Capitalizing on Virtual Delivery of Community Programs to Support Health and Well-Being of Older Adults

The essential role of physical therapy providers in the care and recovery of patients infected with COVID-19 has been well delineated.^1,2 However, the pandemic has a wider reach. Many older adults will likely experience long-term health consequences due to increased daily sedentary behavior and social isolation. Physical therapists can play a key role in mitigation of chronic disease, falls, and mobility-disability suffered by older adults as a result of the response to the pandemic.³

Prior to the pandemic, community organizations such as Area Agencies on Aging, faith-based organizations, SilverSneakers, and the YMCA provided older adults with in-person, evidence-based programs (EBPs) to promote fall prevention, physical activity, and chronic disease management. EBPs are a specific type of program offered in the community that have been rigorously studied and deemed effective in improving health and well-being by reducing disease severity, disability, and/or injury. EBPs are led by trained facilitators who use standardized programs with ongoing monitoring to maintain fidelity.⁴ Programs can complement physical therapy and serve as an additional resource in the care of aging adults.

In 2018, approximately 61,000 older adults in the United States completed in-person EBPs for falls prevention and chronic disease self-management.⁵ In March, the pandemic necessitated an almost overnight transition in these programs to virtual delivery. This innovation provided an opportunity to explore many questions for these programs: Would older adults engage in programs virtually? If so, how? Is virtual a viable medium for long-term engagement? For physical therapists, there is an opportunity to explore: Could engaging older adults in available virtual programs to support health and well-being be an effective adjunct to therapy? What programs are available, and which should I recommend? What will be the impact on health and functional outcomes for older adults?

Virtual Adaptation of Community Programs as a Result of the Pandemic

EBPs were offered almost exclusively in-person prior to COVID-19; however, due to current health guidelines, onsite access to many programs is not available. Fortunately, organizations quickly expanded resources virtually, thereby expanding their reach geographically. A survey of EBPs conducted by the University of Washington Health Promotion Research Center in July 2020 provides answers to the current and potential role of virtual delivery of EBPs for older adults.⁶ Respondents included 390 individuals representing 275 organizations, 36 states, and 9 countries. Programs were offered in multiple languages in diverse settings. Between May 1 and July 13, 2020, more than 2397 participants were reached through 1 or more remote EBPs. Programs utilized a variety of methods to reach participants; 40% used a video conference platform such as Zoom or Skype, 13% phone, and 9% a combination of phone/video and mailed toolkits. The main gap in access to programs was experienced by individuals with limited access to technology. The overwhelming positive response to virtual delivery resulted in over 75% of EBPs now offering or planning to offer virtual programs.^7,8

In addition to EBPs, other organizations have increased virtual accessibility to their programs, providing greater access to both older adults and physical therapists wishing to explore program content.⁹ For example, SilverSneakers⁹ launched live and on-demand exercise classes and workshops when the pandemic required closure of on-site programs. Weekly instructor-led Facebook live classes¹⁰ generated over 7.7 million minutes viewed in just 6 weeks.⁷ On-demand exercise classes and videos on health topics were made available on YouTube. The YMCA also quickly pivoted to support older adult members and nonmembers during the pandemic. Programs such as “Your Y at Home for Active Older Adults”¹¹ offer on-demand exercise videos for strengthening, aerobic training, and tai chi. Fitness coaching, nutritional tips, and diabetes prevention programs are now offered virtually. Many YMCAs are also providing resources, meal support, and wellness checks through phone calls, text messages, and emails.¹² Area Agencies on Aging have similarly adapted and increased services and resources.¹³ Beyond the pandemic, it is our professional and ethical responsibility to be aware of and connect older adults to community-based resources that can help meet their health needs beyond physical therapy.

The shift to virtual is very new, but the number of programs and the reception of these programs by older adults warrants that physical therapists consider the value of integrating evidence-based, widely available, and low-cost (often free) virtual programs as an adjunct to therapy and part of discharge plans during the pandemic and beyond. Although few studies are available on the virtual implementation of EBPs, 2 pilot studies conducted prior to COVID-19 on different virtual delivery methods of the Otago Exercise Program demonstrated feasibility and resulted in functional improvements.^14,15

Access to and Use of Technology by Older Adults

Health care providers may be concerned about barriers to older adults’ accessing and using technology. However, the digital divide is narrowing. A study among 4 diverse cohorts of older adults indicates over 80% of older adults have a smartphone and 64% to 78% use online banking.¹⁶ A series of SilverSneakers Pulse Surveys with over 5000 respondents provided insights into how older adults were adapting to the COVID-19 shelter-in-place orders.^7,9 One-half of those surveyed said exercise was the largest healthy behavior disrupted due to the closure of gyms and their inability to utilize their favorite equipment or attend classes. SilverSneakers expanded their virtual programming solutions to meet the need. Older adults increased technology adoption from 27% to 74% in 1 month to engage in SilverSneakers and/or to communicate with friends and family. Of those who adopted technology, 67% reported increased comfort with digital solutions compared with pre-COVID-19, with Zoom being the preferred platform. One-third indicated they will continue to incorporate digital solutions for activities beyond exercise after stay-at-home orders are lifted. Similarly, preliminary data from focus groups of older adults with Parkinson’s disease who attended onsite exercise classes and transitioned to the same program delivered virtually preferred the virtual program (Bennett HB, Vincenzo JL, Oholendt C, unpublished data, 2020).

Some older adults need assistance to access or acclimate to technology. The National Council on Aging reports multiple EBPs successfully transitioned to virtual delivery by mailing older adults a step-by-step packet to assist with access to programs through Zoom (developed and shared by Rush University Medical Center).¹⁷ If an older adult or someone with a disability does not have technology or needs adapted technology resources, every state has a federally funded program dedicated to providing or loaning out equipment that can be completed by the individual in need.¹⁸ To locate available programs, contact local community partners such as the Area Agency on Aging,¹⁹ state units on Aging,²⁰ health departments, YMCAs,²¹ faith-based organizations, and local senior centers. Look online for the nearest university Extension program²²; every state has at least 1 federally funded, land-grant university that provides health and wellness outreach. National and international organizations such as the National Council on Aging, The Administration for Community Living,²³ and the National Resource Center for Engaging Older Adults²⁴ continually update their websites with virtually available health and wellness resources for older adults and health care providers.

Call to Action: Facilitating Older Adults’ Engagement in Virtual Community Programs

The Gerontological Society of America called for individuals to “innovate existing systems to reduce poor health outcomes during and after the pandemic.”²⁵ The Asian Working Group for Sarcopenia released a call to action to develop innovative services to manage secondary consequences of the pandemic among older people.²⁶ The global community has robustly responded by evolving prevention and health promotion programs to expand virtual access. The virtual evolution of community-based programs creates opportunities for physical therapists to connect patients to virtually available community resources during the pandemic and beyond.

Community-based organizations are valuable to physical therapists because they offer free or low-cost resources and/or EBPs to reduce falls, improve physical activity, and increase self-management of chronic conditions such as diabetes and arthritis. Relationships between clinical providers (eg, physical therapists) and community organizations that provide resources and support to engage and empower older adults to self-manage their health and wellness are mutually beneficial. Collaborating can provide programs, support, and referrals to engage older adults during and following an episode of care, resulting in a lower burden of care associated with aging and chronic conditions and improved outcomes.^27,28 Equally important, physical therapists can offer expertise to community organizations and older adults by serving as referral sources, educators, and clinical partners to organizations, thereby helping maintain program sustainability and extending program reach.²⁹

An example of this collaboration in action occurred with a physical therapist in North Carolina who worked with a community-based organization to offer a virtual balance improvement program based on the Otago Exercise Program. The community-based organization was familiar with all participants and referred them to the physical therapist. She conducted an online falls risk screen using the STEADI toolkit. Eligible participants were invited to attend a Zoom call twice per week. During the call, they were led by the physical therapist through a series of warmup exercises and then the 17 Otago Exercise Program exercises. The program started with 3 participants in April and increased to 15 participants by October. The program has been so successful and generated such interest that when the lead physical therapist was unavailable to teach, another physical therapist was recruited to cover. The community-based organization is continuing to refer clients to this program and sees it as a value added to their current programming. The physical therapist also refers her clients to other virtual programs offered by the community-based organization, such as virtual tai chi, as appropriate based on the clients’ abilities.

It is imperative for physical therapists to be aware of the virtual adaptations of community programs and incorporate them into our plans of care for multiple reasons. First, virtual health promotion programs can help mitigate the short- and long-term consequences of the pandemic. Second, EBPs and other programs promote a continuum beyond an episode of care that facilitates optimal patient outcomes. Finally, it is our professional and ethical responsibility to connect older adults to resources that can help meet their health needs beyond physical therapy.

Physical therapy providers are in a strategic position to educate and facilitate older adult engagement in virtual resources to ameliorate the secondary consequences of COVID-19. Beyond this, we have a responsibility to develop community partnerships and connect older adults to necessary resources to promote a continuum of care after an episode of physical therapy. Community partners serve this function through health promotion and disease prevention programs that are now available virtually.

Author Contributions

Concept/idea/research design: J.L. Vincenzo, L. Schrodt, J.L. Tripken, J.C. Sidelinker, T.E. Shubert

Writing: J.L. Vincenzo, C.G. Hergott, L. Schrodt, B. Rohrer, J. Brach

Data collection: J.L. Tripken

Consultation (including review of manuscript before submitting): J.L. Tripken, K.D. Shirley, J.C. Sidelinker, T.E. Shubert

Funding

Dr Vincenzo is funded by the Translational Research Institute (TRI), grants KL2 TR003108 and UL1 TR003107 through the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH). Dr Brach is funded by NIH K24 AG057728 and NIH P30 AG024827. Dr Shubert is funded under CDC Grant#5R44CE002343–03; SIP 14–020; SIP 12–058.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest. They declare that they have no relevant conflicts of interest with this work.