1. RAMS, REx & REPS! SUSIE DINAN-YOUNG & SARA WICEBLOOM LLT TUTOR DAY NOV 2008

2. RISK ASSESSMENT AND MANAGEMENT STRATEGY RISK ASSESSMENT AND MANAGEMENT STRATEGY THE EXERCISE REFERRAL PROCESS & THE REGISTER OF EXERCISE PROFESSIONALS

3. THE EXERCISE REFERRAL PROCESS & Risk Assessment & Management Strategy Community Diagnosis Prioritise Problems Detailed Problem Analysis Risk Assess,Stratify & Refer Patients for exercise Pre Exercise & Risk Assessment, assess venue,transport,exercise… Re-Assessment NHS National Quality Assurance Framework 2001, Gagaro,Dinan Lenihan, Iliffe Community Practitioner 2000 Exercise & Risk Assessment, venue,transport,exercises,instrs… QA Review :GP/Ex Instructor/Patient Evaluation Evaluation,External Review & Strategy Review Prioritise Problems RAM Policy &Strategy

4. RECOMMENDATION & REFERRAL Recommendation Receptive, motivated, self directed Health needs not requiring tailored exercise Referral Needs help with motivation, interpretation, supervision, monitoring Needs help with choice & progression of FITT  specific health and functional outcomes Needs tailored exercise NHS National Quality Assurance Framework 2001

5. RiSK STRATIFICATION For EXERCISE Not a single rating(multipathology) Not a one off rating: review Risk of acute event Risk of developing/aggravating/worsening a specific condition over time Ensure patient data is current Match expertise and experience to need Refer on if not competent Extrinsic risk factors crucial

6. RiSK STRATIFICATION For EXERCISE The patient The environment The professional The evidence & best practice base The systems,protocols & proceedures The support systems

7. RiSK STRATIFICATION For EXERCISE Accidents DO happen: Lessons are learnt 3 CASE Studies 2008 All 3 patients were female & 75+ All 3 sustained Hip # 1 also sustained a wrist # and later died 1 in a PSI session;1 getting into the provided transport,1 in a PSI exit route class

8. RiSK STRATIFICATION For EXERCISE Accidents DO happen: Lessons are learnt CS 1 PSI session Qualified PSIs PSI in –service training top ups +CPD QA System of PSI instructor/content Evaluation(diluted FaME model:register & patient satisfaction only) NQAF Ex Referral Systems but not fully adapted for PSI No RAMS

9. RiSK STRATIFICATION For EXERCISE Accidents DO happen: Lessons are learnt CS 2 PSI session Qualified PSIs PSI in-service training top ups +CPD QA System of PSI instructor/content Evaluation(FaME model:register,TUAG,180 Turn & patient satisfaction) NQAF Ex Referral Systems adapted for PSI RAMS followed but not published

10. RiSK STRATIFICATION For EXERCISE Accidents DO happen: Lessons are learnt CS 3 PSI Exit route multi-pathology session Qualified PSI CPD but no PSI in-service training top ups No QA System of PSI instructor/content Evaluation(register & patient satisfaction only) NQAF Exercise Referral Systems but not adapted for PSI No RAMS

11. A SERVICE CONTINUUM REFERRAL SENIORS EXERCISE Community Based: Advanced Exercise Instructor Special Populations SPECIALIST RESTORATIVE EXERCISE Community Based: Advanced Exercise Instructor Special Populations+++ Led CHAIR BASED EXERCISE Community based: Advanced Exercise Instructor Special Populations+++; Chair Exercise Leaders Led REHABILITATION EXERCISE Hospital Based: Physiotherapy Led Pre-Exercise Assessment

12. Health & Safety Concious Exercise Process RAMS Policy & Strategy Inclusion criteria Risk stratification criteria Pre & ongoing assessment Referral systems & tools Specialist qualifications Competence & risk match Progressive evidence based, tailored exercise Environment/Equipment match Quality assured Evaluated outcomes, internal & external systems review Partnership

13. Service continuum Quality Assured exit routes Interdisciplinary/interagency partners Inductions in health settings Accessible venues Elder friendly transport Sustainable services EXERCISE FOR FRAILER OLDER PEOPLE also

14. SPECIALIST EXERCISE Exercise referral works as a therapeutic intervention for preventing falls and improving function and quality of life in 75+ older patients in general practice. ; Gagaro,Dinan Lenihan, Iliffe Community Practitioner 2000Skelton,Dinan,Campbell,Rutherford Age and Ageing 2005;

15. BEST BUY ‘I am prepared to pay but I’d prefer it on the NHS as I can be sure its safe and it works then’