Recommendations for Improving Otago Exercise Program Implementation at UNC University Physical Therapy Clinics

Recommendations for Improving Otago Exercise Program Implementation at UNC University Physical Therapy Clinics

By Jonathan Earles, SPT

Background

During my time in the Doctor of Physical Therapy program at UNC, I gradually cultivated an interest in working with older adults. This interest most directly stems from my second and third clinical placements, working and learning in acute care at the Durham Veterans Administration Medical Center and in the Encompass Health Rehabilitation Hospital of Columbia. In each setting, working predominately with older adults, I felt that I had both a phenomenal learning experience and an opportunity to provide valuable services.

Following these experiences and determined to learn more, I first enrolled in SOWO 843: Older Adults: Theory and Practice through the UNC School of Social Work. This class touched on many themes previously introduced in PHYT 736: Physical Therapy for Older Adults; and afforded me the opportunity to further explore the unique challenges and rewards found when working with older adults. I also signed up to work with Vicki Mercer, PT, PhD on her project “Falls Prevention in Primary Care: An interdisciplinary approach to reducing risk of falls in older adults” for the fall 2019 semester. Dr. Mercer’s project was the first significant experience I had with the Otago Exercise Program (OEP), a falls prevention program originally designed at the University of Otago in Dunedin, New Zealand.¹ My capstone built on these experiences by evaluating the screening and referral processes for fall risk among Medicare-enrolled, community-dwelling older adults accessing primary care at UNC Health clinics like the Family Medicine Clinic (FMC), and examining the appropriateness of the OEP as an intervention for patients presenting to UNC UPT clinics.

Statement of Need

Estimates indicate that up to 35% of adults over the age of 65 and up to 50% of adults experience a fall each year.² Between 20-30% of older adults who experience a fall suffer from moderate or severe injuries, which can lead to a loss of independence or death.¹ When a patient arrives at an UNC UPT clinic with impaired balance or gait, their PT must decide which intervention is most appropriate relative to their individual situation and the nature of their deficits. The Otago Exercise Program is a home-based intervention comprised of strengthening and balance retraining exercises that has been shown to reduce the risk of death and falls rate among older adults.² The OEP is beneficial for community-dwelling older adults who are independent with functional mobility and who are safe to perform exercises at home, but who still possess gait, balance, or strength deficits which could be addressed with lower extremity strengthening and balance exercises.¹ Early conversations with Dr. Mercer and other physicians and PTs at UNC, in the fall of 2019, indicated that the OEP demonstrates potential underutilization as an intervention in UPT clinics. As the OEP is an evidence-based intervention which can reduce the fall risk of high-functioning older adults without requiring a full in-person plan of PT care, improving its implementation may help reduce the rate of falls among patients accessing primary care at UNC Health.

Project Overview

This purpose of this capstone project consists of three parts: 1) Evaluate the fall risk screening and referral processes at the UNC Family Medicine Center, 2) Determine the extent to which the Otago Exercise Program is used in UNC UPT clinics by gathering information directly from physical therapists and by utilizing any available information pertinent to patients’ experiences, and 3) Summarize recommendations for improving the falls prevention process at UNC for community-dwelling older adults, including screening and referral, but most especially focused on the use of the OEP.

The origins of this project go back to the fall of 2019 with my completion of a critically appraised topic (CAT)comparing the relative falls prevention efficacy of the OEP to other interventions. The Evidence Table I produced for this project built on this base of information, evaluating the efficacy of the OEP, exploring alternative delivery models of the OEP, and examining factors that may improve the patient experience with using the OEP and that may improve adherence to a primarily home-based program. For example, this evidence table informed the final “summary of recommendations” by demonstrating the importance of patients’ intrinsic motivation and ability to self-appraise when considering adherence.³ There is also evidence supporting the consistent use of exercise calendars and evaluating patient readiness to make lifestyle changes like self-monitoring exercise when initiating a home-based program.³ In addition, the evidence table informed recommendations to re-evaluate the frequency and feasibility of the check-in phone calls used in the OEP, as phone calls may increase the benefits of home-based exercise programs via improved accountability.⁴

Other previous work that informed this capstone includes the project led by Dr. Vicki Mercer. In the fall of 2019, my classmate Katie Owens and I worked with CMAs at the FMC to evaluate their fall risk screening procedures. At the FMC, CMAs screen older adults for fall risk in part by administering the Timed Up and Go test (TUG). After discussing the process with the CMAs, Katie, and Dr. Mercer, we determined that useful next steps included a handout for patients explaining their performance on the TUG and recommending that they discuss physical therapy with their physician. To this I added a TUG instruction sheet for CMAs, and a similar set of OEP instructions for UPT clinicians; and have housed all three documents in my discussion of my project’s Health Literacy Considerations.

To gather information about how PTs use the OEP, I created a series of Interview Questions and interviewed four UNC DPT faculty members regarding their experience with the OEP. In all four interviews, both perceived barriers and benefits were discussed and recorded. These interviews also provided valuable insights into patient experiences with the OEP, due to one PT’s ability to reference de-identified patient cases during her interview. I recorded and transcribed each interview, then compiled the  PT Interview Findings into a single document.

The final result of this project is a Summary of Recommendations for improving OEP use in UPT clinics, which drew from each of the above products to provide a list of potential ways to boost the “consistency, frequency, and quality with which the OEP is used in UNC outpatient clinics as a falls prevention intervention for community-dwelling older adults.”

Product Links

• CAT
• Evidence Table
• Health Literacy Considerations
• PT Interview Questions
• PT Interview Findings
• Summary of Recommendations

Evaluation

The primary means of evaluation for this capstone came in the form of direct feedback from committee members. First, when drafting the interview questions for discussing the OEP with UNC clinicians, the members of my committee provided guidance on crafting questions that would elicit the most useful answers from interview subjects. I next sent draft versions of the “PT interview findings” and “health literacy considerations” documents to members of my capstone committee at the midterm point of the spring semester. They were able to make comments on each document and return their feedback in word document format. Their feedback was pivotal towards informing the direction of the remainder of my project. This process was repeated in early April with all of the products introduced above, and I used committee feedback to finalize these documents.

Self-Reflection

I feel that I was able to meet most of the personal learning objectives I created when initially formulating my capstone in the fall of 2019. I wanted to develop my interdisciplinary communication and was able to do so while working with the CMAs at the FMC. I wanted to improve my professional writing skills and produce audience-appropriate messages across a variety of target audiences, and with my committee’s feedback, felt I was able to do this with my “health literacy” and “recommendations” products especially. Finally, I wanted to build on my experience with developing a CAT by further working with searching for and synthesizing literature and working on my Evidence Table offered me that opportunity.

I am pleased with the end results of this project, primarily that the individual components of this project coalesced smoothly into a single document which I believe has real clinical utility. The recommendations presented in this project offer several potential avenues for improving the implementation of the Otago Exercise Programs at UPT clinics. Due in part to the reduction of patients seen at UPT clinics during the coronavirus pandemic, it was ultimately beyond the scope of this project to see these recommendations put into action, namely the UPT inservice and even the placement OEP reminders in clinic offices. Nevertheless, I look forward to delivering these recommendations to stakeholders, like Dr. Mercer, and tracking their progress in the future.

Acknowledgements

I would first and foremost like to thank my capstone advisor, Vicki Mercer, PT, PhD for her tireless assistance with developing and completing the foundational ideas of this capstone. Thank you for being so generous with your time, energy, and expertise. I couldn’t have done it without you.

Thanks also to Tiffany Shubert, PT, PhD and Carol Giuliani, PT, PhD, FAPTA for their willingness to serve on my capstone committee and to offer invaluable feedback towards my project.

I would also like to thank Jon Hacke, PT, DPT, Mike McMorris, PT, DPT, and Jeff O’Laughlin, PT, DPT for donating their time in sitting for interviews and providing thoughtful insight into the current use of the OEP at UNC.

Thanks to Deborah Thorpe, PT, PhD for her work in guiding us through the capstone process, and for answering the questions that I had along the way.

Finally, thank you to the entirety of the Class of 2020, y’all are some of the most caring people I’ve ever had the privilege of knowing and I appreciate each and every one of you.

 

References

1. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Tools to Implement the Otago Exercise Program: A Program to Reduce Falls. First Edition. Available at: https://www.med.unc.edu/aging/cgec/exercise-program/tools-for-practice/
2. Thomas S, Mackintosh S, Halbert J. Does the ‘Otago exercise programme’ reduce mortality and falls in older adults?: a systematic review and meta-analysis. Age and Ageing. 2010;(39)6: 681–687. https://doi-org.libproxy.lib.unc.edu/10.1093/ageing/afq102
3. Essery R, Geraghty A, Kirby S, Yardley L. Predictors of adherence to home-based physical therapies: a systematic review, Disability and Rehabilitation. 2017;(39)6: 519-534, DOI: 3109/09638288.2016.1153160
4. Light K, Bishop M, Wright T. Telephone Calls Make a Difference in Home Balance Training Outcomes: A Randomized Trial. Journal of Geriatric Physical Therapy. 2016;(39)3: 97-101. doi: 10.1519/JPT.0000000000000069

Top Image: https://www.laterlifetraining.co.uk/courses/otago-exercise-programme-leader/about-otago-exercise-programme-leader/