Table 1.

Summary of potential courses of action needed to improve quality community care.

Levels	Current challenge	Potential actions/measures	Overall aim
Research level	Limited evidence for benefits and effective assessment measures	Continue to build specific evidence for different disease severity, PD phenotype subpopulations, among persons who have cognitive impairment, and in all practice settings.	Generating evidence to inform best practice
		Develop research with proper design, sufficient power and a proper regard for safety issues.
		Make available more funding opportunities for non-pharmcological interventions
	Limited translation of the research evidence to practice	Define recommendations on how to adapt research studies into practice. Use trained clinical Parkinson experts to deliver interventions in experimental studies consistently, with little variation across practices, and in accordance with guideline recommendations or research protocols	Refine the care strategy and its implementation. Inform future implementation efforts
Instructor level	Limited expertise among professionals delivering the programs	Support PD expertise among instructors via specific training, adequate ongoing educational support, and continuous contact with people with PD (by increasing referrals for increased case load and thus, more expertise)	Providing safe evidenced-based practices (better care).
			Reduce unnecessary procedures
			Reduce unrealistic expectations in people with PD, particularly for those with a less favorable profiles for certain exercises
Patient level	Barriers to participation in exercise	Implement strategies to bypass common barriers such as fluctuations in health, concerns about safety, time management strategies, culturally appropriate care, insufficiently engaging exercise options, use of technology to facilitate access to expert care.	Increase participation via easy access to safe, cost free, engaging exercise oportunities
		Provide programs that cost less, involve less travel, provide physical or psychological benefits and supervised by qualified professionals
	Reduced awareness of such programs as options of care	Inform about access to these programs through awareness campagnes for people with PD regarding the existence evidence-based exercise programs and where such programs can be received	To generate informed people with PD that have active participation to make the right decisions for their health
Organizational level	Slow dissemination of the new evidence-based practices	Create an organized infrastructure to provide support to exercise instructors and other implementers to introduce consistently changing practices and embrace additional changes when never new evidence emerges.	Facilitate quick efficient dissemination of the new evidence-based practices.
		Use online communities to disseminate new research findings	Developing an evidence standard infrastructure for assuring and assessing the implementation of community practice
	Access to programs in the community	Reduce PD-specific critical barriers to participation: • 1-Traveling barriers with organized community transportation systems (e.g., “exercise bus”). Delivering online services with teaching courses on how to use technology. • 2-Financial barriers via provision of affordable services with covered services either through nonprofit, volunteer-run initiatives or integrated as part of the healthcare systems. Include a community exercise program as a health insurance benefit. • 3-Location barriers via creating safe places to exercise. • 4-Cultural barriers via hiring translators to favor underserved populations.	Making programs available and accessible to people with PD to promote better care and ultimately reduce costs to health care systems
	Reduced public awareness of existing programs in the community	Improve public awareness of how to access most beneficial exercise programs. Role for patient’s associations.	Raising awareness of evidence-based exercise programs to increased public interest in community exercise programs (and influence the direction of clinical research, and thus advance clinical practice)
	Unmonitored proliferation of programs	Redefine new care strategy for health system, definingclear desired outcomes and penalties for imposing practices upon people with PD that are not sufficiently evidence-based, including financial support and limited resources	Guarantee safe effective programs delivered