DNP 740 Week 6 Evidence-Based Population Interventions Example

Otago at Home, Tai Chi in the Church Hall and Rails From the Fire Department: Selecting Evidence-Based Fall Interventions That Fit a Rural County's Remote Townships

[Student Name]

University of Phoenix

DNP/740: Clinical Prevention and Population Health

Week 6 Assignment

[Instructor Name]

[Date]

The county and figures are composites written for a model paper.

Last week I argued that most prevention effort in our county should go to primary prevention offered to the whole older population, backed by screening and follow-up after injury. This paper chooses the programs that will deliver that strategy. It sets selection criteria, evaluates four candidate interventions against published evidence and against the conditions of the two remote townships where fall calls concentrate, and names the package that the Week 7 program plan will build on.

Selection Criteria

Five criteria shaped the decision. The first was strength of evidence: randomized trials or systematic reviews showing a reduction in falls or fall injuries. Second, reach: whether the intervention can get to residents who do not drive and seldom see a clinician. Third, delivery demands: whether our county has, or can train, the people required. Fourth, cost within a small health department budget and a state injury prevention grant. Fifth, fit with the determinants identified in Week 3, especially old housing, distance and isolation. An intervention had to meet the first criterion to be considered at all; the other four decided among those that did.

The Otago Exercise Program

The Otago program is a set of progressive strength and balance exercises taught in the home over several visits and practiced independently with a booklet, plus a walking plan. Robertson et al. (2001) tested it in a randomized trial of 240 adults aged 75 and older in a rural region of New Zealand, delivered not by a physical therapist but by a nurse trained for the purpose and working from a home health service. Falls fell by 46% in the exercise group, there were no fall-related hospital admissions among exercisers compared with five among controls, and the program was most cost-effective among participants aged 80 and older. A pooled analysis of four Otago trials found a 35% reduction in both falls and fall injuries, with injury benefits concentrated among people 80 and older (Robertson et al., 2002). For our townships, where the nearest physical therapist is a 35-minute drive away, a nurse-delivered home program answers the distance problem directly.

Tai Ji Quan: Moving for Better Balance

Li et al. (2005) randomized 256 inactive adults aged 70 and older to tai chi three times a week for six months or to stretching. At six months the tai chi group had 38 falls compared with 73, fewer fallers (28% versus 46%) and fewer injurious falls, and the risk of multiple falls was 55% lower after adjustment. Gains in balance and reduced fear of falling persisted six months after the classes ended. Li et al. (2008) then translated the program to six community centers in Oregon and evaluated it with the RE-AIM framework: all six centers adopted it, it reached 87% of the target population, and instructors delivered it with good fidelity. Classes need a trained instructor but no equipment, and a church hall is enough space.

A Group Program for Fear of Falling

Tennstedt et al. (1998) tested an eight-session group program that addresses fear of falling and the activity restriction that follows it, recruiting 434 adults aged 60 and older from 40 senior housing sites in the Boston area. Participants reported more intended activity and greater sense of control over falls right after the program, and better social function and mobility range at 12 months, but the authors described the effects as modest and noted that they faded without booster sessions. The program did not measure falls as its main outcome. Fear of falling came up repeatedly in our township conversations, so the program is attractive, but its evidence does not meet the first criterion for a fall reduction package on its own.

Home Modifications

Our determinants paper cited a New Zealand cluster trial in which low-cost repairs such as handrails, grab rails and better lighting reduced fall injuries at home (Keall et al., 2015). The volunteer fire department has offered labor, and a local hardware store has offered materials at cost. Home modification answers the housing determinant directly and needs no behavior change from residents beyond agreeing to the visit, which suits people wary of classes.

Comparing the Options

Applied to the criteria, Otago scores highest on evidence, reach and fit for homebound township residents, and its delivery demand is manageable because a nurse can be trained. Tai chi scores well on evidence and on reach for residents who can get to a church hall, and it adds a social element that addresses isolation. Home modifications score well on fit and cost. The fear of falling program falls short on the first criterion, so its content will be folded into the tai chi sessions rather than offered as a separate program. Stevens and Lee (2018) estimated that nationally a single clinical intervention such as tai chi, Otago or occupational therapist home modification could prevent between about 9,500 and 45,000 medically treated falls a year, depending on the eligible population, which supports combining several rather than relying on one.

The Chosen Package

The program will offer Otago through the clinic's fall prevention nurse and one home health nurse for residents who screen positive and cannot travel; Tai Ji Quan classes twice a week in each township church hall and at the senior center, taught by two instructors trained through the state's aging network; and free home modifications through the fire department for any resident 65 or older who requests them. Medication review by the clinic's pharmacist will be attached to each positive screen. Together these interventions cover primary prevention for everyone, secondary prevention for those at risk and support after injury.

Adapting to the Townships

Adaptation will keep the core elements that produced results in the trials: the progression and frequency of the Otago exercises and the three-times-weekly dose for tai chi where attendance allows. What changes is delivery. Classes will meet after the Sunday service and on Wednesday mornings when the church runs its food pantry. Otago visits will be scheduled with meal deliveries so residents are expecting a visitor. Materials will use large print and local photographs.

Ethical and Equity Considerations

Offering home exercise only to residents who screen positive could leave out people who were never screened, so any township resident may self-refer. Classes will be free, and the fire department's volunteers will offer rides. Trials enrolled mostly women, and men in the townships are less likely to attend group classes, so the program will recruit through the hunting club and the volunteer fire department, where many older men gather.

Conclusion

Measured against evidence, reach, delivery demands, cost and fit, the nurse-delivered Otago program, Tai Ji Quan classes and home modifications form the package for our county, with medication review attached to positive screens. Each addresses a determinant identified earlier: distance, isolation or housing. Next week I will build these interventions into a program plan and logic model with measurable outcomes.

References

Keall, M. D., Pierse, N., Howden-Chapman, P., Cunningham, C., Cunningham, M., Guria, J., & Baker, M. G. (2015). Home modifications to reduce injuries from falls in the home injury prevention intervention (HIPI) study: A cluster-randomised controlled trial. The Lancet, 385(9964), 231-238. https://doi.org/10.1016/S0140-6736(14)61006-0

Li, F., Harmer, P., Fisher, K. J., McAuley, E., Chaumeton, N., Eckstrom, E., & Wilson, N. L. (2005). Tai chi and fall reductions in older adults: A randomized controlled trial. The Journals of Gerontology: Series A, 60(2), 187-194. https://doi.org/10.1093/gerona/60.2.187

Li, F., Harmer, P., Glasgow, R., Mack, K. A., Sleet, D., Fisher, K. J., Kohn, M. A., Millet, L. M., Mead, J., Xu, J., Lin, M., Yang, T., Sutton, B., & Tompkins, Y. (2008). Translation of an effective tai chi intervention into a community-based falls-prevention program. American Journal of Public Health, 98(7), 1195-1198. https://doi.org/10.2105/AJPH.2007.120402

Robertson, M. C., Campbell, A. J., Gardner, M. M., & Devlin, N. (2002). Preventing injuries in older people by preventing falls: A meta-analysis of individual-level data. Journal of the American Geriatrics Society, 50(5), 905-911. https://doi.org/10.1046/j.1532-5415.2002.50218.x

Robertson, M. C., Devlin, N., Gardner, M. M., & Campbell, A. J. (2001). Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. BMJ, 322(7288), 697-701. https://doi.org/10.1136/bmj.322.7288.697

Stevens, J. A., & Lee, R. (2018). The potential to reduce falls and avert costs by clinically managing fall risk. American Journal of Preventive Medicine, 55(3), 290-297. https://doi.org/10.1016/j.amepre.2018.04.035

Tennstedt, S., Howland, J., Lachman, M., Peterson, E., Kasten, L., & Jette, A. (1998). A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. The Journals of Gerontology: Series B, 53B(6), P384-P392. https://doi.org/10.1093/geronb/53B.6.P384