Nearly eight years ago, Oakland University physical therapy researchers were contacted by the Auburn Hills Community Senior Center director, Karen Adcock, who identified a gap in her ability to fully meet the needs of the older adults in her community. She and her staff were observing older adults with physical decline and believed a healthcare assessment was warranted. However, as the older adult’s decline was not always associated with a specific medical diagnosis, the individual did not meet the “traditional” paradigm for rehabilitative focused physical therapy.
What the senior center staff had likely been observing were individuals who were pre-frail or possibly even frail. In 2011, Fried et al. were among the first to suggest frailty to be a clinical syndrome that includes the presence of at least three of the following: unintentional weight loss, self-reported exhaustion, grip strength weakness, slow walking speed, and low physical activity.1 Frailty is an independent predictor of fall events, worsening mobility or disability, hospitalization, and death.1
Dr. Chris Wilson and I were at the table for the early discussions with the Auburn Hills Community Senior Center related to this recognized need. He and I identified an intersection between our scholarly agendas and passions that ultimately proved valuable to address this concern. Specifically, Dr. Wilson’s research efforts include management of late-stage chronic disease and frailty in older adults and my efforts are aimed at implementing upstream and prevention focused approaches in community dwelling and home-bound individuals. We both fully appreciated the gap in care for the older adults Karen Adcock identified as they were all too familiar within our own clinical practices. I suspect many other physical therapists have often had this thought when providing care to an older adult, “If I had only seen this patient 6-months ago maybe this --insert a preventable condition or event-- could have been prevented.” It was during these early discussions with the Auburn Hills Senior Center that the home-based older persons upstreaming prevention physical therapy (HOP-UP-PT) foundational independence program was conceived.
While there are evidence-based screenings available to physical therapists that can identify functional decline, environmental risk, and prevention focused interventions, often times a rehabilitative approach to care (versus a prevention-focused approach) is still the predominant industry norm when seeking and providing physical therapy services. Notably, early conceptual framework development for what is now known as the HOP-UP- PT program, came about soon after the State of Michigan approval of direct consumer access to physical therapy services. This provision opened additional opportunities to shift the paradigm in the delivery of care for persons seeking a physical therapist for the purpose of preventing injury or promoting fitness without a physician referral.
The HOP-UP-PT program uses direct referral to physical therapists from the community; thereby, bridging public/community health by way of physical therapists as the entry point into the medical/healthcare system. To date the program has received more than $500,000 in grant funding, has 13 peer reviewed publications, and numerous state and national presentations that support the program’s positive impact on reducing the negative sequelae of aging. This includes the published outcomes of a randomized clinical trial examining the impact of the HOP-UP-PT program on older Michiganders.2 Specifically, the clinical trial provides evidence of an 8-fold decrease in those at highest risk of a fall event as well as statistically significant reductions in fall risk metrics among all HOP-UP-PT program participants.
Furthermore, an open access master class article titled, “State of the Art Physiotherapist-Led Approaches to Safe Aging in Place” provides evidence for the utility for specific tools and identifies the HOP-UP-PT program as a case example of best practice for safe aging in place.3 The article further suggests programs “integrating both community and healthcare approaches have strong evidence for their utility; however, implementation for these preventative approaches are lagging behind” given the exponential population growth of those over 65 years.”3
Another publication which analyzed adjunctive data available from the clinical trial suggests physical therapists providing care the direct consumer access approach should routinely “incorporate cardiovascular and cognitive screenings with strong psychometric properties to assure safety for older adults prior to engagement in PT-led prevention programs.”4 Despite this evidence and the availability of direct access to physical therapy services for preventions focused interventions, reimbursement for this approach remains vague and illusive. This presents an inherent risk many physical therapists are not willing to take on.
Research related to reimbursement of the HOP-UP-PT program is ongoing using support from a Michigan Health Endowment Fund-Healthy Aging award. This has championed opportunity for Oakland University Physical Therapy researchers to explore reimbursement of prevention-focused services. To that end Drs. Chris Wilson, Lori Boright, and I are collaborating with Henry Ford Home Health Care to provide the program to older adults and then examine the reimburse and administrative outcomes. Using the traditional Medicare Part B reimbursement pathway most commonly employed in the outpatient physical therapy practice setting, the home healthcare agency applies its expertise in community and home healthcare delivery to provide the HOP-UP-PT Foundational Independence Program.
An early pilot study of six older adult HOP-UP-PT participants had promising outcomes which we aim to further support with a more robust sample that is currently in the data collection phase. Another important aspect of the collaborative efforts with Henry Ford Home Health Care has been transitioning the paper evaluation and visit documentation used in the earlier research into an electronic medical record format. This has associated costs of financial and administrative resources that are also being analyzed as component of moving the program into clinical practice. This approach has been a practice pattern shift for home healthcare providers who most frequently provide care to homebound individuals. Naccarato et al. describes administrative barriers to this innovative delivery model including challenging reimbursement consideration and uncompensated travel time.5 However, it is necessary for the physical therapy discipline to continue to advocate for care models and reimbursement practices that best meet the needs of the aging population.
Does prevention focused physical therapy care for older adults sound interesting to YOU?
Education on the delivery of the HOP-UP-PT foundation independence program has been created, tested, and is now approved for 4 hours of State of Michigan continuing education as an asynchronous learning opportunity here. Additionally, a free community ambassador training education is available on the HOP-UP-PT website.
Some older adults may need additional prevention focused education. To address this issue, educational modules created with the intention of delivery by physical therapists and physical therapy assistants to older adults have been developed and are available upon request. Community facing education videos are now available for safe fall recovery, urinary incontinence and fall prevention, frailty, Timed Up and Go Test, Otago Level B, and motivational interviewing. In addition to corresponding educational content for these videos, content on physical therapist delivered emergency readiness in the home and technology literacy assessment and interventions are available.
Physical Therapist led prevention-focused approaches offer an opportunity to expand the value of healthcare delivery while concurrently improving the quality of life among older adults. The physical therapy profession is “well positioned to embrace a prevention focused paradigm shift to become gateway healthcare providers with targeted approaches that empower older adults to stay safe and active in their homes and community using programs such as HOP-UP-PT.”6
Sara Arena PT, MS, DScPT
Professor and Director of Oakland University Physical Therapy Program
Co-principal of HOP-UP-PT
References:
1. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156. doi:10.1093/gerona/56.3.m146
2. Arena SK, Wilson CM, Boright L. et al. Impact of the HOP-UP-PT program on older adults at risk to fall: a randomized controlled trial. BMC Geriatr 21, 520 (2021). https://doi.org/10.1186/s12877-021-02450-0
3. Wilson CM, Arena SK, Boright LE. State of the Art Physiotherapist-Led Approaches to Safe Aging in Place. Arch Physiother 12, 17 (2022). https://doi.org/10.1186/s40945-022-00142-5
4. Arena SK, Wilson CM, Boright L, Webster O, Pawlitz C, Kovary C, Esper E. Medical Clearance of Older Adults Participating in Preventative Direct Access Physical Therapy. Cureus. 2023 Mar 5;15(3).
5. Naccarato A, Wilson CM, Arena SK. Perceptions of Rehabilitation Managers on Implementation of the Home-Based Older Person Upstreaming Prevention (HOP-UP) Program: A Retrospective Qualitative Analysis. Cureus 13(4): e14760. doi:10.7759/cureus.14760
6. Wilson C, Arena S, Boright L. Home-based Prevention Care to Facilitate Safe Aging in Place: The HOP-UP-PT Case Example. GeriNotes. 2022; 29(2):24-30.
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