Abstract
Background and Purpose.
The Agency for Healthcare Research and Quality highlights the need for sustainable linkages between clinical and community settings to enhance prevention and improve care of people with chronic conditions. The first step in promoting linkages is understanding the knowledge and use of evidence-based programs by physical therapy (PT) professionals. Therefore, the objective of this study was to describe the knowledge and referral to evidence-based programs in the community by a convenience sample of PT professionals and to examine the characteristics of those who refer to evidence-based programs.
Methods.
A cross-sectional web-based survey containing 36 questions regarding respondents’ demographics and evidence-based program knowledge and referral practices was disseminated to a convenience sample of PT professionals via email, news-blasts, social media, and word of mouth.
Results and Discussion.
459 PT professionals completed the survey. Approximately half reported practicing for >20 years and 75% are members of the American Physical Therapy Association (APTA). The majority (74%) are aware of evidence-based programs; however, fewer (56%) refer to these programs. Compared to individuals who do not refer to evidence-based programs, individuals who refer are more likely to be involved in PT organizations and be an APTA Geriatrics member. Of the individuals who do not refer to evidence-based programs, 21.5% reported not knowing they existed and 33% reported not knowing where the programs are located.
Conclusion.
Most survey respondents reported knowing about evidence-based programs and more than half reported being aware of the evidence-based programs available in their communities. These results indicate many PT professionals already have a knowledge of evidence-based programs to support clinic-community linkages. As survey respondents were a sample of convenience and likely do not represent all PT professionals in the United States, the results should be interpreted with caution. Additional research on a more representative sample is needed to fully understand the current utilization of evidence-based programs which will enable us to design efforts to improve the clinic to community transition. Improving linkages between PT professionals and community resources has the potential to benefit both patients and clinicians and lessen the burden on the healthcare system.
Keywords: evidence-based programs, transitions of care, knowledge
INTRODUCTION
Management of persons with chronic disease is a prevalent and costly problem for healthcare systems. The Chronic Care Model identifies essential elements of the healthcare system that encourage high quality chronic disease care.1,2 The original model was directed toward clinical healthcare systems to promote productive interactions between informed patients and proactive healthcare teams for improved functional and clinical outcomes.1,2 The Expanded Chronic Care Model (ECCM) was later developed to better integrate population health promotion and increase emphasis on the role the community plays in prevention and management of chronic disease.3 The ECCM promotes collaboration across clinical healthcare services and community support systems to best meet the needs of patients and communities. The Agency for Healthcare Research and Quality (AHRQ) also highlights the need for sustainable linkages between clinical and community settings to enhance prevention and improve care of people with chronic disease.4
Community-based organizations (CBOs) work at the local level to provide evidence-based health promotion programs and are a key partner in helping older adults live healthier lives. Evidence-based programs are designed and tested for specific populations, proven to be effective, and translated into practice models that are easily implemented by CBOs.5 Evidence-based programs are vetted based on rigorous criteria by national organizations such as the Administration for Community Living, National Council on Aging (NCOA), and the Centers for Disease Control (CDC).6CBOs, such as Area Agencies on Aging, senior centers, faith-based organizations, and YMCAs, offer evidence-based programs to improve chronic disease self-management, physical activity, behavioral health, and fall prevention. Thus, CBOs play a critical role in building and sustaining clinical and community linkages. Given their expertise and regular face-to-face contact with patients, physical therapy (PT) professionals (i.e. physical therapists and physical therapist assistants) are well-poised to build a continuum that helps transition patients to better self-management, through utilization of community resources to bridge the clinic-to-community gap.7
Numerous community resources exist but when recommending programs, the quality of the program and its appropriateness for each individual should be considered. The aging services network has been working since 2003 to increase the availability of effective disease prevention and health promotion programs. Currently, there are dozens of evidence-based programs to reduce fall risk, promote physical activity, and manage chronic conditions available in communities across the United States. In addition to formal evidence-based programs, other community resources such as fitness centers, YMCA’s and programs such as SilverSneakers® are available to assist with self-management of chronic conditions and to promote the health and well-being of older adults.
PT professionals often identify and treat issues related to fall risk, decreased physical activity and chronic conditions which could benefit from referral to resources in the community. The first step in promoting linkages between the PT clinic and the community is understanding the knowledge and use of evidence-based programs by PT professionals. The extent to which PT professionals are aware of and refer to evidence-based programs and community resources is unknown. Therefore, we sought to begin to describe the knowledge and use of evidence-based programs by PT professionals and to examine the characteristics of those who refer to evidence-based programs. Understanding the current utilization of evidence-based programs in the community by PT professionals will enable us to design efforts to improve the clinic to community transition. Improving linkages between PT professionals and community resources has the potential to benefit both patients and clinicians and to lessen the burden on the health care system.
METHODS
This cross-sectional survey of a convenience sample of PT professionals in the United States was deemed exempt by the University of Arkansas for Medical Science’s Institutional Review Board (IRB). Written informed consent was not obtained; however, information about the nature of the survey, and how to contact the IRB was included in the introduction and no personal identifying information was obtained. The survey was developed, distributed, and managed using Redcap (Research Electronic Data Capture) tools hosted at University of Arkansas for Medical Sciences. The funders played no role in the design, conduct, or reporting of this study.
Survey Instrument
The survey was developed by a task force of experts from the Academy of Geriatric Physical Therapy, a component of the American Physical Therapy Association (APTA-Geriatrics) and the NCOA. An objective of the task force was to improve care of older adults and cross-collaboration with other organizations.
The task force developed a web-based cross-sectional survey to identify falls-risk management and evidence-based program referral practices among PT professionals treating older adults. The web-based survey was piloted for content validity by the panel and revisions were made prior to finalizing the survey. Reliability was not determined. The survey contained 36 questions regarding respondents’ demographics and two subsets of questions related to (1) falls-risk management and (2) evidence-based program referral practices (see eAppendix). In pilot testing, the survey took approximately 20 minutes to complete. This study focused on the subset of questions related to evidence-based program referral practices including programs that have met the Administration for Community Living’s criteria for highest level of evidence and are included on the NCOA’s list of evidence-based programs for fall prevention or health promotion/disease prevention. In addition to the NCOA approved evidence-based programs we also inquired about other community programs and resources.
Survey Distribution
The open-access, public survey was disseminated to a convenience sample of PT professionals via email, news-blasts, social media, and word of mouth between September and November 2019. Data were collected anonymously from PT professionals in the United States. Incomplete surveys (n=1) were omitted from the analyses.
Data Analysis
We used appropriate descriptive statistics (means, standard deviations, frequencies, and percentages) to summarize demographic characteristics of the survey respondents. Some categorical variable classes were combined to provide more meaningful classifications or due to small frequencies. Additionally, frequency counts and percentages were used to summarize survey responses related to knowledge and use of community interventions and reasons for not referring to evidence-based programs. To compare characteristics between survey respondents that do and do not know about evidence-based programs in the community and between survey respondents that refer and do not refer to evidence-based programs, we used independent samples t-tests for continuous data and chi-square and Fisher’s Exact tests for categorical data. SAS® version 9.4 (SAS Institute, Inc., Cary, North Carolina) was used for all statistical analyses.
RESULTS
Between September and November 2019, 459 PT professionals (88% physical therapists, 12% physical therapist assistants) representing 49/50 states completed the survey. Table 1 depicts the characteristics of survey respondents. Respondents were on average 48 years of age and primarily female. Approximately half had earned a doctorate in physical therapy degree (DPT) and had been practicing physical therapy for more than 20 years. Three quarters of the respondents were members of the American Physical Therapy Association (APTA) with the majority also being members of sub-specialty sections and academies. The most common section/academy membership reported included geriatrics and neurologic. Approximately 56% of respondents were American Board of Physical Therapy Specialists in selected clinical practice areas. Most (81%) were employed full-time with 30% spending 0–25% of their time in patient care and 45.5% spending >75% of their time in patient care. Most worked in outpatient/wellness (46%) or skilled nursing settings (34%) and reported over 75% of their caseload was older adults.
Table 1.
Demographics of survey respondents, mean±standard deviation or n(%)
| Characteristic | Survey respondents N=459 |
|---|---|
|
| |
| Age | 47.6±12.0 |
| Gender | |
| Male | 75 (16.3) |
| Female | 379 (82.6) |
| Prefer not to respond | 5 (1.1) |
| Occupation | |
| PT | 406 (88.5) |
| PTA | 53 (11.6) |
| Degree | |
| Associate | 33 (7.2) |
| BS | 80 (17.4) |
| MS | 79 (17.2) |
| DPT | 212 (46.2) |
| EdD/PhD | 44 (9.6) |
| Other | 11 (2.4) |
| Years in practice | |
| ≤5 | 48 (10.5) |
| 6–10 | 76 (16.6) |
| 11–20 | 101 (22.0) |
| >20 | 234 (51.0) |
| APTA member | |
| Yes | 344 (75.0) |
| No | 107 (23.3) |
| missing | 8 (1.7) |
| APTA Section/Academy member | |
| No | 121 (26.4) |
| 1 | 122 (26.6) |
| 2 | 132 (28.8) |
| 3 or more | 84 (18.3) |
| APTA Section/Academy member | |
| Geriatrics | 267 (58.2) |
| Neurologic | 94 (20.5) |
| Orthopaedic | 51 (11.1) |
| Home health | 48 (10.5) |
| Health policy and administration | 20 (4.4) |
| Acute care section member | 33 (7.2) |
| Aquatic section | 7 (1.5) |
| Cardiovascular and pulmonary | 18 (3.9) |
| Electrophysiology and wound | 13 (2.8) |
| Education section member | 57 (12.4) |
| Federal | 7 (1.5) |
| Hand and upper extremity | 1 (0.2) |
| Oncologic | 12 (2.6) |
| Pediatric | 5 (1.1) |
| Private practice | 10 (2.2) |
| Research | 23 (5.0) |
| Sports | 10 (2.2) |
| Women’s health | 11 (2.4) |
| Any board certified clinical specialist | 257 (56.0) |
| Cardiovascular and pulmonary | 1 (0.2) |
| Geriatrics | 140 (30.5) |
| Neurology | 37 (8.1) |
| Oncology | 1 (0.2) |
| Orthopedics | 18 (3.9) |
| Sports | 3 (0.7) |
| Women’s health | 0 (0.0) |
| Clinical electrophysiology | 0 (0.0) |
| Pediatrics | 1 (0.2) |
| Involved in PT organization | 246 (53.6) |
| Member of other professional organization | 118 (25.7) |
| Involved in other organization | 52 (11.3) |
| Practice setting | |
| Outpatient/Wellness | 211 (46.0) |
| Acute care | 63 (13.7) |
| Assisted living | 67 (14.6) |
| Inpatient rehabilitation | 30 (6.5) |
| Skilled nursing facility | 157 (34.2) |
| Home health | 92 (20.0) |
| Academic program | 55 (12.0) |
| Other | 38 (8.3) |
| Employment status | |
| Full-time | 373 (81.3) |
| Part-time/per diem/other | 85 (18.5) |
| N/A | 1 (0.2) |
| Percent of time in patient care | |
| 0–25% | 139 (30.3) |
| 26–50% | 40 (8.7) |
| 51–75% | 71 (15.5) |
| 76–100% | 209 (45.5) |
| Percent caseload 65+ | |
| 5–25% | 36 (7.8) |
| 26–50% | 41 (8.9) |
| 51–75% | 92 (20.0) |
| 76–100% | 278 (60.6) |
| Not treating/missing/N/A | 12 (2.6) |
APTA = American Physical Therapy Association
The knowledge and use of community interventions is shown in Table 2. The majority (74%) of respondents were aware that the NCOA recommends certain evidence-based programs; however, fewer respondents (56%) refer to these programs. Of those individuals who were aware of evidence-based programs, more than half (63%) reported that evidence-based programs are offered in their community. The most common programs that PT professionals refer to include the Otago Exercise Program (25.9%), A Matter of Balance (17.9%), Tai Chi for Arthritis (17.7%) and YMCA Moving for Better Balance (13.5%). Other common community referrals included to a local gym (50.1%), local senior center (56.6%) or SilverSneakers® programs (55.8%). Of the 144 individuals who do not refer to evidence-based programs, 21.5% reported not knowing they existed and 33% reported not knowing where the programs are located. Approximately 12% reported preferring to do clinical physical therapy care than referring to community evidence-based programs (Table 3).
Table 2.
Knowledge and use of community interventions in those who screen for falls risk (n=459)
| Question regarding knowledge and use | N(%) |
|---|---|
|
| |
| Do you know the NCOA recommends certain evidence-based health promotion/disease prevention programs for older adults? | |
| Yes | 338 (73.6) |
| No | 121 (26.4) |
| Are any of the listed evidence-based programs offered by providers in your community? | |
| Yes | 290 (63.2) |
| No | 34 (7.4) |
| I don’t know | 135 (29.4) |
| Do you ever refer to evidence-based health promotion/disease prevention programs? | |
| Yes | 255 (55.6) |
| No | 144 (31.4) |
| I don’t know | 26 (5.7) |
| Missing | 34 (7.4) |
| Which health promotion/disease prevention programs do you refer to in your community? (could select more than one) | |
| A Matter of Balance | 82 (17.9) |
| Active Choices | 2 (0.4) |
| Active Living Every Day | 5 (1.1) |
| Arthritis Foundation Aquatic Program | 43 (9.4) |
| Bingocize | 2 (0.4) |
| CAPABLE | 1 (0.2) |
| Chronic Disease Self-Management | 27 (5.9) |
| Diabetes Self-Management | 26 (5.7) |
| Enhance Fitness | 11 (2.4) |
| Falls Talk | 10 (2.2) |
| FallScape | 0 (0.0) |
| Fit and Strong | 16 (3.5) |
| Geri-Fit | 8 (1.7) |
| Healthy Moves for Aging Well | 5 (1.1) |
| Healthy Steps for Older Adults | 13 (2.8) |
| Healthy Steps in Motion | 2 (0.4) |
| On the Move | 8 (1.7) |
| Otago Exercise Program | 119 (25.9) |
| Stay Active and Independent for Life | 16 (3.5) |
| Stepping On | 41 (8.9) |
| Tai Chi for Arthritis | 81 (17.7) |
| Tai Ji Quan: Moving for Better Balance | 29 (6.3) |
| Walk with Ease | 11 (2.4) |
| YMCA Moving for Better Balance | 62 (13.5) |
| Other | 33 (7.2) |
| What other community programs or resources do you typically refer your patients to? (could select more than one) | |
| Local gym | 230 (50.1) |
| Local senior center | 260 (56.6) |
| Area Agency on Aging | 101 (22.0) |
| YMCA | 149 (32.5) |
| Silver Sneakers | 256 (55.8) |
| Other | 56 (12.2) |
| I usually don’t refer to community programs | 48 (10.5) |
Table 3.
Reasons for not referring to EBPs (n=144)
| Reason (could select only 1 reason) | Counts (%) |
|---|---|
|
| |
| I did not know they existed | 31 (21.5) |
| I do not know where they are located | 48 (33.3) |
| I know there are not any in my area | 8 (5.6) |
| I prefer to do individual PT | 17 (11.8) |
| Not currently treating patients | 14 (9.7) |
| No specific reason | 25 (17.4) |
| Missing | 1(0.7) |
Compared to individuals who do not know about evidence-based programs, individuals who know about evidence-based programs are younger, more likely to be a PT, member of the APTA, and involved in a PT organization (Table 4). Individuals who know about evidence-based programs are also more likely to be members of APTA-Geriatrics, American Board of Physical Therapy Specialists in geriatrics and spend less time in patient care. Individuals who refer to evidence-based programs also tend to be members of APTA-Geriatrics, practice in the outpatient/wellness setting and have a caseload that has a high percentage of older adults (Table 5). Individuals who are American Board of Physical Therapy Specialists in orthopedics are less likely to refer to evidence-based programs.
Table 4.
Demographic characteristics of survey respondents by knowledge of EBPs (n=459)
| Knows about EBPs Mean±SD or N (%) (n=338) |
Does not know about EBPs Mean±SD or N (%) (n=121) |
P-value | |
|---|---|---|---|
|
| |||
| Age | 48.4±11.9 | 45.3±11.9 | 0.0124 |
| Gender | 0.4460 | ||
| Male | 51 (15.1) | 24 (19.8) | |
| Female | 283 (83.7) | 96 (79.3) | |
| Prefer not to report | 4 (1.2) | 1 (0.8) | |
| Occupation | 0.0028 | ||
| PT | 308 (91.1) | 98 (81.0) | |
| PTA | 30 (8.9) | 23 (19.0) | |
| Degree | 0.0654 | ||
| Associate | 19 (5.6) | 14 (11.6) | |
| BS | 58 (17.2) | 22(18.2) | |
| MS | 60 (17.8) | 19 (15.7) | |
| DPT | 153 (45.3) | 59 (48.8) | |
| EdD/PhD | 39 (11.5) | 5 (4.1) | |
| Other | 9 (2.7) | 2 (1.7) | |
| Years in practice | 0.0595 | ||
| ≤5 | 30 (8.9) | 18 (14.9) | |
| 6–10 11–20 |
52 (15.4) 72 (21.3) |
24 (19.8) 29 (24.0) |
|
| >20 | 184 (54.4) | 50 (41.3) | |
| APTA member | 0.0435 | ||
| Yes | 259 (76.6) | 85 (70.3) | |
| No | 71 (21.0) | 36 (29.8) | |
| No response | 8 (2.4) | 0 (0.0) | |
| Involved in PT organization | 203 (60.1) | 43 (35.5) | <0.0001 |
| Member of other organization | 96 (28.4) | 22 (18.2) | 0.0148 |
| APTA Section/Academy member | 0.0993 | ||
| No | 83 (24.6) | 38 (31.4) | |
| 1 | 85 (25.2) | 37 (30.6) | |
| 2 | 101 (29.9) | 31 (25.6) | |
| 3 or more | 69 (20.4) | 15 (12.4) | |
| APTA Section/Academy member | |||
| Geriatrics | 216 (63.9) | 51 (42.2) | <0.0001 |
| Neurologic | 71 (21.0) | 23 (19.0) | 0.6403 |
| Orthopaedic | 32 (9.5) | 19 (15.7) | 0.0611 |
| Home health | 36 (10.7) | 12 (9.9) | 0.8210 |
| Health policy and administration | 17 (5.0) | 3 (2.5) | 0.2383 |
| Acute care | 29 (7.7) | 7 (5.8) | 0.4858 |
| Aquatic | 5 (1.5) | 2 (1.7) | 1.0000 |
| Cardiovascular and pulmonary | 13 (3.9) | 5 (4.1) | 1.0000 |
| Electrophysiology and wound | 9 (2.7) | 4 (3.3) | 0.7513 |
| Education | 45 (13.3) | 12 (9.9) | 0.3310 |
| Federal | 5 (1.5) | 2 (1.7) | 1.0000 |
| Hand and upper extremity | 1 (0.3) | 0 (0.0) | 1.0000 |
| Oncologic | 8 (2.4) | 4 (3.3) | 0.5246 |
| Pediatric | 5 (1.5) | 0 (0.0) | 0.3321 |
| Private practice | 7 (2.1) | 3 (2.5) | 0.7277 |
| Research | 17 (5.0) | 6 (5.0) | 1.0000 |
| Sports | 4 (1.2) | 6 (5.0) | 0.0242 |
| Women’s health | 9 (2.7) | 2 (1.7) | 0.7354 |
| Any board-certified clinical specialist | 159 (47.0) | 43 (35.5) | 0.0287 |
| Cardiovascular and pulmonary | 1 (0.3) | 0 (0.0) | 1.0000 |
| Geriatrics | 119 (35.2) | 21 (17.4) | 0.0003 |
| Neurology | 27 (8.0) | 10 (8.3) | 0.9237 |
| Oncology | 1 (0.3) | 0 (0.0) | 1.0000 |
| Orthopedics | 10 (3.0) | 8 (6.6) | 0.0989 |
| Sports | 0 (0.0) | 3 (2.5) | 0.0180 |
| Women’s health | 0 (0.0) | 0 (0.0) | ----- |
| Clinical electrophysiology | 0 (0.0) | 0 (0.0) | ----- |
| Pediatrics | 1 (0.3) | 0 (0.0) | 1.0000 |
| Employment status | 0.1837 | ||
| Full-time | 272 (80.5) | 101 (83.5) | |
| Part time/per diem/other | 66 (19.5) | 19 (15.7) | |
| No response | 0 (0.0) | 1 (0.8) | |
| Practice setting | |||
| Outpatient/Wellness | 154 (45.6) | 57 (47.1) | 0.7698 |
| Acute care | 45 (13.3) | 18 (14.9) | 0.6682 |
| Assisted living | 50 (14.8) | 17 (14.1) | 1.0000 |
| Inpatient rehab | 21 (6.2) | 9 (7.4) | 0.6399 |
| Skilled nursing facility | 113 (33.4) | 44 (36.4) | 0.5597 |
| Home health | 66 (19.5) | 26 (21.5) | 0.6438 |
| Academic program | 46 (13.6) | 9 (7.4) | 0.0728 |
| Other | 32 (9.5) | 6 (5.0) | 0.1225 |
| Percent of time in patient care | 0.0012 | ||
| 0–25% | 119 (35.2) | 20 (16.5) | |
| 26–50% | 29 (8.6) | 11 (9.1) | |
| 51–75% | 51 (15.1) | 20 (16.5) | |
| 76–100% | 139 (41.1) | 70 (57.9) | |
| Percent caseload 65+ | 0.6476 | ||
| 0–25% | 26 (7.7) | 10 (8.3) | |
| 26–50% | 27 (8.0) | 14 (11.6) | |
| 51–75% | 65 (19.2) | 27 (22.3) | |
| 76–100% | 211 (62.4) | 67 (55.4) | |
| No response | 9 (2.7) | 3 (2.5) | |
EBPs = Evidence-based programs
APTA = American Physical Therapy Association
Table 5.
Demographic characteristics of survey respondents by referral to EBPs (n=399)
| Refers to EBPs Mean±SD or N (%) (n=255) |
Does not refer EBPs Mean±SD or N (%) (n=144) |
P-value | |
|---|---|---|---|
|
| |||
| Age | 48.5±11.8 | 46.4±12.7 | 0.1021 |
| Gender | 0.6139 | ||
| Male | 45 (17.7) | 21 (14.6) | |
| Female | 206 (80.8) | 122 (84.7) | |
| Prefer not to report | 4 (1.6) | 1 (0.7) | |
| Occupation | 0.2433 | ||
| PT | 234 (91.8) | 127 (88.2) | |
| PTA | 21 (8.2) | 17 (11.8) | |
| Degree | 0.2837 | ||
| Associate | 15 (5.9) | 9 (6.3) | |
| BS | 47 (18.4) | 23 (16.0) | |
| MS | 47 (18.4) | 22 (15.3) | |
| DPT | 113 (44.3) | 70 (48.6) | |
| EdD/PhD | 23 (9.0) | 19 (13.2) | |
| Other | 10 (3.9) | 1 (0.7) | |
| Years in practice | 0.1534 | ||
| ≤5 | 24 (9.4) | 20 (13.9) | |
| 6–10 | 44 (17.3) | 22 (15.3) | |
| 11–20 | 47 (18.4) | 36 (25.0) | |
| >20 | 140 (54.9) | 66 (45.8) | |
| APTA member | 0.7621 | ||
| Yes | 193 (75.7) | 108 (75.0) | |
| No | 56 (22.0) | 34 (23.6) | |
| No response | 6 (2.4) | 2 (1.4) | |
| Involved in PT organization | 154 (60.4) | 66 (45.8) | 0.0050 |
| Member of other organization | 72 (28.2) | 37 (25.7) | 0.6690 |
| APTA Section/Academy member | 0.5428 | ||
| No | 64 (25.1) | 38 (26.4) | |
| 1 | 68 (26.7) | 43 (29.9) | |
| 2 | 69 (27.1) | 41 (28.5) | |
| 3 or more | 54 (21.2) | 22 (15.3) | |
| APTA Section/Academy member | |||
| Geriatrics | 164 (64.3) | 73 (50.7) | 0.0078 |
| Neurologic | 55 (21.6) | 30 (20.8) | 0.8632 |
| Orthopaedic | 26 (10.2) | 19 (13.2) | 0.3632 |
| Home health | 24 (9.4) | 11 (7.6) | 0.5477 |
| Health policy and administration | 12 (4.7) | 7 (4.9) | 0.9443 |
| Acute care | 16 (6.3) | 10 (6.9) | 0.7946 |
| Aquatic | 6 (2.4) | 1 (0.7) | 0.4297 |
| Cardiovascular and pulmonary | 12 (4.7) | 5 (3.5) | 0.5579 |
| Electrophysiology and wound | 8 (3.1) | 4 (2.8) | 1.0000 |
| Education | 31 (12.2) | 21 (14.6) | 0.4893 |
| Federal | 5 (2.0) | 1 (0.7) | 0.4251 |
| Hand and upper extremity | 1 (0.4) | 0 (0.0) | 1.0000 |
| Oncologic | 7 (2.8) | 4 (2.8) | 1.0000 |
| Pediatric | 3 (1.2) | 2 (1.4) | 1.0000 |
| Private practice | 4 (1.6) | 1 (0.7) | 0.6578 |
| Research | 14 (5.5) | 8 (5.6) | 0.9781 |
| Sports | 4 (1.6) | 5 (3.5) | 0.2936 |
| Women’s health | 7 (2.8) | 4 (2.8) | 1.0000 |
| Any board-certified clinical specialist | 113 (44.3) | 65 (45.1) | 0.8735 |
| Cardiovascular and pulmonary | 0 (0.0) | 1 (0.7) | 0.3609 |
| Geriatrics | 88 (34.5) | 37 (25.7) | 0.0683 |
| Neurology | 18 (7.1) | 15 (10.4) | 0.2422 |
| Oncology | 0 (0.0) | 1 (0.7) | 0.3609 |
| Orthopedics | 6 (2.4) | 9 (6.3) | 0.0494 |
| Sports | 1 (0.4) | 0 (0.0) | 1.0000 |
| Women’s health | 0 (0.0) | 0 (0.0) | ---- |
| Clinical electrophysiology | 0 (0.0) | 0 (0.0) | ---- |
| Pediatrics | 0 (0.0) | 1 (0.7) | 0.3609 |
| Employment status | 0.5150 | ||
| Full-time | 207 (81.2) | 113 (78.5) | |
| Part time/per diem/other |
48 (18.8) | 31 (21.5) | |
| Practice setting | |||
| Outpatient/Wellness | 130 (51.0) | 56 (38.9) | 0.0201 |
| Acute care | 38 (14.9) | 18 (12.5) | 0.5071 |
| Assisted living | 42 (16.5) | 17 (11.8) | 0.2074 |
| Inpatient rehab | 18 (7.1) | 11 (7.6) | 0.8303 |
| Skilled nursing facility | 76 (29.8) | 56 (38.9) | 0.0640 |
| Home health | 47 (18.4) | 24 (16.7) | 0.6580 |
| Academic program | 33 (12.9) | 18 (12.5) | 0.8991 |
| Other | 24 (9.4) | 11 (7.6) | 0.5477 |
| Percent of time in patient care | 0.3766 | ||
| 0–25% | 84 (32.9) | 44 (30.6) | |
| 26–50% | 24 (9.4) | 12 (8.3) | |
| 51–75% | 46 (18.0) | 19 (13.2) | |
| 76–100% | 101 (39.6) | 69 (47.9) | |
| Percent caseload 65+ | 0.0004 | ||
| 0–25% | 12 (4.7) | 21 (14.6) | |
| 26–50% | 22 (8.6) | 17 (11.8) | |
| 51–75% | 42 (16.5) | 34 (23.6) | |
| 76–100% | 171 (67.1) | 69 (47.9) | |
| No response | 8 (3.1) | 3 (2.1) | |
EBPs = Evidence-based programs
APTA = American Physical Therapy Association
DISCUSSION
Understanding the current awareness and utilization of evidence-based programs and other community resources by PT professionals will inform efforts to facilitate the clinic to community transition. Therefore, we sought to begin to describe the knowledge and use of evidence-based programs by a convenience sample of PT professionals and to examine the characteristics of those who refer to evidence-based programs. Most survey respondents (74%) reported knowing about evidence-based programs and 63% reported being aware of the evidence-based programs available in their communities. These results indicate many PT professionals already have a knowledge-base about evidence-based programs to support clinic-community linkages. In fact, 56% reported referring patients to evidence-based programs. PT professionals with board-certification in geriatrics, more experience and professional association involvement, and who work in outpatient/wellness settings with a high percentage of older adult patients demonstrated greater knowledge of evidence-based programs. It is likely that PT professionals with board-certification and who are involved in professional association activities have greater exposure to professional literature and educational programming that has enhanced their knowledge of evidence-based programs. PT professionals who work in outpatient/wellness settings with a greater percentage of older adults were more likely to refer to evidence-based programs. Compared to other settings such as acute care or skilled nursing facility, out-patient physical therapy care is on a point in the care continuum that is closer to and more likely to utilize community services. Given the community delivery of most evidence-based programs, referrals may be greater for older adults who are community-dwelling and who are functionally able to access transportation to community sites and participate in the types of programs offered. The results indicate PT professionals who are board-certified in orthopedics are less likely to refer to evidence-based programs may be explained by the demographic of their patient population which may have been younger and not appropriate for referral to evidence-based programs.
The Otago Exercise Program (OEP) was the program older adults were most frequently referred to. The OEP is a unique evidence-based program in that it is often delivered by a PT professional typically in a 1:1 model, compared with other community-based evidence-based programs that are more commonly offered in group formats by trained lay facilitators or instructors. PT professionals may have been more likely to refer to the OEP because they or someone in their clinic was certified in its delivery and/or because of confidence in the 1:1 model for older adults at risk for falling.8–10
A higher proportion of PT professionals referred older adults to A Matter of Balance, Tai Chi for Arthritis, and YMCA Moving for Better Balance. Each of these programs is approved by the NCOA as an evidence-based program for falls prevention. A Matter of Balance focuses on strategies to reduce fear of falling, while Tai Chi for Arthritis and YMCA Moving for Better Balance utilize tai chi and tai chi-based principles to improve mobility, balance, and reduce fall risk. The higher number of referrals to these programs indicate some PT professionals are including evidence-based programs to address the complex problem of falls among older adults. Referrals to these evidence-based programs likely also reflect the prevalence and specific programs available in each respondent’s region.11 A Matter of Balance and Tai Chi for Arthritis were some of the first programs designated as evidence-based programs and are widely disseminated throughout CBOs and therefore more likely to be available locally and known by PT professionals.12 Because almost half our sample worked in outpatient/wellness practices it is also likely they more frequently referred to programs that fit the needs and higher functional abilities of older adults who reside in the community and are able to attend community programs.
One-third to half of PT professionals reported referring to community sites, such as YMCA’s, senior centers, gyms, and locations that offered SilverSneakers®. This encouraging finding helps support that PT professionals are linking some older adults to community resources, some of which may offer evidence-based programs. Senior centers and YMCA’s do offer some evidence-based programs, such as YMCA Moving for Better Balance, A Matter of Balance, and Tai Chi for Arthritis, so it is possible that PT professional referrals to these types of sites may have included referrals to evidence-based programs. SilverSneakers®, a no-cost health and fitness benefit that is included with many Medicare plans, is also available at gyms, community centers and other locations.
Although 74% of survey respondents are aware of evidence-based programs, only 56% refer patients to them and a maximum of 57% report referring to any other community programs or resources. The most frequently cited reasons for not referring to evidence-based programs were a lack of knowledge of where they offered (33%) and not knowing they existed (22%). Our findings indicate PT professionals who are not aware of evidence-based programs are more likely to be PTAs, non-APTA members, and not involved in a PT organization. Several efforts to disseminate knowledge about the value of evidence-based programs have been sponsored by APTA-Geriatrics. Dating back to at least 2013, educational programming at national APTA conferences has included sessions highlighting evidence-based programs and their potential benefit for improving outcomes among older adults. Therefore, other means of improving awareness of evidence-based programs are necessary. In 2018, APTA-Geriatrics and the NCOA formed a task force to collaboratively improve clinic-to-community connections. The task force has developed resources and materials to educate PT professionals about evidence-based programs and the benefits of partnering with CBOs. These resources are freely available on the APTA-Geriatrics website to non-members as well as members to help extend dissemination. However, the best strategies for enhancing reach to non-members are not yet known. Future research should focus on improving knowledge translation and include a broad sample of PT professionals.
Despite a lack of awareness among some PT professionals and barriers to referral, approximately 50% of PT professionals report referring older adults to evidence-based programs or other community resources in alignment with the ECCM. PT professionals, with their expertise and regular face-to-face contact with patients, are well positioned to facilitate the clinic and community interactions and relationships that are critical for supporting population health promotion. PT professionals can and should identify effective programs in their community, refer patients and help support participation in these programs.3
Limitations and Future Directions
Our study has limitations that should be considered when interpreting the findings. Most notably, the survey respondents were a sample of convenience and are not representative of all PT professionals. Most of the respondents (75%) were APTA members which is much greater than the general population of PT professionals in which only 22% are APTA members. Given that APTA members are more likely to be knowledgeable of evidence-based programs, our findings likely overestimate the knowledge and referral to evidence-based programs. Despite this limitation, we believe this research is an important first step in understanding the knowledge and use of evidence-based programs. Additional research conducted in a more representative sample is needed to confirm these findings and to fully understand the current utilization of evidence-based programs by PT professionals in the United States. In addition, the nature of the questions (i.e., asking directly if PT professionals are aware of evidence-based programs) may lead to response bias in that respondents may give answers that they believe are socially acceptable. Findings from this study can guide the development of additional surveys and interview questions which can be deployed to a more representative sample of PT professionals. In addition, future work should expand to include the input from multiple stakeholders representing the clinic, the community, and the patient to gain a broader more diverse perspective.
CONCLUSIONS
Understanding the current knowledge and utilization of evidence-based programs in the community by a convenience sample of PT professionals is the first step in designing efforts to improve the clinic-to-community transition. The ultimate goal of improving linkages between PT clinics and community resources is directly in line with the ECCM and will likely benefit patients, clinicians, and the community and may in turn lessen the burden on the healthcare system.
Supplementary Material
Funding:
This work was supported in part by the National Institute on Aging at the National Institutes of Health (K24 AG057728 to JSB and P30 AG024827) and the Translational Research Institute grant through the National Center for Advancing Translational Sciences of the National Institutes of Health (KL2 TR003108 to JLV and UL1 TR003108).
REFERENCES
- 1.Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2–4. https://www.ncbi.nlm.nih.gov/pubmed/10345255. [PubMed] [Google Scholar]
- 2.Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74(4):511–544. https://www.ncbi.nlm.nih.gov/pubmed/8941260 [PubMed] [Google Scholar]
- 3.Barr VJ, Robinson S, Marin-Link B, et al. The expanded Chronic Care Model: An integration of concepts and strategies from population health promotion and the Chronic Care Model. Hosp Q. 2003;7(1):73–82. 10.12927/hcq.2003.16763. [DOI] [PubMed] [Google Scholar]
- 4.Programs: Prevention & chronic care: Improving primary care practice: Clinical-community linkages. Agency for Healthcare Research and Quality. https://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/index.html. Accessed March 11, 2018. [Google Scholar]
- 5.Evidence-based programming for older adults. Lausanne: Frontiers Media; 2015. [Google Scholar]
- 6.About Evidence-Based Programs. National Council on Aging. Evidence-Based Programs for Professionals Web site. https://www.ncoa.org/article/about-evidence-based-programs. Published 2020. Updated Oct 01, 2020. Accessed June 29, 2021.
- 7.Fishleder S, Petrescu-Prahova M, Harris JR, et al. Bridging the gap after physical therapy: Clinical-community linkages with older adult physical activity programs. Innov Aging. 2018;2(1):igy006. 10.1093/geroni/igy006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Shubert TE, Goto LS, Smith ML, Jiang L, Rudman H, Ory MG. The Otago Exercise Program: Innovative delivery models to maximize sustained outcomes for high risk, homebound older adults. Front Public Health. 2017;5:54. 10.3389/fpubh.2017.00054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Shubert TE, Smith ML, Goto L, Jiang L, Ory MG. Otago Exercise Program in the United States: Comparison of 2 implementation models. Phys Ther. 2017;97(2):187–197. 10.2522/ptj.20160236 [DOI] [PubMed] [Google Scholar]
- 10.Shubert TE, Smith ML, Ory MG, et al. Translation of the Otago Exercise Program for adoption and implementation in the United States. Front Public Health. 2014;2:152. 10.3389/fpubh.2014.00152. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Hamel C, Hekmatjah N, Hakakian B, et al. Evidence-based community fall prevention programs at senior centers near 10 US academic centers. J Am Geriatr Soc. 2019;67(7):1484–1488. 10.1111/jgs.15961. [DOI] [PubMed] [Google Scholar]
- 12.Brach JS, Juarez G, Perera S, Cameron K, Vincenzo JL, Tripken J. Dissemination and implementation of evidence-based falls prevention programs: Reach and effectiveness. J Gerontol A Biol Sci Med Sci. 2021. 10.1093/gerona/glab197. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.