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Second Invitational Continuing Education Conference Community-Based Prevention and Management of Cardiovascular and Other Chronic Diseases among Caribbean Elderly: A Focus on Nursing Leadership

WORKSHOP SESSION IVCornerstones of Policy

Development and Implementation

Bougainvillea Room

Cornerstones of Policy Development and Implementation

Pamela Duncan PhD, PT, FAPTADuke University

GenerateEvidence viaResearch

Synthesize the evidence

DevelopEvidenceBasedAlgorithm

Apply &EvaluateAlgorithm

Levels:Patient ProviderCommunity

Community: Support & sustain PA plans

Providers:Skill setTime

Patients:CapabilitiesCircumstances Preferences

Adapted from The Path from the Generation of Evidence to the Application of Evidence (Haynes and Haines, 1998, BMJ)

Translation to Practice

Guidelines

Research on falls prevention & exercise interventions

• Science is Complicated- Clinical Practice and Implementation More Complicated

Real-World Implementation:The influence of content, context, and process

Implementation

ProcessBehavior change strategies

• client motivation/behavior• provider practices

Systemic processes• supervisory practices• quality improvement

Engagement• Patient, provider,

community exercise and aging programs

Content• Evidence development

& testing

• Evidence interpretation & packaging

Adapted from Pettigrew et al, 1992 by Chambers, Ringeisen, Hoagwood & Patel, 2002

ContextExternal:

• Political and Professional

• Economic (e.g., reimbursement)

• Social

Internal: •Org culture & structure•Practice setting characteristics•Local stakeholders (e.g., attitudes and behaviors)

Example from Stroke Rehabilitation

We are establishing the science of rehabilitation and recovery

Effects of rehabilitative training on motor maps

from Nudo, et al., Science, 1996

Numerous Resources for Evidence

• Canadian Stroke Network: http://www.canadianstrokenetwork.ca/

• a) StrokEngine- http://www.medicine.mcgill.ca/Strokengine/

• b)Evidenced Based Review of Stroke Rehabilitation: http://www.ebrsr.com/

• c) SCORE Recommendations- (from Canadian Stroke Network)

• Cochrane Reviews

• PeDRO- Physiotherapy Evidence Database: (The Consumer Perspective-and Professional Perspective

Health Condition(disorder/disease)

Impairment Activity Participation

Contextual FactorsA. EnvironmentalB. Personal

A Revised Conceptual ModelFor PRACTICE

CapacitySkill

Motivation

Accelerated Skill

Acquisition Program (ASAP)

)

WE ARE ESTABLISHING THE RULES of PRACTICE

• WE ARE EVALUATING THESE RULES-– ICARE

• IT Also ALL ABOUT THE DOSING

What are the exercise parameters that ensure training intensity?

• Dose-response: – Frequency – number of training sessions in a week– Intensity – within session attributes

• time in activity • level of activity

– energy expenditure• progression

– Duration of training – total number of training sessions

IT IS ALSO ABOUT THE TIMINGand Severity OF THE

INTERVENTION

• Acute• Sub acute• Chronic

• MILD , Moderate, Severe

• “Neurological Diseases are COMPLEX– AND in FACT MAY NOT BE neurological..

– THE BRAIN IS NECESSARY BUT NOT SUFFICIENT

– Example: Stroke

Stroke is Complex

• Multiple Systems and Multiple Providers

• Scope of Problems and Co-morbidities Are Broad

Stroke Is Complex and It is a Chronic Disease!

• Recovery is projected across months

• In chronic stroke with aggressive treatments and in “select” patients may enhance recovery

• Post-acute stroke is also about re-stroke, functional decline, medical co-morbidities and intervening co-morbidities

Walking/Balance

Mobility Limitation(Sudden Onset)

PT

Age in Years

Current Model

Walking/Balance

Mobility Limitation(Sudden Onset)

PT

Age in Years

Actual Model

Whitson et al: JAGS 2006

• Increase fractures rates in FRG 4-7 ..first year

Kaplan-Meier Results: Time to first fracture

0.9

1.0

TIME TO FIRST FRACTURE (years)

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0

4.7%

2.7%

Estimated 1-Year Fracture Rate: 2.7% (95% CI 2.3-3.1%)Estimated 2-Year Fracture Rate: 4.7% (95% CI 4.1-5.3%)

Results: Total FIM Score and Fracture Risk after Stroke

0.90

0.91

0.92

0.93

0.94

0.95

0.96

0.97

0.98

0.99

1.00

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0

Time to first fracture (years)

Discharge FIM Score <54

Discharge FIM Score >90

Discharge FIM Score 54-90

Falls in Leaps N= 284Rankin 2-4, living in community

348 Falls/144 individuals71 Multiple FallersSerious Falls 22/18 individuals

18 Fractures

Range of Steps Taken 2 months Post Stroke (Individuals independently walking but <.8m/sec

from the Leaps Trial)

Exercise Tolerance Test @ 2 months post-stroke

0

1

2

3

4

5

Moderate Severe

Est

imat

ed P

eak

METS

3.7*3.3

Voluntary Fatigue

Cadence < 40 rpm

HTNBorg > 18

90% THR

Dyspnea

OtherS-T Segment Depression

31%

8%

1% 1%

22%

16%

1%

20%

51% of ETT’s terminated secondary to voluntary or involuntary fatigue

Ambulatory individuals are de-conditioned at just 2 months post-stroke

2 months post stroke individuals discharged home ambulatory

• They do not walk much

• They have limited aerobic capacity

Evidence-Based Recommendations for –Post Acute Care

AHA/ VA Post Acute Care GuidelinesCanadian Stroke Care Royal College of Physicians

• “Evidence- Based Practice”– Science– Conceptual Models– Evidence Based Guidelines– Outcomes

So What’s the PROBLEM?

• Science is complicated ,, clinical practice more complicated..

“How difficult is the decision making process…!!!”

So What’s the PROBLEM?

• Science is complicated ,, clinical practice more complicated..

Roberto Gatti, Milan“…

2901 articles- Big Reading Assigment

Salbach et al., 2007

Challenges of Rehabilitation Practice

• Limited intensity, frequency and duration

• Tremendous Variability in Practice/Techniques

• Very little active time during physical therapy sessions and limited progression

• Lack of harmonization of outcome measures

Challenges

• Fragmented Care-– SILOS- acute, rehabilitation, home, community

Community Wellness Programs

• After discharge from formal rehabilitation, walking deficits remain so availability of accessible community-based wellness programs are essential

• There exists a current need for these to be established internationally

• Example:

•EMPOLI- Community of PHYSIOTHERAPISTS AND COMMUNITY PROGRAM

•

Empoli Italy

• Geriatrician , ( Empoli Helath District- Manages Community Based Programs and Rehabilitation

• Develop Best Practice Models with His Rehab Provider

• Established Community Based Programs• Established clinically relevant data bases-

Measured the Outcomes• Support of Italian Health Ministry

APA PROJECT:Start: 10.12.2003Courses: 251Regular attendance >4200

Coordination CenterLower Limbs in Water (35)

Stroke (29)

Parkinson (10)FP & Chronic Back Pain (177)

Fucecchio

S. Croce S.A.

Castelfranco

Montopoli

S. Miniato

Gambassi

Montaione

Montelupo

Castelfiorentino

Empoli

Montespertoli

Certaldo

Capraia e Limite

Cerreto Guidi Vinci

APA in ASL 11 - Tuscany

Community settingsMultiple providers (no-profit and profit)

Low cost covered by the participants

0

1

2

3

4

Baseline 6 Months Baseline 6 Months

scor

e

0

1

2

3

4

Baseline 6 Months Baseline 6 Months

scor

e

0

2

4

6

8

10

12

Baseline 6 Months Baseline 6 Months

scor

e

APA group

Control group

Preliminary study - Short Physical Performance Battery

0

4

Baseline 6 Months Baseline 6 Months

scor

e

(Groups: NS, Phases: NS, G*P: P<0.0001) (Groups: 0,029, Phases: NS, G*P: NS)

(Groups: NS, Phases: NS, G*P: P<0.0001) (Groups: NS, Phases: NS, G*P: P<0.0001)

Gait Repeated chair standing

Balance Summary performance score

* t – test, p < 0.016, T0-T6 e T0-T12

No differences between T6 and T12

0369

121518

Baseline 6 Months 12 Months

* *

Hamilton Depression Scale – 1 year follow upIncluded only individuals withdepressive symptoms (HDS >8)

• Engaged the Community in AFA Day- To Celebrate the Successes

Walking/Balance

Mobility Limitation(Sudden Onset)

PT

Age in Years

Sustained Model

Community Wellness Programs/intermittent re-assessment

Getting Beyond the Plateau

J Rimmer- University of Illinois

Community SettingSelf Managed Home Program

Fitness CenterRecreation Facility

Senior Center

Transitional SettingAmbulatory Care or Outpatient

Home Services

Rehabilitation

Community Exercise

Rehabilitation SettingHospital

Rehabilitation CenterLong-Term Care Facility

Real-World Implementation:The influence of content, context, and process

Implementation

ProcessBehavior change strategies

• client motivation/behavior• provider practices

Systemic processes• supervisory practices• quality improvement

Engagement• Patient, provider,

community exercise and aging programs

Content• Evidence development

& testing

• Evidence interpretation & packaging

Adapted from Pettigrew et al, 1992 by Chambers, Ringeisen, Hoagwood & Patel, 2002

ContextExternal:

• Political and Professional

• Economic (e.g., reimbursement)

• Social

Internal: •Org culture & structure•Practice setting characteristics•Local stakeholders (e.g., attitudes and behaviors)

Influencing Health Policy: The Ideal

Clinically relevant outcomesof substantial public health importancethat are cost effective

Reduce fractures, decrease health care utilization

Ecologically Valid Health Indicators

Patients Live LongerPatients Do Not Go to Nursing HomesReduced HospitalizationsReduced Rate of Bad Events ( eg balance

program reduces rates of injurious falls or hip fractures)

Ultimately Must Establish Performance Measures- Process

• Center for Medicare and Medicaid- Pay for Performance Measures

• Center for Medicare and Medicaid- Preventable conditions- Will NOT Pay

• Accessing Care for Vulnerable Elders – Quality Indicators

• JACHO – Certification

Develop Coalitions

Developing Integrated Programs from Department of Public Health

• Example from North Carolina Falls Coalition

• NC Department of Public Health- Multiple Stakeholders- Medical and Community Public Health

1. Infrastructure Development and Maintenance

• Establish and maintain coalitions of key stakeholders to systematically indentify needs, resources, and successes to build capacity

WHO ARE YOUR STAKEHOLDERES-

2. Community Awareness and Education

• Develop and apply effective social marketing and practices to engage and better inform the public and specific constituencies about falls risks and inactivity– FOCUS on HEALTH and FUNCTION

3. Provider Education

• Identify develop and implement training programs for clinical and community providers and enable them to plan, deliver, and evaluate the effective evidence-based programs and practices

4. Risk Assessment and Intervention

• Create and implement plans to identity and establish necessary complements of risk assessment and intervention strategies to address diverse needs of those of risk for falls and inactivity

• e.g. screening multiple entry points ( primary care providers, fitness centers, faith communities, senior centers, health fairs, parks and recreations)

5. Surveillance and Evaluation

• Monitor the growth and outcomes of programs and the processes,

• Use information for quality assessments andidentifying new goals and strategies.