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

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

• 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

• 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

• 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

• 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

Initial Eval Discharge
PT
Evidence–Based Programs
7

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

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Evidence-based
Medicine
Use of current best evidence in making decisions about the care of individual patients
Evidence-based
Public Health
Evidence-based
Behavioral
Medicine
Evidence-based
Health
Promotion
Evidence to inform public health decisions
Evidence-based interventions for health promotion and disease prevention
Evidence-based programs and policies adapted from behavioral sciences, public health, aging services sectors
From Dr. Marcia Ory
10

EBHP: Proven Programs Guarantee
Outcomes
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
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• 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”
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2003-2006:
2001:
• Develop evidence-based models for seniors
• 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

15

• 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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• 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)
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• 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

• 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

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

• 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

• 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)
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• 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

THE CDC? Falls Prevention?
The Otago Exercise Program
Stepping On
Tai Chi – Moving for Better Balance

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

Month
Week
Home
Exercise
Visits
Telephone
Follow-up
Monitoring of Exercises
Completed
Monitoring of any Falls
1 2
X X
1 2
X
X
X
X
X
X
3 4 5
X
X
X
X
X
X
X
X
X
6
X
X
X
7
X
X
X
8 9 10 11 12
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
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• 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

• 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

• 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.”

• 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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• 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

• 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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• Deliver program as intended
• Ensure participants perform exercises correctly and safely
• Monitor and progress
• Adapt as necessary
• Provide support and motivation

• 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

• 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

• 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)

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

• 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

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

• 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

• 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

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

• 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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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

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
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12% or less
12.1% to 13.0%
13.1% to 14.4%
14.5% to 15.9%
More than 16%
The average for NC is 12.0%.
The range is from 6.3% to 23.6%

• North Carolina Falls Prevention
Coalition
• WNC Partnership for Public Health
• Senior Health Initiative: What is Public
Health’s Role?
• WNC Fall Prevention Coalition
53

Raleigh
Winston-Salem Greensboro
Asheville
Cherokee
Graham
Clay
Swain
Macon
Ashe
Watauga
Alleghany
Surry Stokes
Wilkes
Avery
Caldwell
Madison
Buncombe
McDowell
Burke
Catawba
Polk
Rutherford
Lincoln
Gaston
Iredell
Yadkin
Davie
Rowan
Cabarrus
Forsyth
Davidson
Stanly
Rockingham
Guilford
Randolph
Caswell
Moore
Chatham
Lee
Person
Wake
Warren
Franklin
Halifax
Northampton
Hertford
Gates
Bertie
Nash
Martin
Wilson
Pitt
Beaufort
Johnston
Greene
Harnett
Wayne
Lenoir Craven
Hoke Jones
Union Anson
Sampson
Duplin
Scot land Onslow
Carteret
Falls Prevention
Coalitions
Region A Health
Promotion
Western NC
FP Regional
Piedmont Area
Charlotte
Robeson
Bladen
Columbus
Brunswick
Pender
Metrolina
Guilford County
Chapter of the NC
FP Coalition
Eastern NC
Tyrrell
Dare
Hyde

• 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

• Multi-agency partnership
• Health department, senior center, hospital, university, pharmacies
• Risk factor screening
Fall history
Vision
Gait and balance
Home safety
Postural hypotension Footwear
Medications Mobility aids
(AGS, 2011)
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• 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

• 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

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

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
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• Continuum of care
• Adjunct to therapy
• Discharge planning
• Community service and visibility
• Fee-for-service programs
• Host or become trained

Community
Awareness
& Education
Provider
Education
Fall
Prevention
Screening &
Risk
Assessment
62

• 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?

• 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

• 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.

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

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-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

• 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

• 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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• 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

• 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

• 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

• 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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Tiffany Shubert tshubert@med.unc.edu
Lori Schrodt lschrodt@email.wcu.edu
Terry Shea tshea@uwhealth.org
76