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Falls Prevention Awareness Day September 23rd

Last year my 80 year old grandmother fell walking back from my cousins wedding reception, luckily she grabbed onto my sister and broke her fall. Nevertheless as we studied the sidewalk for several minutes only to discover its perfectly flat surface and our tremendous worry… my dear grandmother could think of nothing other than her embarrassment. We later learned from my grandfather that she has fallen several times over the last few months; she shook it off with laughing commentary in the background saying he was exaggerating. Whereas I appreciate her humor, it is no laughing matter. 2.5 million elderly adults are treated in the ER for fall injuries, with one out of five falls result in broken bones. With those statistics I continue to worry about the next time she falls and my sister isn’t there.

Pick up your cars, grandma is coming over!

With that said, today being Falls Prevention Awareness day I cannot help but think of everyone in my life that is prone to falling… which I am sure you are now pondering yourself. So we should all take a minute (or longer depending on how caught up you are on house chores!) and look around our environment for fall hazards and think about prevention. I have a two year old son that contributes a lot to fall hazards with his hotwheels toys strewn all over the house, which makes my house a high risk zone no doubt! I have to ask what’s on my grandmothers floor?! We need to encourage our elderly loved ones to remove fall risk factors in their homes too; broken steps, faulty handrails, uneven pavement, clutter, throw rugs, poor lighting… grandchildren toys! However most of all we need to make sure they are still getting out of the house and do NOT let the fear of falling limit their mobility. Lower mobility is a major fall risk factor due to deteriorating body strength, which in return also influences balance. It is argued strengthening your balance is the single most important factor in avoiding falls. Senior centers across the country teach classes to elderly adults called “Matter of Balance” (I have taught a few in the past!), they are a great way to teach folks about balance strengthening through exercise and awareness of ‘fall-ty’ habits.

Working for Wellpepper and learning more each day about how it is helping patients, I cannot help but think about how mHealth technology could also help with fall prevention. There are several balance strengthening exercises that we do in our ‘Matter of Balance’ classes at the senior center that could be very easily translated onto the mHealth platform. Honestly now that I think about it the whole class could be taught this way, and might even have better results since a lot of elderly adults express interest in the class, but don’t show up because they are too embarrassed about admitting to of fallen, just like my poor grandmother.

Such thoughts of mine have been expressed officially (to say the least!) by Harvard researchers, because today it was announced on Falls Prevention Awareness Day no less, in a press release, that they are utilizing Wellpepper as an patient engagement solution to lower the costs of care and to improve patient mobility skills as well as muscle strength, endurance and power and to decrease the risk for fall-related injuries such as hip fracture. I cannot wait to see how this study plays out, because it could mean a whole world of good for our lovely elderly family members. I cannot help but visualize how cute my grandmother would be practicing her muscle strengthening exercises on an iPad and the great peace of mind my family would have.

Congratulations team Wellpepper for your involvement in making this Falls Prevention Awareness Day a big notch in your ongoing achievement index!

Posted in: Aging, Behavior Change, Healthcare Research, M-health

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Translating Evidence-Based Interventions to Practice: Falls Prevention and Otago

APTA CSM 2015 Session Recap: Falls Prevention: Otago Program and Behavior Change

Presenters:

Mary Altpeter, PhD

Tiffany Shubert, PhD

Clinical Support for Otago

Clinical Support for Otago

The fact that a session entitled “Falls Prevention: Otago Program and Behavior Change “ ended up in the Health Administration /Policy track at APTA CSM 2015 reinforces that we have a long way to go on translating outcomes-based research into care plans. Otago is a proven and effective set of preventative exercises and care for community-dwelling yet frail adults which improves balance and prevents falls risk. It was developed in New Zealand, at the University of Otago over 14 years ago, and prescribes a set of balance and strength exercises that the patient completes independently over 12 months.

Recommended physical therapy visits to access, teach, monitor, and kick-start patient adherence are to occur over 6-8 weeks and after that patients are encouraged to self-manage, and herein lies the reason that this session is in health policy and administration: this is longer than most insurance covers, and there are not currently enough incentives for remote patient monitoring. However, according to presenter Tiffany Schubert, Otago shows an ROI of $1.25 of every dollar invested as it prevents patients from falling which results deterioration to the patient and further burden on the health system.

Barriers to implementing Otago in the US stem largely from reimbursement and the current incident-based payment model that does not facilitate managing patients over a long period of time. As a result, Otago expert and presenter Tiffany Schubert presented an abridged version that might be easier to fit into current payment models.

Delivering Otago: Calendar view

Delivering Otago: Calendar view

However she is also on a crusade to collect outcomes data for Otago in the US so that these barriers can be overcome as the barriers are not just reimbursement. Clinicians have preconceived notions that patients won’t adhere to plans. Tiffany challenges these misconceptions by asking “are you sure or is it your patients just don’t understand.” We’ve definitely seen this with patients we’ve interviewed: they do want to be adherent to their plans but they find out when they get home that they forgot or are confused. Otago and systems like it work well when there is remote support for the patient.

Clinical Barriers to Implementation

Clinical Barriers to Implementing Otago

Given that Otago requires a high-level of patient self-efficacy, understanding factors that impact behavior change is key in driving long-term outcomes and adherence. Hence, the second half of this presentation, from Mary Altpeter focused on strategies to help patients develop self-management skills to complete the independent part of the program. One of the big misconceptions, that we hear frequently from healthcare providers (and definitely from many of the sensor and tracker vendors), is that knowledge is sufficient to effect change. It’s not, many other factors weigh in including readiness to change and social influences. Understanding more about the patient’s own journey and the patient’s barriers and readiness to change can make a big difference in this area. Also understanding the patient’s goals is crucial and personalizing their risk of not changing their behavior.

Breaking behavior change down into stages can really help move the patient along a path. In this session, Altpeter outlined a 5 stage model to affect patient behavior.

6-Stage Behavior Change Model

6-Stage Behavior Change Model

Understanding that while your assessment may show that the patient is at risk for falls, the patient may not have internalized this. First step is to plant the seed of doubt while the patient is in what is called the “Pre-Contemplation” stage. You can do this by personalizing the risk.

In a falls scenario, patients are not actually worried about falls risk. This sounds counter intuitive, but patient goals are usually not functional goals they are life goals. (We can attest to this from the goals patients set in Wellpepper.) So, the patient may be worried about losing their driver’s license which might happen if they had limited mobility. This is moving to patient-centered goals from clinical goals which personalizes the risk. Find out what the patient might be afraid of losing and this can start to plant the seed of doubt that they might be at risk for falls.

During the Contemplation phase the healthcare professional can help the patient break down what it might look like to be able to embark on a program. What might be their barriers or sticking points to do so? When might they do it? This isn’t about making a plan it’s about facilitating the patient in thinking that a plan might be possible.

The next phase Preparation, occurs when the patient has demonstrated that he or she is ready to change, and this is where we can examine the nuts and bolts, breaking down what may seem like a daunting task (adhering to a program for 12 years), into something manageable. Here is where you help the come up with plans to overcome the barriers you identified. One key barrier is often fear of relapse: that is that when a patient stops doing the plan, they can’t get back on the wagon, so to speak. Making it okay to “start over” is a great way to encourage patients.

During the preparation phase you may also want to help the patient break down the program into smaller goals and manageable chunks so they can see progress during the program. Also help the patient identify rewards that will help drive their adherence. These are both important steps when helping with a large and often intangible goal.

Action is putting the plan into place. Here your main role is to support the patient, help them continue to overcome barriers, and be a cheerleader to keep them going in the case of a relapse.

The final stage is Maintenance (which includes dealing with Relapse). Pointing out the patient progress, possibly by completing another falls assessment and showing the difference is a great way to reinforce that the program worked and it’s worth continuing. Also ask the patient to remember what fears they had before the program and whether they feel that now. Simply shining a light on their own experience can help a lot here.

With an aging population, and rising health costs, translating valuable and proven research like the information in this session into clinical practice is key. Given that the average time from research to implementation is 17 years, and that Otago was invented 14 years ago, we can only hope to see widespread adoption by 2018. That’s also in-line with CMS’s new requirements for 50% of Medicare spend being for new value and outcome-based models. It’s time right?

Posted in: Adherence, Aging, Behavior Change, Exercise Physiology, Healthcare Disruption, Healthcare transformation, Physical Therapy, Rehabilitation Business

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