OTAGO OUTCOMES DATABASE: 6 MONTH FOLLOW-UP OUTCOME DATA -- ENTRY FORM

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1 OTAGO OUTCOMES DATABASE: 6 MONTH FOLLOW-UP OUTCOME DATA -- ENTRY FORM NOTE: Optional -- These fields will be assigned and automatically recorded within patient records in the Otago Outcomes Database. Use this section on the paper data entry forms to assist with filing and record keeping outside if the database (if necessary). Therapist ID: Patient ID: Patient Name: Date of Visit: - _ - _ - _ First: Last Initial: _ / / Are you or do you still plan to work with this patient? : Enter Visit Date (above), then go to Discharge Survey. : Complete 6 Month Follow-Up Survey, below. PATIENT PERSPECTIVE Instructions to Therapist: Please ask the following questions and read the possible answers to your patient. Please record the patient s answer for each question: 1. Would you say that in general your health is: Excellent Very good Good Fair Poor 2. How satisfied are you with your current physical activity levels? Very Mostly Somewhat t at all 3. Please rate your level of agreement with the following statement: Would you say you feel confident that you can keep yourself from falling? Strongly Agree Agree Disagree Strongly Disagree 4. For the next five scenarios, choose the most appropriate answer from the following choices: How much difficulty do you have: 1/6 Some Much Unable to Do Walking across a room? Walking one block? Stooping, crouching, or kneeling? Getting out of a straight back chair? Climbing one flight of stairs? 5. How often do you restrict your activities because of difficulties in walking?

2 6. How often do you have someone to help you with your exercises between Physical Therapy visits? 7. Please rate how often you will be able to do your Otago Exercise Program exercises 3 or more times per week. 8. Please rate how strongly you agree or disagree with this statement: Having taken this program will help me prevent falls in the future. Strongly Agree Agree Disagree Strongly Disagree I don t know THERAPIST PERSPECTIVE Instructions to Therapist: Please answer the following questions about your patient: 1. Number of Otago visits provided to the patient over last 6 months: If 7 or more visits, then answer the following question: Why did you see your patient this many times over the last 6 months? (Select ALL that apply): Patient became ill Patient did not understand exercises Other: 2. Were any PT visits provided that were not Otago specific? If, then answer the following question: How many visits were not Otago specific? 3. Number of follow-up phone calls over last 6 months: 0 If 1 or more phone call, then answer the following question: Please estimate the average amount of time spent per call with this patient: 5 minutes or less 6 to 10 minutes 11 to 15 minutes More than 15 minutes 2/5

3 4. Has the patient had any falls during past 6 months (since starting Otago)? (Include ALL falls, even those previously documented.) I don t know If, then please answer the following questions: Number of falls in past 6 months: Number of falls resulting in injuries: Number of falls resulting in ED visits: Number of falls resulting in hospitalization: Instructions to Therapist: Please respond to the following statements about this patient s Otago prescription: 5. Exercises in addition to the Otago exercises were prescribed to the patient. 6. The exercises were significantly modified for the patient. 7. The patient was progressed to more challenging strength and balance exercises. 8. The patient had access to weights for the appropriate exercises. If, then answer the following question: The weights were increased over the 6 month period. 9. The patient has been prescribed a walking program. If, then answer the following question: The walking program has been progressed over the 6 months. 10. Optional comments about the patient s prescribed Otago Program: 3/5

4 Instructions to Therapist: Please respond to the following statements about the delivery of Otago to your patient: 11. The same therapist has delivered the program. 12. The Agency has been reimbursed for physical therapy visits. I don t know 13. The therapist has been unable to bill for services. 14. The patient has been compliant with the exercise program. Always Most of the time Some of the time t very often Never If Some of the time, t very often, or Never, then answer the following question: The patient was not compliant due to: (Select ALL that apply.) Cognitive Impairment Did not understand exercises Illness Lack of motivation Lack of support Patient unable to purchase/have access to ankle weights Other: 15. The patient has caregiver support to do the exercises. 16. The patient has support from his or her physician. 17. Do you plan to keep your patient on caseload longer than 6 months? If, then answer the following TWO questions: How much longer do you plan to keep your patient on caseload for? 3 months more 6 months more 4/5

5 Please approximate the number of visits you plan to provide to your patient during the plan of care: If more than 3 visits, then answer the following question: Why are you planning on seeing the patient more than the recommended number of visits? (Select ALL appropriate reason(s), below.) Patient became ill Patient does not understand exercises Patient not compliant with exercises Other: FUNCTIONAL MEASURES TUG: Record time to nearest tenth of a second (0.0 sec) Self-selected walking speed: Record walking speed in meters/second 30 Second Chair Stand: Record number of completed raises seconds m/s raises Four Stage Balance Test: Select the position the patient achieved for 10 seconds Endurance: Approximate time (in minutes) the patient can walk independently with or without an aid < If any of the functional measures were not performed, please explain why: By checking this box, you are confirming that all information on the 6 Month Follow-Up Outcome Data Entry Form for this patient is correct and complete. You have now completed the 6 Month Follow-Up Data. Thank you for your time. Remember to transfer information from this paper entry form to the Otago Outcomes Database: https://apps.hpdp.unc.edu/otago Please remember to collect and record the Discharge Outcome Data after 12 months of Otago delivery and/or when you plan to discharge this patient from your caseload. 5/5

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