Physical Therapists Recommending Enhance®Fitness to Expand Reach

Background & Team

The Health Promotion Research Center’s mission is to partner with communities to conduct prevention research promoting healthy aging that is incorporated into community practice.
Y-USA is the national office of the YMCA. Local YMCA branches offer numerous programs for their communities, including physical activity programs.
Enhance®Fitness, owned and licensed by Sound Generations (formerly known as Senior Services), is an evidence-based group exercise program targeted specifically to older adults at all levels of fitness. Enhance®Fitness classes are offered at YMCAs and other community-based settings across the country.
Physical Therapy Clinics: Because of the personal connection and high levels of trust between physical therapists and their clients, we seek to collaborate with physical therapists to connect older adults with community-based physical activity programs.

Core Research Team
Titles and degrees are listed at the time of the project’s completion.

• Miruna Petrescu–Prahova, PhD, Principal Investigator
• Marlana Kohn, MPH, Research Scientist and Research Project Manager
• Lesley Steinman, MSW, MPH, Research Scientist
• Sarah Fishleder, MA, MPH, CPH, Graduate Research Assistant

Phases & Approach

Phase 1: Gather Information (2014-2015)
Learn how physical therapists exchange information with their patients about ongoing physical activity and community resources through clinical observation and interviews with physical therapists.
Learn how YMCAs engage with health care providers in their community, including physical therapists, through interviews with YMCA staff.
Phase 2: Design the System (2015)
Work with the YMCA and physical therapy clinics to create a system for engaging physical therapists to recommend Enhance®Fitness at the YMCA to their older adult patients when appropriate.
Phase 3: Test the System (2016-2018)
In the final step, we will conduct a randomized controlled trial where one group of YMCAs use the system to engage PTs, and another group of YMCAs conduct business as usual. We will compare the results between groups to determine if the system is effective, feasible, and acceptable to older adults, PTs, and YMCA staff.

Year 3 Findings

Highlights following the conclusion of the active intervention phase in October 2017:

• Maintenance phase of the trial began November 2016, when YMCAs in the intervention no longer received active technical assistance on toolkit implementation.
• Midcourse evaluation of the intervention began May 2017.
• All 20 enrolled YMCA Associations participated in interviews about their experiences establishing partnerships and conducting outreach.
• Nine (9) physical therapist partners of intervention YMCAs were interviewed about their experience receiving outreach from the YMCA specific to Enhance®Fitness.
• Preliminary analysis of Enhance®Fitness enrollment data and provider outreach data.

Here are some of the findings from the evaluation:

• YMCAs in the intervention arm reported that the toolkit served as an adaptable and highly useful resource.
• Both the YMCAs in intervention and control group highlighted organizational barriers to increasing Enhance®Fitness capacity and conducting outreach.
• Physical therapists are invested in building linkages with the YMCA and greatly value in-person contact for outreach.

Next steps:

• Beginning September 2017, the research team is working to design and implement an “intervention supplement” that will address specific findings from midcourse evaluation and process outcome data to date.
• Data collection for the trial will extend through September 2018.

Notable dissemination efforts of preliminary findings:

• Several manuscripts are under development and focus on:
• Developing the intervention toolkit
• Physical therapy clinic capacity for community-clinical linkages
• Developing and pilot testing a partnership evaluation tool for community organizations
• Research was also presented at several academic conferences including APHA, GSA, Academy Health and Elder Friendly Futures.

Year 2 Findings

In the second year of the project, we synthesized the formative research, developed the intervention, and launched the randomized controlled trial.

Highlights of the development process and start of the trial:

• In September 2015, the research team and a partner from YMCA of the USA met to outline the structure and content of the intervention. The team:
• Selected a phased 7-month capacity-building intervention modeled on the Institute for Healthcare Improvement’s Breakthrough Series Promoting organizational change through collaborative learning.
• Developed an intervention toolkit including monthly charts of work, activities, worksheets, and support materials
• In January 2016, the draft toolkit was reviewed and revised by the research team and key partners.
• In February 2016, physical therapist and YMCA partners reviewed the toolkit for feasibility.
• Final preparations were made to launch a randomized trial testing the toolkit:
• The toolkit was finalized after incorporating input from the feasibility review.
• An online data entry system was built to collect intervention process data.
• 20 YMCA associations enrolled in the study were randomized to either the intervention or control.
• All participating YMCAs attended study orientation webinars and a project kick-off call.
• The randomized controlled trial launched on April 1, 2016.
• YMCAs in the intervention arm completed monthly toolkit activities from April through October 2016, and received support via monthly technical assistance calls.
• YMCAs in the control arm conducted business as usual.
• Data collection for the trial will continue through March 2018.

Year 1 Findings

In the first year, we conducted formative research through observations of physical therapists (PTs) interacting with patients in clinical settings and interviews with PTs and YMCA staff.
Here are some of the findings that drove the design of the intervention to be tested:

• A physical therapy visit fosters dialogue around appropriate physical activity.
• Both PTs and patients see value in physical activity; written information would be helpful for them.
• PT/patient priorities align with EF goals: to improve function, prevent reinjury, reduce pain, and provide a safe, fun activity that is tailored individually to participants.
• PTs are interested in building partnerships with physical activity programs in the community.
• PTs want detailed knowledge of a program’s foundation and structure, and the people delivering it, in order to recommend it to their patients.
• PTs are interested in seeing a coordinated, safe continuum of care for their patients.
• YMCA staff have an extremely diverse set of resources, experience, partnerships, and personalities.
• YMCA representatives feel additional partnerships would benefit their programs.
• Support in providing outreach and expansion would be welcomed by YMCA staff.

Research Citation

Healthcare Cost Differences with Participation in a Community-Based Group Physical Activity Benefit for Medicare Managed Care Health Plan Members. Ronald T. Ackermann, Barbara Williams, Huong Q. Nguyen, Ethan M. Berke, Matthew L. Maciejewski, James P. LoGerfo (July 2008)

Impact of a Managed-Medicare Physical Activity Benefit on Health Care Utilization and Costs in Older Adults With Diabetes. Huong Q. Nguyen, Ronald T Ackermann, Ethan M Berke, Allen Cheadle, Barbara Williams, Elizabeth Lin, Matthew L Maciejewski, James P LoGerfo (January 2007)

Implementation and effectiveness of a community-based health promotion program for older adults. J I Wallace, D M Buchner, L Grothaus, S Leveille, L Tyll, A Z LaCroix, E H Wagner (July 1998)

The Effects of a Community-Based Exercise Program on Function and Health in Older Adults: The EnhanceFitness Program. Basia Belza, Anne Shumway-Cook, Elizabeth A. Phelan, Barbara Williams, Susan J. Snyder, James P. LoGerfo (August 2006)

Centers for Medicare & Medicaid Services,2013 (PDF)

Development and validation of criterion-referenced clinically relevant fitness standards for maintaining physical independence in later years. Roberta E Rikli, C Jessie Jones (May 2012)