National Exercise Referral Framework Draft 2 Consultation - - PowerPoint PPT Presentation

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National Exercise Referral Framework

Draft 2 Consultation Presentation

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Global Context

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National Context

National Physical Activity Plan

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Physical Activity and Health

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Chronic Condition Risk Reduction* All-cause mortality 30% CVD, CHD, stroke 20-35% Diabetes 30-40% Hip fractures 36-68% Colon cancer 30% Breast cancer 30% Depression/dementia 20-30% Loss of function 20%

* Adults meeting the recommended 30 min of PA on ≥5 d/wk

Physical Activity and Health

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Global prevalence of physical inactivity

31%

Physical Inactivity is a global priority

Irish prevalence of physical inactivity

60%

As Presented by Prof. Fiona Bull, MBE at the NEHRF Expert Symposium in DCU on 19th June, 2014

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WHO, 2009

2 4 6 8 10 12 14 16 High Blood Pressure Tobacco Use High Blood Glucose Physical Inactivity Global Mortality (%)

Risk Factors for Mortality

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The Toronto Charter for Physical Activity: A Global Call for Action

The Seven Investments

• 1. A ‘whole of school’ approach to physical activity involves prioritizing: regular

highly-active, physical education classes and providing suitable physical environments to support structured and unstructured physical activity throughout the day

• 2. Transport policies and systems that facilitate walking, cycling and public transport
• 3. Urban design regulations and infrastructure that’s provides for equitable and safe

access for recreational physical activity and recreational or transport-related walking and cycling across the life course

• 4. Physical activity and NCD prevention integrated into primary healthcare systems

by including physical activity as an explicit element of regular behavioural risk factor screening for NCD prevention, patient education and referral

• 5. Public education including mass media to raise awareness and change social

norms on physical activity

• 6. Community-wide programmes involving multiple settings (cities, workplaces) and

sectors that mobilise and integrate community engagement and resources

• 7. Sports systems and programmes that promote ‘sport for all’ and encourage

participation across the life span

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Physical Activity Pathways in Healthcare Model

Brief advice (BA): This describes a short intervention (usually approx. 3 minutes) and involves opportunistic advice to raise awareness of, and assess a person’s willingness to engage in further discussion about, healthy lifestyle issues. It usually involves giving information about the importance of behaviour change and simple advice to support this behaviour change. Brief intervention (BI): Involves opportunistic advice, discussion, negotiation or

• encouragement. The intervention can vary from basic advice to more extended,

individually-focused attempts to identify and change factors that influence activity levels. Exercise Referral (ER): This involves the ‘referral of a patient by a healthcare professional to a service offering an assessment of need, development of a tailored physical activity programme, monitoring of progress and a follow-up. Service here means i) a publically funded or privately operated service which may take place within a gym, leisure centre or at some other location and/or ii) an individual exercise professional operating an exercise referral service in a variety of settings.

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• Evidence supports the effectiveness of brief advice and brief

intervention by healthcare professionals to increase physical activity levels among the general population, and in particular inactive adults

• Recommended by NICE

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Evidence suggests ER is an effective targeted health intervention for specific patients, but it has limited evidence as an effective intervention for the general population

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Recommendation 2: Policy makers and commissioners should fund exercise referral schemes for people who are sedentary or inactive and have existing health conditions or other factors that put them at increased risk of ill health if the scheme:

• Incorporates behaviour change techniques
• Collects a minimum set of data
• Makes the data available to inform future practice

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Aim: To increase PA levels in individuals living with established NCD or disability Objectives:

• To provide ER to quality, safe and effective supervised PA
• pportunities for those with an established NCD or disability
• To develop the knowledge, attitude and skills of health professionals

and PA service providers in relation to PA and its role for the primary and secondary prevention of NCDs

• To develop a method for process and outcome evaluation of the

NERF in order to determine its effectiveness over time Vision: Those living with NCDs or disability will enjoy more active and healthier lives

NERF

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Category A Those with moderate to severe NCDs or disability that is significantly impacting on quality of life and health care utilization and that would benefit from regular physical activity. Category B Those with definite but mild NCDs or disability that is not (yet) significantly impacting on quality of life and/or health care utilization but that is likely to have a significant health impact in the future and that would benefit from regular physical activity. Category C Those who are inactive or sedentary or at risk of developing a NCD and who would benefit from regular physical activity

Target Population

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A B C

Low Level Supervision Self-directed PA Programmes High Level Supervision Medium Level Supervision

Referral Referral Brief Advice Brief Intervention

Participant Pathways

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Category A

• Require a high level of supervision
• Referral to a NERF designated high

support centre, where accessible

• All can be prescribed home-based PA

programmes by appropriately trained personnel

• Participant transition to lower levels of

supervision is recommended

A

High Level Supervision

Referral

Participant Pathways

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B

Medium Level Supervision

Referral

Category B

• Require a medium level of supervision
• Referral to a NEHRF approved exercise facility
• r community-based PA programme
• All can be prescribed home-based PA

Participant Pathways

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C

Low Level Supervision

Brief Intervention

Category C

• Require a low level of supervision
• The NERF recommends brief advice and brief

intervention

Participant Pathways

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Exercise Referral Pathways

A

Referring Practitioner Service Provider Exercise Referral Unit

Feedback

B

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Referring Practitioner

Referring practitioners may include, but is not restricted to, the following:

• General practitioners
• Hospital physicians and multidisciplinary colleagues
• Primary care teams
• Practice nurses
• Clinical nurses specialists
• Physiotherapists
• Allied health professionals (e.g. occupational therapists)
• Community care personnel (e.g. nurses, dieticians,

pharmacists, social workers)

• Mental health professionals

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1.Patient Recruitment

• 3. Intervene
• Exercise Referral
• 2. Screen

4.Active Participation

• 5. Follow-up /

Review

Roles & Responsibilties of Referring Practitioners

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Pre-contemplation Contemplation/ Preparation Absolute contraindication to exercise

Assess suitability of participant based on inclusion /exclusion guidelines and clinical judgement

Category A

Patient Recruitment Screen Intervene Active Participation Review

Assess current level of physical activity. Data recording & monitoring system

Meeting recommendations for health?

Yes No Assess stage of behaviour change Patient leaves pathway Patient leaves pathway Patient chooses to become active on their own Receives Exercise Referral Independent ‘free living’ activity e.g. walking, cycling, gardening etc. Exercise Referral to ER high supervision centre or instructor At 3, 6 and 12 months: Review patient progress Patient sets goal and becomes more active Category B Exercise Referral to ER medium supervision centre or instructor Reinforce & encourage to continue to be more active Offer brief advice Patient leaves pathway Receives Exercise Referral Opportunistic and routine consultations Initiation via disease register Purpose To support delivery of ER within the healthcare system Target Audience: Category A and B INTERVENTION DELIVERY: Exercise Referral: General Practitioners, Practice Nurses, Allied Health Professional etc

Roles & Responsibilties of Referring Practitioners

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• An understanding of the NERF protocols and procedures
• An understanding of both the benefits and risks of physical activity
• Training in motivational interviewing to be able to determine the

participant’s stage of behaviour change and facilitate behaviour change

• f potential candidates for the scheme

Competencies/Training Requirements

• CPD
• Adapted HSELand Promoting

Physical Activity

• Appropriately accredited
• Easily accessible

Immediate Workforce

• Integrated into the pre-service

curriculum on any vocational programme related to healthcare Future Workforce Training Delivery

Referring Practitioners

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• User-friendly electronic referral system
• Where possible link to Healthlink
• Referral handbook
• Brief intervention pamphlets (for those in precontemplation)

Infrastructure and Resources

Referring Practitioners

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Exercise Referral Pathways

A

Referring Practitioner Service Provider Exercise Referral Unit

Feedb ack

B

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Exercise Referral Unit

The ERU will be under the direction of the HSE’s national programmes. It will be a remote resource and through the use of technology will: i. be a source of advice and support to the referring practitioners with the purpose of increasing referring practitioner capacity and the frequency of direct referral from referring practitioner to service provider ii. in cases of uncertainty, to take referrals from the referring practitioner and match the patient to a suitable local service provider

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ERU

Patient Referring Practitioner Service Provider

Exercise Referral Unit

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• Established organizational and personnel management skills
• A degree in physiotherapy, occupational therapy, medicine or exercise

science with significant (i) clinical, (ii) physical, (iii) medical, (iv) mental health, (v) pharmacological and (vi) neurological knowledge

• Significant knowledge of NCDs and the specific exercise concerns for each

Competencies and Training

• Given access to all relevant medical information required to undertake

suitability screening

• Where possible, this will be facilitated through Healthlink

Infrastructure & Resources

Exercise Referral Unit

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Referring Practitioner Exercise Referral Unit High Support Centre Service Provider Healthlink Medical Records Health Professional

NERF Communication

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Service Provider

The role of NEHRF service provider is open to all appropriately trained service providers. Service providers may include, but is not restricted to, the following:

• PA leaders (e.g. walking leaders)
• Self-employed personal trainers
• Appropriately qualified exercise facility staff
• Graduate exercise specialists (exercise or sport scientists,

physios)

• Graduate specialists (OTs, cardiac and pulmonary

rehabilitation nurses)

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Participant Acceptance Screen Intervene Monitor Review

Obtain informed consent from the participant to undertake a pre-exercise assessment Conduct an appropriate pre-exercise assessment Explain the pre-exercise assessment results to the participant Liaise with referring practitioners and the ERU to accept referrals Schedule the participants first consultation/visit Check the appropriateness of the referral Inform participant about the NERF and their responsibilities Participant receives on-going feedback on progress and programme adaptations as required Assist the participant in setting their PA goals and action plan Participant management systems are in place to monitor attendance and identify drop out Check referral form contains all relevant information No Yes No Yes Attendance Follow-up Non- attendance Participant decides to do nothing further at the

• moment. Participant offered

BA & leaves pathway.

Participant leaves pathway

Participant decides to do nothing further at the

• moment. Participant offered

BA & leaves pathway. Structured exercise class Supported 12 week graduated walking/activity programme Independent ‘free living’ activity e.g. walking, cycling, gardening etc. Supported programme on CV machines in gym Participant chooses to fully engage with the NERF Participant’s progress is monitored , recorded and communicate to referring practitioner / ERU At 3, 6 and 12 months: Review progress as per guidelines in the NEHRF Evaluation Framework Review Review Participant offered a range of PA opportunities

Roles & Responsibilties of Service Providers

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High Level of Supervision

Service Provision

Medium Level of Supervision Low Level or Remote Supervision

High Support Centres Exercise Facilities Community-based PA Programmes Self-directed PA Programmes

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Service Provision

• Accommodate primarily category A (and category B in appropriate cases)
• With an element of medical cover
• Ideally located in primary care centres, hospitals and/or academic centers

throughout Ireland

• e.g. hospital-based rehabilitation centres; Croi Heart and Stroke Centre;

MedEx, DCU; Living Health gym, Mitchelstown

High Level of Supervision

High Support Centres

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Service Provision

• Available space to safely undertake exercise sessions
• Equipment that will allow provision of aerobic and strength content
• Changing facilities
• Safe and convenient access for participants with musculoskeletal disability
• Immediate access to an AED

Infrastructure & Resources Facilities

High Level of Supervision

High Support Centres

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Service Provision

• Maximum ratio of participants to instructors is dependent on the participant’s

risk of an event during exercise

• 5:1 to 15:1 – recommended centres use clinical judgment
• No class should take place without 2 delivery personnel immediately available

Infrastructure & Resources Staffing

High Level of Supervision

High Support Centres

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Service Provision

Infrastructure & Resources Medical Support

• In classes with high-risk participants, a physician or hospital staff with

appropriate training should be immediately available

• In classes with low risk participants, physician availability is not a requirement
• In HSCs based outside a hospital setting, an emergency room should be

available with access to a crash cart

High Level of Supervision

High Support Centres

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Service Provision

Infrastructure & Resources Data-handling

• Efficient, electronic data management system with appropriate controls in

respect of confidentiality

• Adherent to appropriate ethical approval and informed consent procedures, all

centres must agree to providing access to participant data for the purpose of programme monitoring/evaluation and for research purposes

High Level of Supervision

High Support Centres

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Service Provision

• Accommodate primarily category B (and category A in appropriate cases)
• Local leisure centres and suitable community venues in both public and

private ownership

• With trained exercise professionals and/or input from HSE PA coordinators,

physiotherapists, nurses, and others

• Certification and inspection of facilities will be self-policing through the

completion of an annual audit form screened by the ERU

Exercise Facilities Community-based PA Programmes

Medium Level of Supervision

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Service Provision

Infrastructure & Resources

• Facility, staffing, and data handling resource requirements are identical to HSCs
• Onsite medical support is not necessary

Exercise Facilities Community-based PA Programmes

Medium Level of Supervision

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Service Provision

• Accommodate primarily category B (and category A in appropriate cases)
• Include structured (e.g. Green Steps) and unstructured (walking, jogging)

PA opportunites within the community, or sports clubs for health

• Supported where possible and appropriate by a mixture of HSE health

promotion staff, community physiotherapy teams, LSPs, local authority and local development programme staff, and advocacy groups

• To ensure programme suitability for Category B participants, the

programme will self-certify and be subject to spot checks by the ERU

Exercise Facilities Community-based PA Programmes

Medium Level of Supervision

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Service Provision

Infrastructure & Resources

• Appropriately stocked first aid kit and access to a person qualified in first aid
• Awareness of the location of a community AED and personnel trained in its use

Exercise Facilities Community-based PA Programmes

Medium Level of Supervision

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Service Provision

• Low level or remote supervsion for category A and B undertaking

PA at home or in their own locality

• Programmes will ideally be evidence-based/informed
• Developed using diverse and emerging methods of mHealth and

technology for remote tuition, feedback and monitoring

• E.g. Step to a Better Belfast; Scottish GP prescribed pedometer

walking challenge

• Involve participants setting their own goals and achieving these

through independent ‘free-living’ activity

• Home/community physiotherapy teams may provide support

Low Level or Remote Supervision

Self-directed PA Programmes

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High Level of Supervision

Service Provider Training

Medium Level of Supervision Low Level or Remote Supervision

High Support Centres Exercise Facilities Community-based PA Programmes Self-directed PA Programmes

National Clinical Leads Irish Medical Community Exercise Referral Unit National Regulatory Body

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High Level of Supervision

Service Provider Training

Medium Level of Supervision

High Support Centres Exercise Facilities Community-based PA Programmes

EQF Level ≥6 / QQI Level ≥7/8 BSc honours degree MSc degree For structured exercise classes EHFA Level 3 is recommended Recommendations: Standards for PA leaders <EHFA Level 3

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Training Delivery

• Public or private educational providers, e.g. Higher Education

Institutions, who have programmes that meet appropriate external accreditation and validation standards and who demonstrate that they have competent staff and adequate facilities in place to deliver the above education/curriculum will provide training for service providers

• Training in exercise referral should be integrated into the pre-service

curriculum on any vocational programme related to service provision for NERF

• Ideally, in time the development of an appropriate, accredited

interactive e-learning training module is recommended

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Duration of Service Provision

1

• Fixed-duration once off programme of 12 weeks

2

• Fixed duration programme with option of repeating the programme if

necessary (re-referral)

3

• Ongoing relationship with participant, which could be achieved a

number of ways:

a

• Continuation in a supervised or peer-led programme within

the service structure

b

• Independent PA with reassessment and programme review

at intervals

c

• Planned participation in short duration ‘refresher’

programmes

d

• Maintained contact with encouragement/advice without any

face to face contact

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NERF Management

ERU

Patient Referring Practitioner Service Provider National Manager

• Established organizational and personnel management skills
• A degree level qualification where exercise or sports medicine, physiotherapy,
• r nursing have formed a major component of the qualification

Competencies and Training

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MINIMUM EVALUATION BASELINE DURING THE SCHEME 12 WEEKS 6 MONTHS 12 MONTHS Process Participant characteristics Service Utlization Outcome PA levels Awareness, knowledge, and attitudes PA levels Awareness, knowledge, and attitudes PA levels Awareness, knowledge, and attitudes PA levels Awareness, knowledge, and attitudes

Evaluation Framework

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OPTIMAL EVALUATION BASELINE DURING THE SCHEME 12 WEEKS 6 MONTHS 12 MONTHS Process Participant characteristics Service utlization Scheme fidelity Participant satisfaction Outcome PA levels Awareness, knowledge, and attitudes Physiological

• utcomes

Psychological well- being Disease risk Health care utilisation PA levels Awareness, knowledge, and attitudes Physiological

• utcomes

Psychological well- being Disease risk Health care utilisation PA levels Awareness, knowledge, and attitudes Physiological

• utcomes

Psychological well- being Disease risk Health care utilisation PA levels Awareness, knowledge, and attitudes Physiological

• utcomes

Psychological well- being Disease risk Health care utilisation

Evaluation Framework

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Key Partners

• GPs
• Referring Clinicians
• REPs Ireland
• HSE
• Charities
• Health Insurance

Companies

• Leisure Centres
• LSPs
• Higher Eductional

Institutions

• Healthy Ireland

Key Activities

• Publicity
• Accredited Training
• Screening & referral of

patients

• Service – access to

personalised training , structured and unstructured exercise resources

Value Propositions

• Personalised exercise

programme with impact measurement;

• High Quality Service;
• Efficiency &

Effectiveness

• Multiple access points;
• Impact and outcome

data collection;

• Management of results
• f health awareness

campaigns - Ratios,

• Environment, Times
• Cost Structure

Patient Relationship

• Closer to personalised

needs of the patient;

• More effective

management of patient progress

• Dedicated Personal

assistance

• Patient Community

platform

Customer Segments

• Patients with CVD
• Patients with Obesity
• Patients with COPD
• Patients with Diabetes
• Patients with

Claudication

• Patients with

Respiratory

• Problems
• Oncology Patients
• Mental Wellness

Patients

• Patients with

Osteoporosis

• HSE (exercise impact

measurement)

• Health Insurance

companies (health evaluation)

Key Resources

• Patients
• Medical staff in HSC
• ERU
• Local health

partnerships

• Gyms and leisure

centres

• Cardiac Rehab centres
• GP trainers
• Higher Educational

Institutions

Channels

• Closer to personalised

needs of the patient;

• More effective

management of patient progress

• Dedicated Personal

assistance

• Patient Community

platform

Cost Structure

• Education & training for service providers (HSE)
• Direct cost (printing)
• Equipment
• Staff training & salaries?
• Staff for improved ratios
• Medic (high support centres only)

Revenue Streams

• Multi-tiered payment options: Pay service provider per play, Pay

monthly/annual

• Discount for medical card holders
• Better cash flow for exercise facilities
• External funding
• Reduced cost of healthcare

Business Model