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. Author manuscript; available in PMC: 2022 Jul 1.
Published in final edited form as: Top Geriatr Rehabil. 2021 Jul-Sep;37(3):163–167. doi: 10.1097/TGR.0000000000000322

Clinical-Community Connections: Incorporating Evidence-Based Programs for Improved Patient Outcomes

Lori A Schrodt 1, Rachel A Sledge 2, Colleen Hergott 3, Beth Rohrer 4, Jennifer Sidelinker 5, Jennifer S Brach 6, Jennifer Vincenzo 7, Kathleen D Shirley 8, Tiffany E Shubert 9
PMCID: PMC8336763  NIHMSID: NIHMS1681615  PMID: 34366559

Abstract

Incorporating evidence-based community programs into clinical care recommendations and goals may help bridge the clinic-to-community transition for older adults. Engagement in evidence-based programs can help older adults manage chronic conditions and reduce fall risk through behavior change and self-management following a clinical episode of care. This paper describes evidence-based fall prevention and physical activity programs, provides resources to locate programs, and strategies to match older adults to the right programs.

Keywords: older adults, exercise, physical activity, fall prevention, evidence-based programs, community-based programs

INTRODUCTION

The prevalence of chronic conditions among older adults has a significant impact on physical therapists’ (PTs) and physical therapist assistants’ (PTAs) delivery of care. According to the latest statistics provided by the American Heart Association, at least 48% of all adults in the United States have some form of cardiovascular disease.1 An estimated 67% of adults over age 65 experience multimorbidity, defined as the presence of two or more chronic conditions.2 The prevalence of multimorbidity increases steeply each decade of life, with 82% of individuals 85 years and older experiencing at least two chronic conditions.2 In addition to increased disease burden, multimorbidity is associated with poor functional status, falls, disability, and reduced quality of life.2,3 The high incidence of chronic disease in older adults and the associated need for self-management training can pose challenges for PTs. Successful transition to a self-directed exercise program is an essential component of the physical therapy plan of care to maintain or improve upon the functional gains made during therapy.

Each year almost 30% of older adults experience a fall, of those 10–14% sustain an injury.4 Many risk factors for falls such as leg muscle weakness and poor balance require long term self-management by patients after the conclusion of a physical therapy episode of care. Ongoing exercise performance that totals 3 or more hours per week and includes a high-challenge balance component has the greatest impact on reducing falls.5

The transition from clinician-directed fall risk intervention to patient self-management can pose a significant challenge. Older adults are often reluctant to engage in intense exercise without supervision and support. Group exercise programs led by a trained facilitator can successfully provide the appropriate type and amount of exercise, or supplement a home exercise program.5 Exercise adherence and engagement in fall prevention strategies (e.g. reduction in risky behaviors) are also higher for group programs, or with structured support as compared to traditional physical therapy home exercise programs.6–8 Thus, participation in community programs may help older adults engage in daily exercise and implement fall reduction strategies.

Successful referrals to community-based organizations that can help patients transition to ongoing self-management can be difficult to navigate. However, as reimbursement models evolve from volume to value-based payment with the support of functional outcomes, there is an increased financial incentive to help patients transition from clinical management to self-management strategies.9,10 It is imperative that clinicians help patients access community resources that empower them to manage ongoing conditions and improve health and wellness.

The National Council on Aging (NCOA) is a non-profit, charitable organization that provides a voice for older Americans through three initiatives; healthy living, economic security, and public policy. The NCOA has been instrumental in increasing sustainability, use, and access to evidence-based programs (EBPs).11 The NCOA partners with non-profit organizations, businesses, and the government to provide innovative evidence-based community programs and services, online help, and advocacy for people 60 years of age and older.11 The NCOA also houses the National Chronic Disease Self-Management Education Resource Center and the National Falls Prevention Resource Center.

The NCOA recently partnered with the Academy of Geriatric Physical Therapy, a component of the American Physical Therapy Association (APTA Geriatrics), to educate PTs and PTAs about healthy aging resources and to encourage referrals to EBPs available in their communities.12 This initiative promotes clinical-community partnerships for the benefit of older adults while concurrently expanding the reach and influence of physical therapy in health promotion and wellness.

The purpose of this article is to describe the importance of fall risk management and physical activity promotion EBPs in the transition of care to foster patient self-management after a physical therapy episode of care. This paper will also provide resources for professionals to help patients access these beneficial programs.

EVIDENCE-BASED PROGRAMS

EBPs offer effective ways to improve health and well-being by reducing disease severity, disability, and injury among older adults.13 To be recognized as an EBP, a program must meet strict criteria established by the Administration for Community Living.14 These programs have been rigorously tested, proven to demonstrate health benefits, and are designed to ensure standardized program delivery.13 EBPs address four broad categories: 1) falls prevention, 2) general wellness and physical activity, 3) chronic disease self-management, and 4) behavioral health.14 Information about specific EBPs can be found at the NCOA Center for Healthy Living.15

To achieve the proven benefits of an EBP, the specific program goals should align with the patient’s goals, and the patient should fit the description of the target audience.16 Each EBP has a standard set of elements to help determine if the program is appropriate for the patient’s clinical needs. For example, Enhance®Fitness describes a target audience of older adults from the frail to the fit. The class is recommended for older adults with sufficient strength and seated balance skills to participate in group settings. The physical activity program focuses on four key areas of health: cardiovascular, balance, strength and flexibility.17

Evidence-based fall prevention programs

Evidence-based fall prevention programs contain essential components for helping older adults manage fall risk. These elements include balance and strengthening exercises, mind-body or awareness training, recommendations for home modifications, and cognitive-behavioral strategies to address fear of falling.4,16 EBPs are engaging programs designed to deliver appropriately dosed exercise that promotes continued participation. These programs are usually eight or more weeks in duration and meet either in-person or virtually 1–3 times a week. Programs are adaptable and designed to accommodate different ability levels.

The Otago Exercise Program (OEP) is typically led by a PT. The OEP is a progressive strengthening, balance, and walking program designed to improve mobility and reduce fall risk for older adults who are less mobile and more frail.18 The program consists of 17 strength and balance exercises performed for 30 minutes, 3 times per week. Over time exercise intensity is modified by adjusting repetitions, resistance though ankle weights, or exercise complexity. The 30-minute walking program is completed 3 times per week, alternating days with the strength and balance exercises.

During the first 8 weeks, or “clinical phase”, the patient is guided and progressed through exercises under the direction of a PT.18 After this time, the patient is transitioned to a self-directed phase for the remaining 4–10 months of the program. Patient support is provided through check-in phone calls from the PT at regular intervals. Exercises can be adjusted based on the patient’s status.19 The OEP has been successful in both home and outpatient PT-led models. Models have also shown success in which a PT and lay leader collaborate to implement the program.18 The OEP can also be introduced during the early stages of rehabilitation and continue as the patient progresses throughout the course of skilled therapy care. The OEP is most effective for adults over age 65 who are at high risk of falling and those over the age of 80. It may not be effective for those at low risk of falling or those who are strong enough to participate in a community-based program.20

The A Matter of Balance (AMOB) and Stepping On programs focus on evidence-based education, fall risk management, and behavior change.21,22 These programs are designed for adults over age 60 who are cognitively intact, want to learn strategies for managing fall risk, improve flexibility, balance, and strength. While both programs are provided in a participatory group-based format, AMOB is designed to reduce the fear of falling, whereas Stepping On aims to promote an active lifestyle with a focus on risk factor management.

Evidence-based physical activity programs

Many EBPs focus on increasing physical activity through strengthening and balance activities and reducing fall risk. Enhance®Fitness is a group-based exercise program for adults who can walk independently in the community. Exercises can be adapted to be performed in sitting and/or standing. Each Enhance®Fitness class includes postural awareness training, low impact aerobic training, progressive strengthening exercises with free weights, static and dynamic balance training exercises, and stretching.17,23

Various tai chi programs have shown a significant reduction in falls, pain, and fear of falling, as well as improved mobility, cognition, and self-reports of well-being.24–26 Several evidence-based tai chi programs are approved for fall prevention including Tai Chi for Arthritis, Tai Ji Quan: Moving for Better Balance, and YMCA Moving for Better Balance.27 These programs all offer simplified forms and modifications for participants with differing abilities and needs (e.g. they can be done in sitting or standing).

Finding evidence-based programs

Historically, community-based organizations, such as Area Agencies on Aging (AAAs), senior centers, YMCAs, and faith-based organizations promote wellness and prevention by serving as a mechanism to deliver EBPs to their local communities. However, many PTs are not aware of the programs or do not know how to access them. In a survey of PTs practicing in the area of geriatrics, the greatest barrier to recommending an EBP to a patient was not knowing where these programs are located.28

AAAs were established to address the local needs of older adults and are organized in many states according to the geographic regions they serve.29 AAAs often provide evidence-based health and wellness programs at senior centers and congregate meal sites. Local AAA can be found through the National Association of Area Agencies on Aging website. Although each AAA website is constructed differently, most can be found within councils of government. Look for the EBP descriptions and offerings on the AAA website under headings for health promotion and disease prevention, healthy living and/or fall prevention. It may be beneficial to also call the local AAA or visit social media pages for more information about specific program times and locations.

The Evidence-Based Leadership Council website is another option for locating organizations who offer EBPs in your community.30 The “Map of Programs” allows for a search of EBPs by zip code and provides information on the programs available, local contact information. and a website link.

In addition to their active adult programming, many YMCA branches offer EBPs to their members and general community members. Common programs are YMCA Moving for Better Balance, AMOB, and Enhance®Fitness. Scholarships, medical memberships, or fee reduction programs may be available to non-members. The YMCA also partners with many health insurance plans (e.g. AARP Medicare Supplement Program, some Medicare Advantage Plans) to provide low or no cost access. Use the YMCA zip code search to locate nearby YMCA branches and contact the branch for more information.31

Using various search approaches may be the best way to identify community-based organizations offering EBPs as not all organizations may be listed under a single website. By contacting individual organizations directly, potential partners can be identified to obtain the most up-to-date information about current and future EBP offerings.

ADDITIONAL COMMUNITY PROGRAM OPTIONS

Often a combination of programs will be needed to meet an individual’s unique needs and promote sustainable interest and engagement. Many older adults will benefit from a strength and balance program for fall prevention, as well as increased physical activity consistent with the Department of Health and Human Services 2018 Physical Activity Guidelines.32

If evidence-based fall prevention or physical activity programs are not available in the community of interest, the best option may be to refer to a nationally disseminated exercise program such as SilverSneakers®. Many Medicare Advantage plans include a SilverSneakers® membership that provides access to participating fitness facilities, community centers, virtual group fitness classes, and on-demand exercise videos. SilverSneakers® group exercise classes are taught by specialized instructors who ensure a safe and functional exercise environment. Research studies support the health benefits of SilverSneakers®, including lower health care costs, reduced risk of depression, lower likelihood of hospitalization, and fewer activity impairments.33–36 SilverSneakers® classes are designed for every fitness level and are designed to improve mobility, cognitive health, strength, balance, socialization, and chronic condition management.

There may also be several local fitness facilities or senior and community centers that offer a variety of exercise programs to older adults. Community exercise programs not designated as an EBP may not be supported by research to reduce fall risk and improve physical fitness. It may be helpful for a clinician to contact the instructor to learn more or participate in a class to optimally and safely refer patients.

It is important to find exercise professionals that are an appropriate match for each individual’s needs and who can provide expertise, supervision, and motivation beyond the PT episode of care. Connecting with qualified exercise professionals, such as an exercise physiologist, personal trainer, or group exercise instructor, can be a valuable way to help sustain regular physical activity. The most well-respected national certifications are accredited by the National Commission for Certifying Agencies. Online registries such as American College of Sports Medicine ProFinder can assist with finding a certified exercise professional in the search area and may be an excellent starting point for developing a network of community partners.37

As community options are explored, venues such as local gyms, churches, and local hospitals should also be vetted for programs. Considering a variety of settings expands networking opportunities for developing community partnerships to meet the health needs of older adults.

VIRTUAL OPTIONS

Virtual options for implementing EBPs exist and are also important to consider. The OEP, for example, shows great promise for virtual delivery and may be an effective option for community-dwelling older adults who have an established plan of care.38 While the initial visits for OEP are typically conducted in-person, the follow-up sessions are performed by the PT virtually via telehealth. PTs are also exploring models where the entire OEP program is implemented virtually.18 Many EBPs and organizations have online resources for both members and non-members. For example, SilverSneakers® On-Demand™ is a program with exercise videos that can be done at home and includes various options such as cardiovascular and strength training programs, tai chi, and a 12-week fall prevention series.39 The YMCA also offers a variety of online exercise and wellness programs to members and non-members.40 Virtual programs also allow greater accessibility by PTs to audit content and determine the appropriateness of programs for patient participation.

At this time, some traditional face-to-face EBPs may be offering classes through video-conferencing platforms until social distancing and group activity restrictions are lifted. Check with local programs to see if they are providing virtual options for their current programming. Some older adults may also benefit from a virtual home-based option if transportation and mobility limitations are a significant barrier to attending classes.

CONNECTING PATIENTS TO PROGRAMS

Unfortunately, simply referring a patient to an EBP may not be enough to ensure participation. Starting the conversation early during the physical therapy plan of care can help set the expectation for transition to self-management with an EBP as a long-term goal. Patients can be encouraged to identify familiar community locations where EBPs may be offered, such as churches, senior centers, the YMCA, or online. This can help ease the transition to a long term physical activity plan and provide an opportunity to problem solve any barriers before completing physical therapy.41

Attending one or more EBP sessions with a patient as part of a skilled physical therapy plan of care may help support a successful transition to self-management. Attending a trial class together in-person or online may also provide an opportunity for individualized exercise adaptations based on skilled clinical expertise in the program environment. It is important to check with the beneficiaries’ Medicare Part B provider and liability insurance for coverage of off-site treatment first. Facilitating a connection with a supportive peer, such as individuals currently attending a program, can be another effective way to engage patients in a long-term physical activity or fall prevention program. Lastly, pre-registering a patient for a program if it will not be available until after the physical therapy episode of care, can also increase the likelihood of a successful transition to an EBP. If these programs are not available in the desired geographic area, consider implementing the OEP to get started right away.

Helping patients find the right fit

Matching individuals to the most appropriate community-based program necessitates careful consideration of their preferences, goals, transportation needs, and resources. Because EBPs focus on different components of health, it is imperative that the program’s goals align with the patient’s goals. Engaging patients by considering their goals and expectations can help guide the matching process and optimize motivation to participate. While some organizations offer their EBPs to the general community for no or low cost, others may be cost-prohibitive. Some organizations may offer financial assistance to those who qualify. Individual exercise and socialization preferences also warrant strong consideration. An individual who is more outgoing may enjoy the camaraderie of a group exercise program, whereas someone who is uncomfortable exercising in a group setting may prefer an individual option. The patient’s cognitive status and ability to follow instructions in a potentially distracting environment are also factors to consider for the successful utilization of an EBP.

CONCLUSION

Older adults benefit from support and guidance to optimize their health and fitness. Clinical-community partnerships between PTs and EBPs can help provide this guidance in a way that is tailored to individual needs. Participation in EBPs is a viable approach to help older adults achieve a sufficient amount of exercise and include high-challenge balance exercise to reduce fall risk. Framing fall risk management in a similar context as chronic condition management may help older adults understand the need for continued exercise after transitioning from physical therapy services. Starting the conversation early, identifying and troubleshooting potential barriers to participation, and selecting an EBP that aligns with the individual’s goals are important factors for successful transition. Ultimately, incorporating EBPs into clinical practice increases the value of care by improving outcomes and reducing the burden of chronic conditions.

Acknowledgement:

The authors would like to thank Jacqueline Osborne DPT, GCS for oversight and editorial contributions.

Conflicts of Interest and Source of Funding: Dr. Schrodt is currently receiving a grant (PF-PTFA-690831) from the Parkinson’s Foundation. Dr. Vincenzo is currently receiving grants (KL2 TR003108 and UL1 TR003107) from the Translational Research Institute through the National Center for Advancing Translational Sciences of the National Institutes of Health. Dr. Rohrer is currently employed by Tivity Health, the administrator of SilverSneakers. Dr. Brach is currently receiving grants (K24 AG057728, R01 AG045252, NIH P30 AG024827) from the National Institutes of Health. Dr. Shubert is currently receiving grants (R44CE002343–03, SIP 14–020, SIP 12–058) from the Centers for Disease Control and Prevention. The remaining authors declared no funding sources. All authors are members of a partnership task force between the Academy of Geriatric Physical Therapy, a component of the American Physical Therapy Association, and the National Council on Aging.

Contributor Information

Lori A. Schrodt, Department of Physical Therapy, Western Carolina University, Cullowhee, NC.

Rachel A. Sledge, Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC

Colleen Hergott, Department of Physical Therapy, Augusta University, Augusta GA.

Beth Rohrer, Tivity Health, Franklin, TN.

Jennifer Sidelinker, Genesis HealthCare, Kennett Square, PA.

Jennifer S. Brach, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA.

Jennifer Vincenzo, Department of Physical Therapy, University of Arkansas for Medical Sciences, Little Rock, AR.

Kathleen D. Shirley, Physical Therapy and Wellness Consultant, Jacksonville, FL.

Tiffany E. Shubert, Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC.

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