Development and evaluation of community-clinical linkages between physical therapy clinics and EnhanceFitness, an evidence-based physical activity program for older adults
Fishleder, Sarah Louise
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Background: Many barriers exist to older adult participation in physical activity (PA), despite known benefits. Enhance®Fitness (EF) is a nationally-disseminated evidence-based group exercise program for older adults. Clinical-community linkages (CCL) are partnerships between clinical entities and community-based health promotion organizations. Referrals from physical therapists (PTs) through clinical-community linkages offer novel, promising opportunities to increase older adult engagement in appropriate community-based PA programs. Methods: In Chapter 2, we examined changes in, and predictors of, participant physical function as measured by three tests. We analyzed EF participant data (n=6,442) collected longitudinally in 16-week program cycles using random effects linear regressions for each physical function test: arm curls, chair stands, and eight-foot up-and-go. In Chapter 3, we assessed the capacity of PTs to participate in such linkages. We collected qualitative data from April to July of 2015 via structured direct observations (n=39) in five Seattle-area PT clinics, and semi-structured phone interviews (n=30) with PTs across 14 states. We conducted thematic analysis using a priori themes based on the Etz et al. (2008) Bridging Model: capacity to assess patient risk, ability to provide brief counseling, capacity and ability to refer, and awareness of community resources. In Chapter 4, we conducted a comprehensive literature review to identify content areas and existing instruments; developed new items and modified content and design of existing items; and assessed content validity with review from three expert panels. We conducted 10 cognitive interviews to assess face validity, and tested construct validity using known group validation with participants from an ongoing CCL focused research project. Results: In Chapter 2, we found attendance predicted clinically significant improvements in all three physical function tests. Less improvement was associated with being female, less active at baseline, above age 75, not married or partnered, in fair or poor health, and having a disability. In Chapter 3, results show that PT assessment of risk is integrated in practice, and referrals to physical activity programs in the community may be facilitated by the intensity of PT sessions and focus on benefits of exercise. However, such referrals are hampered by a lack of program knowledge, concerns about program safety, and lack of communication systems. Successful partnerships may need to be initiated by community programs, and begin at the clinic level. In Chapter 4, feedback from experts and cognitive interviews included framing the survey as an actionable self-assessment. They provided guidance on language and scoring format. The final instrument includes 15 items across 5 survey domains. The survey overall and three domains (Communication, Referral Process, Feedback) showed construct validity, and a fourth domain (Nature of Organizational Relationship) approached significance. The final domain (Timeliness) did not demonstrate construct validity. Discussion: In Chapter 2, results demonstrate sustained, significant improvements in a population that often faces functional decline. We identify groups at risk of fewer gains. Implications for program delivery include targeting messaging to motivate attendance and general activity, and providing additional support for these groups during EF classes. In Chapter 3, we found PTs have potential to create partnerships with PA programs due to understanding of a patient’s physical abilities, patient rapport, and partnership buy-in. Targeting evidence-based programs capable of continuing therapy gains could improve partnership capacity. Systemic improvements include implementing communication system innovations and partnership activities that facilitate referral processes and increase knowledge/trust in community programs. In Chapter 4, The newly developed Clinical-Community Linkage Self-Assessment Survey may be a useful tool for assessing the strength of clinical-community linkages from the perspective of a community organization. It is important to stakeholders, and meets their criteria of being brief, accessible, and pragmatic. Additional validity testing is needed with a larger sample, and from a clinic perspective. An important addition is the development and testing of an accompanying Recommended Action Guide that maps directly to the self-assessment, and provides step-by-step guidance.
- Health services