Integrating Physiotherapy and Occupational Therapy for Persons with Chronic Disease: Lessons Learned from Research in Primary Care

Transcription

1 Integrating Physiotherapy and Occupational Therapy for Persons with Chronic Disease: Lessons Learned from Research in Primary Care Lori Letts & Julie Richardson School of Rehabilitation Science McMaster University

2 The Integration of Rehabilitation into Primary Health Care for Adults with Chronic Illnesses: A Randomized Controlled Trial Lori Letts, Julie Richardson, David Chan, Sue Baptiste, Mary Edwards, Liliana Coman, David Price, Linda Hilts, Paul Stratford, Mary Law Funder: OMHLTC PHCTF Stonechurch Family Health Centre School of Rehabilitation Science and Department of Family Medicine

3 Overall Project Objective To assess the effectiveness and cost of a demonstration project which introduced PT and OT for chronically ill adults into primary health care.

4 Evaluation Randomized Controlled Trial Intervention group: PT and OT in primary health care Control group: Usual care Setting: Stonechurch Family Health Centre Affiliated with the Department of Family Medicine at McMaster Study participants assigned to a single team in the practice with 5 physicians, 17 residents, nursing, access to social work, chaplain. Blind Assessments Outcome assessments administered at four points

5 Sample Eligibility Persons 44 years of age and older With one of the following chronic conditions: back pain depression chronic pain COPD diabetes emphysema multiple sclerosis osteoporosis stroke falls Parkinson's disease fibromyalgia cardiovascular disease (CHF, hypertension) arthritis (rheumatoid, osteoarthritis) Had at least 4 visits to the practice in the 12 months prior to recruitment Neither have dementia nor are residing in a long term care facility

6 Primary Care Model for Rehabilitation Intervention Chronic disease 44 years >4 physician visits previous yr Web-based Education Community information Education re: rehabilitation Disease specific info Screen for functional decline, falls, hospitalization Chronic Disease Management CDMSP 1 Individual self-management Activity & Wellness group Walking group Individualized OT/PT Service provision/ collaboration Referral community programs Collaborative Goal Setting Interaction with Primary Health Care Team Education re: rehab roles Interdisciplinary collaboration 1: Based on Chronic Disease Self-Management Program from the Stanford Patient Education Research Center for Chronic Disease

7 Baseline Data (n=303) Mean age = 64 years 56% sample between 46 64yrs 42% sample over 64yrs Gender 63% women Baseline self reported health issues include: High blood pressure 59% Arthritis 38% Diabetes 24% Back problem 48% Weight problem 40% Hearing problem 28% Vision problem 32% Past smoker 54% Current smoker 14%

8 Findings Primary Outcome: Health Status: no significant between group differences on Physical or Mental Components of SF 36 Secondary Outcome: Significantly fewer Planned Hospital Days in intervention group Secondary Outcome: Significantly higher Patient Satisfaction with Rehabilitation Services across 7 domains of the PSQ 18 (revised)

9 Findings (cont d) Fewer falls in the intervention group (not significant) Fewer home hazards in intervention group (not significant) Self management: Communication with physician score higher in intervention group (not significant) Lower Caregiver Strain Index for caregivers in intervention group

10 I Am Able: Population Based Rehabilitation in Primary Care for Persons with Chronic Illness Julie Richardson, Lori Letts, David Chan, Sarah Wojkowski, Alexis Officer, Ainsley Moore, Lisa McCarthy, David Price, Sarah Kinzie, Doug Oliver. School of Rehabilitation Science and Dept of Family Medicine Funded by Ontario Rehabilitation Research Advisory Network

11 Project Goals To assess whether adopting a population based, rehabilitation self management approach that focused on physical functioning as a major health outcome in a primary care setting improved the process and outcome of care for patients with chronic conditions. To evaluate the extent to which members of a Family Health Team integrated the assessment, monitoring and implementation of interventions to maintain physical function of their patients within the process of delivering chronic illness care.

12 Study Design Before after design with age and sex matched controls Participants over 44 years, with at least one chronic condition, 3 visits to their physician in the past year, and willingness to access the internet Two sites: Stonechurch Family Health Centre & McMaster Family Practice

13 I Am Able: Population-Based Rehabilitation Model in Primary Care for Persons with Chronic Illness Intervention Patients SFHC Rehab Assessments -PT, 1 prevention OT Functional Asst - 2 Goals prevention & action plans (SFHC patients only) Performance Measures Self Report Measure Rehabilitation Self Management Program (RSMP) 1 prevention 2 prevention 3 prevention Develop & deliver workshop (5 weeks) - 1 Self prevention Efficacy - 2 Health prevention Care Utilization - 3 Self prevention Rated Health MFP Patients Matched controls Matched controls Capacity Building Workshops Patient Assessment of Chronic Illness Care Primary Care Resources and Support Focus Group (FG) Problem Based Learning Module (PBLM) FG Participant Feedback Chart Reviews FG Online Functional Assessment prevention -- 2 Online prevention messaging with therapists -- 3 Feedback prevention from baseline PFI & RAPA Physical Functioning Inventory Rapid Assessment of Physical Activity Rehab Assessments PT, 1 OT prevention Functional Asst -Goals 2 prevention & action plans (SFHC patient only) Performance Measures Self Report Measure Matched controls Case Reviews with PCPs FG Flow sheet monitoring physical functioning integrated into EMR FG Outcomes * Capacity Building applies only to SFHC

14 Patient Outcomes Primary Outcomes (self report, on line) Physical Functioning Inventory (PFI): Assesses ADL, IADL, mobility and strenuousness of tasks, 21 tasks (0 100) Rapid Assessment of Physical Activity (RAPA): Assesses frequency and duration of aerobic, strengthening and flexibility types of activity (0 7) Secondary Outcomes (performance and self report) Muscle strength, lower extremity function, TUG, 2 minute walk test, self efficacy, self management, assessment of care, health care utilization

15 Summary of Findings PFI: Trend toward improved function in intervention group (may be clinical important difference) RAPA: Significantly increased level of function Greater improvement in intervention group in grip strength, physical activity despite short intervention Increase in self efficacy chronic disease score immediately after workshop not sustained at 4 months, may need reinforcement

16 Lesson 1: Expanded Chronic Care Model Supported Integration Lesson 1: Expanded Chronic Care Model supported integration

17 Lesson 2: Rehabilitation professionals contributed to self management supports Derivatives of Stanford CDSMP developed to incorporate rehabilitation specific content Self management provided individually as well as in group workshops On line assessments and web resources accessible to primary care patients and team members Capacity building initiatives supported other providers to incorporate self management supports into visits

18 Lesson 3: EMR and PHR communications supported integration Electronic Medical Record: OSCAR used for documentation, and secure messaging amongst team Physical Function Flow Sheet develop to support regular monitoring during visits Personal Health Record: MyOSCAR use for patients to complete selfmonitoring and communicate with therapists via secure messaging.

19 Lesson 4: Multiple strategies supported team integration Co location supported informal conversations, patientspecific meetings, interprofessional groups, joint visits Workshops and Problem Based Learning Modules supported information sharing amongst team members Patient specific chart reviews supported team integration of self monitoring and self management PT and OT student placements supported mutually beneficial learning

20 Integration of Rehabilitation Professionals into Primary Care was supported by: Adoption of the Expanded Chronic Care Model Incorporation of rehabilitation principles into existing self management interventions Electronic communications including the e chart, secure messaging, and personal health record for patients Multiple strategies to support integration with the primary care team

21 References Richardson, J., Letts, L., Chan, D., Stratford, P., Hand, C., Price, D., et al. (2010). Rehabilitation in a primary care setting for persons with chronic illness: A randomized controlled trial. Primary Health Care Research and Development, 11, doi: /s Richardson, J., Letts, L., Chan, D., Officer, A., Wojkowski, S., Oliver, D., et al. (2012). Monitoring physical functioning as the sixth vital sign: Evaluating patient and practice engagement in chronic illness care in a primary care setting a quasi experimental design. BMC Family Practice, 13(29). doi: / Published: 3 April 2012

22 Questions? Contacts: Lori Letts Julie Richardson