Public health officials and medical authorities have increasingly recognized falls in older adults in the United States as a significant public health problem.[1-5] Falls, especially injurious falls, can have serious consequences in older adults, leading to loss of functional ability, loss of independence, and early admission to nursing homes.[6-8] Healthcare services and direct medical costs are subsequently affected. Despite the scope of this problem, older adult fall risk is not being adequately addressed in clinical practice. With increasing evidence that exercise-based interventions can prevent falls and reduce fall risk,[10-14] efforts are needed to understand how these effective interventions can be routinely incorporated into clinical settings.
In randomized controlled trials, Tai Ji Quan, a balance training exercise based on martial arts movements, has proven effective at reducing the risk of falling in community-dwelling older adults[15-17] and people with Parkinson's disease who experience postural instability. Subsequently, efforts have been made to put these findings into practice. An initial translational study has shown that this evidence-based program can be effectively implemented in community settings in terms of program adoption, outreach to the target population, and efficacy,[19, 20] but the extent to which referral to an evidence-based fall prevention program can be integrated into standard clinical care of older persons with a history (or a high risk) of falling is unclear. Addressing this question is clinically important if the potential of screening and referral to preventative activities and targeted treatment through clinical care and health services[1, 5] is to be fully realized.
To bridge this research-to–clinical practice gap, the primary aim of this study was to evaluate the dissemination potential of Tai Ji Quan: Moving for Better Balance (formerly known as Tai Chi: Moving for Better Balance)[19, 20] through healthcare providers in outpatient settings. The secondary aims were to evaluate the reach of the program to older adults, community-based class implementation, effectiveness of Tai Ji Quan–based movement practice in reducing falls, and maintenance of referral (by healthcare providers) and continued (postprogram) practice (by participants). The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework[21, 22] was used to evaluate the study aims. On the basis of information derived from focus groups involving target healthcare providers, it was predicted that 20% of solicited providers would refer qualified individuals to the program.
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During the active enrollment period, the study demonstrated a substantially better than projected adoption rate of 62% by a variety of medical providers in terms of referrals to the Tai Ji Quan program. Internal medicine physicians demonstrated the highest referral rate. Physicians generally had a higher rate than physical therapists, suggesting that, at least from this study, providers with medical degrees tend to be more likely to adopt and refer. With respect to settings of clinical practice, providers with practices in urban areas tended to have a higher referral rate than those in rural areas.
Of the 564 individuals referred, 67% were enrolled in the 24-week community-based Tai Ji Quan class. The fall profiles of the participants indicated that high-risk individuals were referred appropriately. More than half of the participants reported falling in the month before the start of the program; the majority of participants reported multiple falls (60%) and fear of falling (78%).
To maximize program dissemination potential, classes were delivered primarily through senior and community activity centers that provided senior services and could be easily accessed by community-dwelling older adults. Of the 11 centers approached, all expressed interest in offering room space (100% adoption) and willingness to assist in planning and scheduling classes. These findings are consistent with a prior community-based study.
Trained instructors successfully implemented the program, with good fidelity with respect to program compliance and adherence to and completion of the training protocol. As was the case in prior work,[15, 19] at the end of the program, participants demonstrated improved balance, gait, mobility, and falls self-efficacy and fewer falls. Despite the duration of the current study (24 weeks vs 12 weeks in a community center outreach study), rates of class participation (75%) and program retention (75%) using the clinical referral method of recruitment were comparable with those of the community center–based promotion and public advertisement method (75% class participation, 80% class attendance). Data from 3-month follow-up in the present study indicated sustainability in that the majority of participants continued their Tai Ji Quan practice, findings consistent with those of prior studies.[15, 16, 19, 26]
In the exit survey, providers indicated that they intended to continue referring patients and encouraging them to do the Tai Ji Quan exercises. The fact that this project received a significant number of referrals after the active enrollment period ended indicated good sustainability. It also suggested that, once providers are made aware of community fall prevention programs, they are likely to use these avenues to support their patients. Thus, community-based programs can become an integral component of successful clinical falls risk screening, assessment, and referral (implementation).
A challenge to sustainability is keeping providers informed about resources, such as evidence-based classes, that are available in their community so that they can continue referring individuals. Experience with this project suggests that communicating frequently with clinicians and program implementers, offering educational outreach workshops, and even providing training in Tai Ji Quan to clinicians may facilitate the referral process. For example, offering physical and occupational therapists the opportunity to undertake the training program as part of their continuing education helped increase referrals during the study period. These clinicians also applied components of the program, for example, the minitherapeutic movements, in their clinical practice. Nevertheless, the feasibility of training clinicians to improve adoption and sustain evidence-based programs in clinical practice was not explicitly evaluated in this study, although it is important and therefore requires formal evaluation in future studies.
This study has some clinical implications. First, with national guidelines recommending Tai Ji Quan exercises for falls prevention,[1, 5] results from this study suggest that it is feasible to engage healthcare providers to make recommendations for evidence-based management of falls and balance-related concerns in older adults. Second, it suggests that, in addition to using recruitment resources from the community (e.g., senior centers or aging services), involving clinicians through a simple referral system is likely to maximize older adult participation in community-based fall prevention programs. Last, Tai Ji Quan programs involve little cost (primarily instructor salary and facilities rental) and are easy to implement (i.e., they are non-equipment dependent with simple practice arrangements). A variety of funding models, including self-supporting user fees, grants, and health reimbursement programs,[36, 37] can be used to establish these programs in community and clinical settings. For example, in the United States, the average cost of a self-support-model Tai Ji Quan class is $3 to $5 per person per class,[19, 38] and the Administration on Aging has facilitated state-wide implementation of evidence-based health and prevention programs, including falls prevention, through grants to local area agencies on aging.
The lack of information about the process that clinicians used to decide whether to refer a patient is a limitation of the current study. This information would be useful for determining how to increase appropriate referrals to fall prevention programs. A second limitation is that there was no mechanism in place to provide participant-specific feedback to individual referring providers, which could be useful to providers in reevaluating an individual's fall-risk. A third limitation is the lack of a comparison group to measure effectiveness. However, it is important to note that the primary purpose of the study was to examine the dissemination potential of an evidence-based program that had demonstrated effectiveness. The results of the secondary outcomes of falls, balance, gait, and physical function further strengthened previous findings of its effectiveness. A fourth limitation is that generalizability of the results may be limited to senior and community activity centers, which were the primary settings for classes in this study, although this program also has been successfully implemented in a variety of other community-based facilities, including YMCAs, YWCAs, and churches. Finally, research assessors were aware of participant intervention status, which was a potential source of bias in the outcome assessments, although none of the research assistants were aware of the study hypotheses, knew any of the participants' previous measurement scores, or were involved in any data entry or analyses.
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We wish to thank all of the participants for their support and dedication to this research project, as well as the healthcare providers who referred individuals to participate in it. Appreciation is also extended to the project instructors and staff.
Conflict of Interest: The project reported in this manuscript was supported through a cooperative agreement with the Centers for Disease Control and Prevention (5R18CE001723). The opinions expressed are those of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. The authors of this paper reported no financial conflicts of interest.
Author Contributions: F. Li originated the study, supervised all aspects of its implementation, performed data analysis, and wrote the article. P. Harmer assisted with the implementation, analysis, interpretation, and the writing of this article. R. Stock and K. Fitzgerald contributed to the concept and design of the research project. J. Stevens, M. Gladieux, L.-S. Chou, K. Carp, and J. Voit contributed substantively to interpretation of the study outcomes and writing and revisions of the article.