National Exercise Referral Scheme Falls Collaborative Presentation. Jeannie Wyatt-Williams National Exercise Referral Coordinator 7 th March 2012

Transcription

1 National Exercise Referral Scheme Falls Collaborative Presentation Jeannie Wyatt-Williams National Exercise Referral Coordinator 7 th March 2012

2 Background In 2006 the Welsh Government (WG) commissioned a review of exercise referral schemes in Wales and agreed to establish a National Exercise Referral Scheme (NERS) alongside a randomised controlled trial (RCT). Funding was given to all 22 Local Authorities (LA) in Wales to support a Coordinator and a number of exercise professionals (EP). All EP s were trained to meet recommended national standards.

3 RCT results The RCT results revealed that participants in the scheme had higher levels of physical activity than the control group. This was significant for patients referred for coronary heart disease risk factors; there were improvements in clients with depression and anxiety the economic evaluation demonstrated a cost per QALY of 12,111. For those who adhere to the full programme the scheme was cost saving ( -367 per QALY).

4 Delivery for Chronic Conditions In April 2008 the Minister for Health agreed to appoint a National Coordinator to be based in Welsh Local Government Association (WLGA) further develop and improve the scheme. I was appointed in August 2008 and worked to develop protocols for standard delivery of physical activity for clients with specific chronic conditions; WG identified priority conditions. These priority conditions have grown annually since 2009

5 Introduction to Falls Prevention The NERS Community Falls Prevention Intervention provides an opportunity for patients to attend an evidence based exercise programme designed to reduce the risk of falls, led by qualified Postural Stability Instructors (PSI). The scheme is based on best practice from the UK, current evidence base and operates to National Standards.

6 Introduction continued The scheme has been supported by the WG, WLGA, Later Life Training (LLT), LA, Public Health Wales (PHW) and Local Health Boards (LHB). The delivery of intervention is based on the 7 evidenced based components from the FaME trial (Skelton and Dinan 2001/2 published 2005) and the OTAGO Trials (Campbell et al 2002)

7 Introduction continued The Royal College Physicians, National Falls and Bone Health Organisational Audit Executive Summary, March 2009 asks; Does the intervention include a validated exercise programme delivered by appropriately trained healthcare professionals and/or exercise specialists: Answer: FaME and/or OTAGO+ level 4 Later Life PSI = YES Therefore NERS Prehab =yes Caution No service in isolation can address Falls in Wales!

8 The principal aims To train EP to meet the LLT PSI Level 4 qualification. To deliver an evidence based NERS Intervention To offer a systematic and safety controlled system of referral to NERS Intervention. To increase the patients strength, balance and co-ordination, wellbeing. To decrease the patients social isolation and risk of fractures. To increase the patients long term adherence to physical activity.

9 Areas delivering Prehab + referral rate AREA REFERRALS AREA REFERRALS APRIL DEC 2011 APRIL DEC 2012 ANGLESEY 35 GWYNEDD 15 BRIDGEND 33 NEWPORT 13 CAERPHILLY 27 POWYS 7 CARMARTHEN 75 SWANSEA 24 CONWY 15 VALE OF GLAMORGAN 12 DENBIGH 7 WREXHAM 73 TOTAL AREAS 12 TOTAL REFERRALS 336

10 Areas with qualified PSI s The other 4 areas have staff completing their qualification AREAS AREAS AREA ANGLESEY DENBIGH POWYS BLAENAU GWENT FLINTSHIRE RCT BRIDGEND GWYNEDD SWANSEA CAERPHILLY MERTHYR TORFAEN CARMARTHEN NEWPORT VALE OF GLAMORGAN CONWY PEMBROKESHIRE WREXHAM

11 Sample of Clinical Rehab Flow Chart PEOPLE AT RISK OF / OR HISTORY OF FALLS R e f e r r a l s G.P. for medication review Optometrist FRAT QUESTIONNAIRE HEALTH CARE PROFESSIONALS SOCIAL CARE PROFESSIONALS NERS EXERCISE PROFESSIONALS AMBULANCE SERVICE GP s SELF REFERRAL + ve risk of falls Entered onto a data base. Referred Multi factorial Risk Assessment Team. (MRA Team) Physio completes Database Patient contacted and invited for a Multi factorial Risk Assessment (MRA) Designated NERS PSI instructors & Physiotherapist from re-ablement team. Joint working to deliver MRA clinic in community venue b a s e d o n a s s e s s m e n t f i n d i n g s Care and repair PSI Falls 48 week Intervention Low level Falls Intervention Physio led Social Services Home Safety Check Exit into suitable Community based Activities Tai Chi NERS Walking Clubs

12 NERS Prehab Intervention Flow Chart Patient meets criteria and agrees to referral to NERS Falls Intervention Ist Consultation Completion of all tests Explain Falls Diary Referral to start 32 week programme during weeks 1-4 Weeks 1-12 skilling up; requires 2 x PSI or 1 PSI +1 assistant Weeks training gains; requires PSI plus 1 assistant Weeks maintenance; requires PSI plus 1 assistant. As NERS exit class Suggested staffing local staff patient ratio to be risk assessed Proposed tests to be carried out at 1 st consultation Falls Efficacy Scale (FES-1) Functional Assessment (all 6 tests) Health questionnaire If time constraints these can be sent out with appointment and returned at 1 st consultation SF12 CONFBal Black fracture risk Activity question: How active are they currently. Please repeat the tests indicated at 32 and 48 weeks Plus the following questions: on weeks 32 and 48 How active are they currently How they are feeling?( ask weekly ) Have they noticed any changes? Has their medication reduced? Has their medical condition changed? Are there any problems or issues about exercising? Is there anything they can do now that they couldn t do before? Repeat the FRAT at week 48 to gauge reduced risk of Falls. Discuss continuing exercise options in the community at week 32 and 48 Exit to suitable community exercise opportunities led by REP s registered Community Instructor.

13 Issues/Benefits Issues Benefits Lack of additional funding to deliver additional conditions. Lack of multi factorial teams in place to assess clients and develop referral pathways. Agreed protocols meet evidence base Standardised delivery Transport Client exercise professional ratio recommendations Rolling programme has now been established in most areas to avoid waiting times Many areas working closely with physiotherapists during first skilling up phase

14 Integration of Health and the National Exercise Referral Scheme in the Prevention and Management of Chronic Conditions Health Interface Exercise Referral Scheme 1. Primary Care Impaired Glucose Tolerance Depression Obesity Level 2 Instructor Musculoskeletal To deliver exit from NERS and entrance to community activity 2. Health Education Programmes Mental Health Lifestyle /behaviour change advice and completion of risk assessment tool to ensure signposting to appropriate intervention Expert Patient Programme (EPP) Condition Specific Education Generic Exercise Referral Level 3 Instructors 3. Rehab Programmes with Specific Exercise Component Back Pain / Chronic Musculoskeletal Falls Specific Exercise Component Level 4 Instructors Heart Failure Cancer Stroke Mental Health Obesity/ diabetes Exit routes Cycling Yoga /Pilates Jeannie Wyatt-Williams Adapted from Bridgend s Model by Melanie Andrews ABMU Health Board Gardening

15 Thank you for listening Jeannie Wyatt-Williams National Exercise Referral Coordinator