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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
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Cornerstones of Policy Development and Implementation
Pamela Duncan PhD, PT, FAPTADuke University
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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
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• Science is Complicated- Clinical Practice and Implementation More Complicated
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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)
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Example from Stroke Rehabilitation
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We are establishing the science of rehabilitation and recovery
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Effects of rehabilitative training on motor maps
from Nudo, et al., Science, 1996
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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
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Health Condition(disorder/disease)
Impairment Activity Participation
Contextual FactorsA. EnvironmentalB. Personal
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A Revised Conceptual ModelFor PRACTICE
CapacitySkill
Motivation
Accelerated Skill
Acquisition Program (ASAP)
)
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WE ARE ESTABLISHING THE RULES of PRACTICE
• WE ARE EVALUATING THESE RULES-– ICARE
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• IT Also ALL ABOUT THE DOSING
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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
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IT IS ALSO ABOUT THE TIMINGand Severity OF THE
INTERVENTION
• Acute• Sub acute• Chronic
• MILD , Moderate, Severe
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• “Neurological Diseases are COMPLEX– AND in FACT MAY NOT BE neurological..
– THE BRAIN IS NECESSARY BUT NOT SUFFICIENT
– Example: Stroke
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Stroke is Complex
• Multiple Systems and Multiple Providers
• Scope of Problems and Co-morbidities Are Broad
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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
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Walking/Balance
Mobility Limitation(Sudden Onset)
PT
Age in Years
Current Model
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Walking/Balance
Mobility Limitation(Sudden Onset)
PT
Age in Years
Actual Model
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Whitson et al: JAGS 2006
• Increase fractures rates in FRG 4-7 ..first year
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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%)
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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
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Falls in Leaps N= 284Rankin 2-4, living in community
348 Falls/144 individuals71 Multiple FallersSerious Falls 22/18 individuals
18 Fractures
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Range of Steps Taken 2 months Post Stroke (Individuals independently walking but <.8m/sec
from the Leaps Trial)
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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
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2 months post stroke individuals discharged home ambulatory
• They do not walk much
• They have limited aerobic capacity
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Evidence-Based Recommendations for –Post Acute Care
AHA/ VA Post Acute Care GuidelinesCanadian Stroke Care Royal College of Physicians
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• “Evidence- Based Practice”– Science– Conceptual Models– Evidence Based Guidelines– Outcomes
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So What’s the PROBLEM?
• Science is complicated ,, clinical practice more complicated..
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“How difficult is the decision making process…!!!”
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So What’s the PROBLEM?
• Science is complicated ,, clinical practice more complicated..
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Roberto Gatti, Milan“…
2901 articles- Big Reading Assigment
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Salbach et al., 2007
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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
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Challenges
• Fragmented Care-– SILOS- acute, rehabilitation, home, community
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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
•
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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
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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
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Community settingsMultiple providers (no-profit and profit)
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Low cost covered by the participants
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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
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* 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)
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• Engaged the Community in AFA Day- To Celebrate the Successes
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Walking/Balance
Mobility Limitation(Sudden Onset)
PT
Age in Years
Sustained Model
Community Wellness Programs/intermittent re-assessment
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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
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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)
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Influencing Health Policy: The Ideal
Clinically relevant outcomesof substantial public health importancethat are cost effective
Reduce fractures, decrease health care utilization
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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)
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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
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Develop Coalitions
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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
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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-
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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
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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
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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)
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5. Surveillance and Evaluation
• Monitor the growth and outcomes of programs and the processes,
• Use information for quality assessments andidentifying new goals and strategies.