledgements: WNC Partnership for Public Heath Jackson County Health Department WNC Fall Prevention Coalition NC Center for Healthy Aging Carolina Geriatric Education Consortium 49

50. Older Adult Population

51. Western NC

52. Western NC: Falls “Hot Spot”

53. 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 53

54. Transylvania Anson Beaufort Bertie Brunswick Camden Carteret Columbus Craven Currituck Duplin Edgecombe Gaston Gates Greene Halifax Harnett Hertford Hoke Hyde Johnston Jones Lee Lenoir Lincoln Martin Moore Nash Northampton Onslow Pamlico Pasquotank Pender Perquimans Pitt Richmond Robeson Sampson Scot land Tyrrell Union Washington Wayne Wilson Alamance Alexander Alleghany Ashe Caldwell Caswell Catawba Chatham Davidson Davie Forsyth Franklin Guilford Granville Iredell Person Randolph Rockingham StokesSurry Vance Warren Watauga Wilkes Yadkin Wake Avery Cherokee Clay Graham Henderson Buncombe McDowell Macon Mitchell Polk Rutherford Swain Madison Haywood Yancey New Hanover Chowan Cumberland Montgomery 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

55. 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 55

56. Community-Clinician Models: Fall Risk Screening Clinic Multi-agency partnership Health department, senior center, hospital, university, pharmacies Risk factor screening 56 Fall historyGait and balance VisionHome safety Postural hypotensionFootwear MedicationsMobility aids (AGS, 2011)

57. 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 57

58. 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

59. 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, d ecreased fall risk 59

60. 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 60

61. Role in Clinical Practice Continuum of care Adjunct to therapy Discharge planning Community service and visibility Fee-for-service programs Host or become trained

62. WNC Fall Prevention Coalition Fall Prevention Community Awareness & Education Provider Education Screening & Risk Assessment 62

63. 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?

64. 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 64

65. 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.

66. 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

67. 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

68. 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

69. 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

70. 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 70

71. So many models, so little time 71

72. 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 72

73. 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 73

74. 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 74

75. …. 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! 75

76. Thank You!! Questions? Tiffany Shubert tshubert@med.unc.edu Lori Schrodt lschrodt@email.wcu.edu Terry Shea tshea@uwhealth.org 76