Objectives The Role of Physical Therapy in Prevention, Wellness, & Disease Management What All PTs &PTAs Need to Know At the end of this presentation you will be able to: Describe the similarities and differences in the terms prevention, wellness, and disease management as applied to physical therapy. 1 2 Objectives Indentify the incorporation of prevention, wellness and disease management in the American Physical Therapy Association s 2013 Strategic Plan Be aware of the research in these areas. Objectives Describe the value of prevention, wellness and disease management strategies for your patients and clients. Explain how the concepts of referral and collaboration are integral to these topics. 3 4 1
Objectives Plan to effectively and efficiently include these strategies in your plans of care. Identify sources of additional information and education. Used to Promote this Presentation Do not miss the opportunity to understand and apply the value of prevention, health promotion, and chronic disease management in your professional practice. Learn why these are important to your patients, to you as a clinician and What APTA is doing to align your future with the future of healthcare. 5 6 Language The great thing about human language is that it prevents us from sticking to the matter at hand. ~Lewis Thomas Our language is funny - a fat chance and slim chance are the same thing. ~J. Gustav White Language Prevention Wellness Disease Management Health Promotion Population Health - later 7 8 2
Prevention Prevention Activities are Directed toward Achieving and restoring optimal functional capacity, Minimizing impairments, functional limitations, and disabilities optimizing activities and participation Maintaining health (thereby preventing further deterioration or future illness) Creating appropriate environmental adaptations to enhance independent function. Guide to Physical Therapist Practice. Second Edition. American Physical Therapy Association. Phys Ther. 2001 Jan;81(1):9-746. 9 Prevention Primary Prevention of disease in a susceptible or potentially susceptible population through specific measures such as general health promotion efforts. Secondary Efforts to decrease the duration of illness, severity of diseases, and sequelae through early diagnosis and prompt intervention. Tertiary Efforts to limit the degree of disability and promote rehabilitation and restoration of function in patients/clients with chronic and irreversible diseases. Guide to Physical Therapist Practice. Second Edition. American Physical Therapy Association. Phys Ther. 10 2001 Jan;81(1):9-746. Prevention Primary Prevention Primary prevention aims to prevent the disease from occurring; It reduces both the incidence and prevalence of a disease. Secondary Prevention after the disease has occurred, but before the person notices that anything is wrong. CDC, Levels of Disease Prevention. www.cdc.gov/excite/skincancer/mod13.htm, accessed 11/6/13 11 Prevention Tertiary Prevention Tertiary prevention targets the person who already has symptoms of the disease. The goals of tertiary prevention are to: prevent damage and pain from the disease slow down the disease prevent the disease from causing other problems (These are called "complications.") give better care to people with the disease make people with the disease healthy again and able to do what they used to do CDC, Levels of Disease Prevention. www.cdc.gov/excite/skincancer/mod13.htm, accessed 11/6/13 12 3
Wellness Wellness: A multidimensional state of being describing the existence of positive health in an individual as exemplified by quality of life and a sense of well-being.» PHYSICAL FITNESS, WELLNESS, AND HEALTH DEFINITIONS BOD Y03-06-16-39 Wellness Dimensions Emotional Intellectual Physical Occupational Social Spiritual National Wellness Institute, www.nationalwellness.org/ 13 14 Wellness Emotional Intellectual (Cognitive) Physical Professional/Vocational (Occupational) Social Spiritual (Environmental) WHOQOL instruments World Health Organization QOL Major Components Physical Psychological Level of independence Social relations Environment Spirituality/religion/personal beliefs 15 16 4
Wellness Cleveland Clinic Wellness Institute Learn about Cleveland Clinic initiatives to prevent illness and foster health. quality wellness programs to change unhealthy behaviors and to make healthy life choices. Lifestyle Medicine Cleveland Clinic Cleveland Clinic's Center for Lifestyle Medicine uses a broad range of evidencebased nutrition, exercise, stressmanagement and other interventions to promote optimal physical, psychological and social well-being.» http://my.clevelandclinic.org/wellness/default.aspx 17 18 Wellness University of Maryland the ongoing process of making deliberate CHOICES to enhance the quality of your life It s a deliberate, holistic and proactive approach to achieving optimum health and not just the absence of disease Involves adopting behaviors to care for yourself physically, emotionally, socially, intellectually, spiritually, and vocationally. Wellness University of Maryland Living well - behaviors to care for yourself physically, emotionally, socially, intellectually, spiritually, and vocationally. Learn more about these six dimensions of wellness and how to make good choices while at Maryland. http://crs.umd.edu/cms/wellness/whatiswellness.aspx 19 20 5
Wellness Disease management Healthy behaviors/choices Supportive environment Multi-dimensional/sectoral Disease management is an approach to patient care that emphasizes coordinated, comprehensive care, along the continuum of disease, and across health care delivery systems. Ellrodt G, Cook DJ, Lee J, et al. Evidence-Based Disease Management. JAMA. 1997;278(20):1687-1692. 21 22 Disease management ICF National Committee for Quality Assurance (NCQA) standardized performance measures: asthma diabetes chronic obstructive pulmonary disease (COPD) heart failure ischemic vascular disease (IVD) 23 24 6
So What is the Problem? Let s start here: One Specific Focus Physical Inactivity and Diabetes State-specific Estimates of Diagnosed Diabetes Among Adults Age-Adjusted Prevalence of Diagnosed Diabetes per 100 Adult Population 1994 and 2005 National Diabetes Surveillance System 25 6 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008 (*BMI 30, or about 30 lbs. overweight for 5 4 person) Trends in Obesity & Diabetes 1990 1999 2008 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 27 28 7
Percent with Diabetes Numer with Diabetes (Millions) 11/16/2013 Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2008 7 6 5 4 3 2 1 0 Percent with Diabetes Number with Diabetes 1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06 Year CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics 20 18 16 14 12 10 8 6 4 2 0 29 How many Americans have diabetes and pre-diabetes? Pre-diabetes is a condition where blood glucose levels are higher than normal but not high enough to be called diabetes. Studies have shown that by losing weight and increasing physical activity people can prevent or delay pre-diabetes from progressing to diabetes. ndep.nih.gov/diabetes-facts/index.aspx#cost30 30 How many Americans have diabetes and pre-diabetes? 25.8 million Americans have diabetes 8.3 percent of the U.S. population. Of these, 7 million do not know they have the disease. How many Americans have diabetes and pre-diabetes? The number of people diagnosed with diabetes has risen from 1.5 million in 1958 to 18.8 million in 2010, an increase of epidemic proportions. In 2010, about 1.9 million people ages 20 or older were diagnosed with diabetes. It is estimated that 79 million adults aged 20 and older have pre-diabetes. ndep.nih.gov/diabetes-facts/index.aspx#cost31 ndep.nih.gov/diabetes-facts/index.aspx#cost32 31 32 8
How much does diabetes cost the nation? Total health care and related costs for the treatment of diabetes run ~ $174 billion/yr. Of this total, direct medical costs (e.g., hospitalizations, medical care, treatment supplies) account for ~$116 billion. The other $58 billion covers indirect costs such as disability payments, time lost from work, and premature death. ndep.nih.gov/diabetes-facts/index.aspx#cost33 34 35 36 9
100 All-Cause Mortality Survival Rate 95 % 90 BMI Category kg/m 18 24.9 25 29.9 37 85 80 > 30 2 4 6 8 10 12 14 16 18 Follow up Years Wei et al. Relationship between low cardiorespiratory fitness and mortality in normal weight, overweight, and obese men. JAMA 282;1547,1999 (n=25,714) 38 Physical Fitness and Health Compelling evidence has shown that CRF is a strong & independent predictor of all-cause and cardiovascular disease mortality CRF is often overlooked compared with risk factors such as hypertension, diabetes, smoking, or obesity. Several prospective studies indicate that CRF is at least as important as the traditional risk factors, and is often more strongly associated with mortality. Previous studies report that CRF appears to attenuate the increased risk of death associated with obesity. Several biological mechanisms suggest that CRF improves insulin sensitivity, blood lipid profile, body composition, inflammation, and blood pressure. Lee DC, Artero EG, Sui X, et, al. Mortality trends in the general population: the importance of cardiorespiratory fitness. J Psychopharmacol. 2010 Nov;24(4 Suppl):27-35 39 Conclusions Of note, our results indicate that a healthy diet and regular physical activity have important health benefits independent of reducing adiposity. Rob M van Dam RM, Li T, Spiegelman D. Combined Impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ2008;337:a1440 40 10
Inactivity Evidence Physical inactivity is the fourth leading cause of death worldwide. Kohl HW, Craig CL, Lambert EV. The pandemic of physical inactivity: global action for public health. Lancet. 2012 Jul 1;380(9838):294-305. Perceived physical fitness & functional capability was an I risk factor for mortality from CVD, CHD or all causes combined BMI not I risk factor Int J Obes Relat Metab Disord. 2000 Nov;24(11):1465-74. 41 42 HHS Physical Activity Guidelines Advisory Panel Report Guideline Released 10/7/08 PA remains significant indicator of health Considering disabled populations 43 44 11
HHS PAG Research Report PAG-AC Charge Advisory Panel Research Report, eg: Cardiorespiratory health Metabolic health Energy balance Relationship to energy balance Adverse events Understudied populations http://health.gov/paguidelines/ The primary focus of the PAGAC scientific review was research on primary prevention and health/fitness promotion. The charge to the was to review existing scientific literature to identify where sufficient evidence exists to develop comprehensive public health PA recommendations to target as necessary specific segments of the population. Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services, 2008. 45 46 PAG-AC Charge PAG-AC recognized many of the health benefits of physical activity for the general population also pertained to populations or health condition that typically excludes them from physical activity and health research. The PAG-AC decided to conduct a separate review of the scientific literature focusing on these three populations: People with various disabilities, Women during pregnancy and the postpartum period, And races and ethnicities other than non-hispanic whites. HHS PAG Messages Strong, consistent observational evidence indicates that mid-life and older adults who participate in regular physical activity have reduced risk of moderate or severe functional limitations and role limitations. 150 min of vigorous activity 75 minutes of moderate activity 47 48 12
HHS PAG Messages Health-care providers can provide useful personalized advice on how to reduce risk of injuries. For people who wish to seek the advice of a health-care provider, it is particularly appropriate to do so when contemplating vigorous-intensity activity, because the risks of this activity are higher than the risks of moderate-intensity activity. http://health.gov/paguidelines/ HHS Physical Activity Guidelines Moderate Evidence A lower risk of: Hip fracture Lung cancer Endometrial cancer And the positive effects of: Weight maintenance after weight loss Increased bone density Improved sleep quality 49 50 HHS Physical Activity Guidelines Moderate to Strong Evidence Better functional health (for older adults) Reduced abdominal obesity HHS Physical Activity Guidelines Strong Evidence A lower risk of: early death coronary heart disease stroke high blood pressure adverse blood lipid profile type 2 diabetes metabolic syndrome 51 52 13
HHS Physical Activity Guidelines Strong Evidence (cont ) A lower risk of: colon cancer breast cancer In addition to: Weight loss, particularly when combined with reduced caloric intake Improved cardiorespiratory & muscular fitness Prevention of falls Reduced depression Better cognitive function for older adults What is Needed to Reap These Health Benefits? 53 54 Children & adolescents (6-17 yrs) 60 min of physical activity a day, moderate or vigorous Three of these days should be vigorous Muscle and bone strengthening 3 times a week Adults (18-64)yrs per week 150 min moderate-intensity or 70 min of vigorousintensity aerobic physical activity, or an equivalent combination. Should be performed in bouts of at least 10 minutes, preferably spread throughout the week. Additional health benefits are provided by increasing to (300 minutes) of moderate-intensity aerobic physical activity, or 150 min a week of vigorous-intensity physical activity, or equivalent combination. Strengthening of all major muscle groups performed on 2 or more days per week. 55 56 14
Aging Adults (65 & up)/week Follow the adult guidelines. If limited due to chronic conditions, older adults should be as physically active as their abilities allow. They should avoid inactivity. Older adults should do exercises that maintain or improve balance if they are at risk of falling. Endurance Relative Intensity Intensity % VO2R % HRR %HRMAX RPE* Very Light <20 <50 <10 Light 20-39 50-63 10-11 Moderate 40-59 64-76 12-13 Hard 60-84 77-93 14-16 Very Hard >85 >94 17-19 Maximal 100 100 20 *Borg RPE 6-12 scale 57 58 Resistance Relative Intensity Intensity % 1 RM Very Light <30 Light 30-49 Moderate 50-69 Hard 70-84 Very Hard >85 Maximal 100 What About People with Disabilities? 59 60 15
Data Points Type of Disability RTCs Non-RTCs Pre/Post Test w/o Control Group Stroke 17 0 6 SCI 5 4 9 MS 11 2 5 PD 5 3 6 MD 5 2 5 CP 5 1 5 TBI 3 0 1 Amputee 10 3 2 Combined 1 1 2 HHS PAG Messages People with chronic conditions and symptoms should consult their health-care provider about the types and amounts of activity appropriate for them. Cognitive not included separately but may be included in Combined. 61 62 HHS PAG Messages When adults with disabilities are not able to meet the above Guidelines, they should engage in regular physical activity according to their abilities and should avoid inactivity. Adults with disabilities should consult their health-care providers about the amounts and types of physical activity that are appropriate for their abilities. 1 st Major Take Away Inactivity in hazardous to your health A little is better than none A lot is best, if done safely/appropriately Our role? Know the Guidelines and how to apply to your patient population, refer, provide educational materials or just ask the first question. 63 64 16
Increasing Activity Beyond Function How to you see your current role? Inactivity is hazardous to your health How might you change that view? Consider how setting and payment affect your view. 65 66 Health Behavior Change Lifestyle changes is central to much of prevention, most of wellness and for physical therapy a significant part of disease management. Lifestyle change involves choices by the patient or client Change is often multi-dimensional Health Behavior Change Internal, eg self efficacy Skills Environment Motivators Resources 67 68 17
Now Let Us Look More Broadly Impact of lifestyle factors on mortality Study of 77,782 middle aged US women 24 year follow-up. Markedly lower mortality Never smoking engaging in regular physical activity, eating a healthy diet avoiding becoming overweight 69 70 Impact of Lifestyle Factors on Mortality Prospective cohort study in US women Age 34-59 Free from CVD and cancer in 1980» Rob M van Dam RM, Li T, Spiegelman D. Combined Impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ2008;337:a1440 71 Impact of lifestyle factors on mortality Lifestyle risk factors Cigarette smoking (ever) Lack of physical activity (<30 min/day moderate to vigorous intensity activity) Low diet quality (lowest three fifths of healthy diet score) Alcohol intake of 0 or 15 g/day Overweight (body mass index 25) Rob M van Dam RM, Li T, Spiegelman D. Combined Impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ2008;337:a1440 72 18
Impact of lifestyle factors on mortality Of 8882 deaths, estimates: 55% of all cause mortality 44% of cancer mortality 72% of cardiovascular mortality during followup Could have been avoided by adherence to lifestyle changes. Rob M van Dam RM, Li T, Spiegelman D. Combined Impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ2008;337:a1440 Age standardised all cause, cancer, and cardiovascular mortality during 24 years of follow-up by number of lifestyle risk factors. Dam R M v et al. BMJ 2008;337:bmj.a1440 73 2008 by British Medical Journal Publishing Group 74 The Impact of Mobility on Quality of Life Among Older Persons Large longitudinal study (n=2473) of older persons moving into retirement Total health conditions not found to make a significant direct contribution to QOL prediction. Mobility had significant direct and indirect QOL Satisfaction with functional capacity with greater total association with QOL Mobility interventions designed to enhance QOL should address satisfaction with functional capacity as well. J Aging Health August 2013 vol. 25 no. 5 723-736 75 Population Health Working Definition of Population Health: Realizing that there is not uniform agreement on the definition of population health, the [IOM] Roundtable will use the following definition to guide its initial conversations. On June 13, 2013, the IOM Roundtable on Population Health Improvement held a workshop to explore the likely impact on population health improvement of various provisions within the ACA. 76 19
Population Health Population Health is "the health outcomes of a group of individuals, including the distribution of such outcomes within the group" (Kindig and Stoddart, 2003). Population Health While not a part of the definition itself, it is understood that such population health outcomes are the product of multiple determinants of health, including medical care, public health, genetics, behaviors, social factors, and environmental factors. On June 13, 2013, the IOM Roundtable on Population Health Improvement held a workshop to explore the likely impact on population health improvement of various provisions within the ACA. 77 78 APTA s Strategic Plan Goals 2: Patient- & Client-Center Care Across the Lifespan Objective A: Increase the prevalence of physical therapists providing prevention (primary, secondary, and tertiary) and wellness services Strategies address both individuals and populations APTA s Strategic Plan Goals 2: Patient- & Client-Center Care Across the Lifespan Objective B: Promote implementation of innovative models of practice that target patient- and client-centered care Integrating prevention and health promotion services in collaborative models of delivery 79 80 20
APTA Task Force Task Force to Define the Role of Physical Therapists in Prevention, Wellness, Fitness, & Disease Management for Public Policy Purposes Charged with developing and presenting to the APTA BoD a description of the role of physical therapists in prevention, wellness, and disease management both for individuals and for populations. (2013 Task Force Charge) APTA Task Force Describe the unique role and value of physical therapists in primary, secondary, and tertiary prevention for individuals and for populations. Analysis of these roles should focus on efficient and effective utilization of resources, including human resources and payment. (2013 Task Force Charge) 81 82 PT Annual Visit Development and Implementation of Standardized Elements for an Annual Physical Therapy Examination (RC 24-11) That the American Physical Therapy Association support the promotion and implementation of Annual Visit with a Physical Therapist by coordinating the development and promulgation of at least the following: PT Annual Visit Standardized elements of an annual physical therapy examination that would meet the needs of all individuals Resources and tools to support the physical therapist in tracking outcomes across the lifespan A marketing and implementation plan to enhance public recognition of the need for, & the benefit of, an annual physical therapy examination 83 84 21
APTA Vision APTA BOD will be sending a new Vision to the 2013 HOD for consideration: How You Practice Vision Statement: The physical therapy profession will transform society by optimizing movement for all people of all ages to improve the human experience. 85 86 Your Current Clinical Practice Prevention? Wellness? Disease management? Routinely? Key Concepts Healthy lifestyle choices Multi-dimensional determinants Collaboration, Consultation, and & Referral 87 88 22
Re-framing the PT Role Ask What are the physical activities to which you would you like to return, if any? If appropriate, talk about their long term life goals. Determine What are the barriers what is the PT role in that patient s or client s vision Plan How can adequate levels of physical activity and a health lifestyle be incorporated into that vision? And How Do You Practice To Support Healthy Lifestyles? 89 90 Scope & Competency Scope & Competency Exam Eval Dx Prog Intervene Exam Screen Screen Collaboration Refer Refer 91 92 23
Scope & Competency Exam Screen Refer Scope & Competency Rolodex! Rolodex!! Rolodex!!! 93 94 2 nd Important Take-away The need to work with a team Face to face Virtually Patient centric - Focused - Coordinated goals - Teamwork 95 96 24
Accountable Care Act To identify and solve the problems that contribute to poor health. So What is Really Happening Out There? A growing recognition that the health care delivery system is responsible for only a modest proportion of what makes and keeps Americans healthy 97 Health care providers and organizations could accept and embrace a richer role in communities, working in partnership with public health agencies, communitybased organizations, schools, businesses, and many others Summary. IOM Roundtable on Population Health Improvement. June 13, 2013 98 Accountable Care Organizations ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. To ensure that patients, especially the chronically ill, get the right care at the right time, avoiding unnecessary duplication of services and preventing medical errors. Accountable Care Organizations When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. ACO. www.cms.gov/medicare/medicare-fee-for-service- Payment/ACO/index.html?redirect=/ACO/. Accessed 11/5/2013 ACO. www.cms.gov/medicare/medicare-fee-for-service- Payment/ACO/index.html?redirect=/ACO/. Accessed 11/5/2013 99 25
Goal of Integrated Care Triple Aim Lower Growth in Expenditures Better Care (Individuals) Better Health (Populations) Health Care Reform's Triple Aim Improve the health of the population; Improve the patient experience, including quality; and Improve the affordability of care by decreasing per capita costs. Berwick, et al. in Health Affairs (May 2008, Vol. 27, No. 3, 759-769 102 Nature, Health & Wellness American Public Health Association New policy calls on public health, medical and other health professionals to raise awareness among patients and the public at-large about the health benefits of spending time in nature and of naturebased play and recreation; Nature, Health & Wellness American Public Health Association Urges such professionals to form partnerships with relevant stakeholders, such as parks departments, school districts and nature centers; and calls for promoting natural landscaping. http://www.apha.org/advocacy/policy 103 104 26
How to Facilitate Healthy Lifestyles US National Physical Activity Plan APTA on the Coordinating Committee Opportunities for your clinic, facility or APTA component to get involved. www.physicalactivityplan.org 105 106 National Physical Activity Plan Business and Industry Education Health Care Mass Media Parks, Recreation, Fitness and Sports Public Health Transportation, Land Use, and Community Design Volunteer and Non-Profit -Transportation -Seatbelt -Motivation 107 108 27
For Prevention, What Else Do You Need to Know? Individual with family history of cardiovascular disease Currently works full time in an office Is a single mom For Prevention, What Else Do You Need to Know? Individual with type 2 diabetes Paresthesia of feet Functionally independent at an ambulatory level Currently using insulin 109 110 For Prevention, What Else Do You Need to Know? Individual s/p SCI; C6-7 quadriplegia Functionally independent in wheelchair mobility Assistance needed with some ADL and IADL 111 Advocacy for Physical Activity As individuals Friends and family As a clinical professional Patients/clients In your community Local initiatives For your profession APTA activities at the state, Section, Assembly, caucus, or at the national level 11 2 28
Resources 2008 Physical Activity Guidelines for Americans Provides resources and clear guidance for the general public Fact Sheet for Professions: Full guidelines for policymakers and health professionals Advisory Report (close to 700 pages) www.health.gov/paguidelines 113 114 The National Center on Physical Activity and Disability APTA participating in an NCPPA grant Jointly developed a co-branded brochure Addresses PTs role in the transition from the medical model to the community. www.ncpad.org Exercise is Medicine Asks all health providers to ask about level of activity as a vital sign. A main target is physicians APTA has been a supporting organization from the start. APTA now on Practice Committee Provides resources you may be able to use to market your services to MDs. www.exerciseismedicine.org 11 5 11 6 29
www.apta.org/pfsp Educational Opportunities, Publications & Other Resources Pocket Guides Stroke Falls Diabetes Pulmonary Pathology SCI Additional Resources www.apta.org/preventionwellness www.apta.org/pfsp www.apta.org/patientcare/behaviorchange 11 7 11 8 Questions, Comments? Lisa L Culver, PT, DPT, MBA Senior Specialist, Clinical Practice American Physical Therapy Association 800/999-2782, ext 3172 lisaculver@comcast.net 119 30