Research Opportunities
RESEARCH OPPORTUNITIES WITH
SIT AND BE FIT
SIT AND BE FIT is looking for research partners to test the effectiveness of the SIT AND BE FIT program. We are especially looking for data supporting our belief that media-based health and fitness programming, like SIT AND BE FIT, offered for free to public television viewers has a positive overall effect on the health and wellness of the aging population in markets where the program airs at least 3 times a week. For more information on research opportunities, contact[email protected].
Current available research on SIT AND BE FIT:
SIT AND BE FIT VIDEOS USED IN HEALTH PROMOTION NURSE INTERVENTION RESEARCH PROJECT
The Health Promotion Nurse (HPN) Intervention is based on the logic that empowering and teaching older adults with chronic illness how to better manage their own health and to interact more effectively with health practitioners will result in improved health and functional outcomes. The HPN builds on the strengths of the patient and helps him/her develop new skills and personal resources needed to maximize health and manage chronic illness on a daily basis. The model is designed for a population of older adults exhibiting a wide range of chronic conditions. Most of the interaction between the HPNs and the participants occurred in the patients’ homes and over the telephone, supplemented by planned (four times over two years) physician-participant-family-HPN planning conferences in the primary care physician’s offices.
One of the greatest challenges to the health and well-being of people over the age of 50 is physical inactivity. These risk factors are more pronounced in older adults that belong to ethnic groups, have multiple chronic conditions, low incomes, depressed, are socially isolated, or live in rural areas. Regular activity in these older adults can facilitate the maintenance of an independent lifestyle, increase muscle mass/strength, decrease falls, improve mental health, and prolong a productive life.
To help facilitate an increase in the study participant’s physical function and well-being, the HPN intervention placed a special focus on increasing physical exercise, activity, and fitness. The Health Promotion Nurses were certified as Fitness Specialists for Older Adults by the world-renowned Cooper Institute for Aerobics Research and received training in Tai Chi.
Using the PRECEDE health education model, the nurse and patient identified the motivating factors, enabling resources, and reinforcing factors that impacted formulation of an activity goal. The nurse and patient then looked at the patient’s “readiness” to increase activity and begin an exercise regimen. Behavioral objectives were delineated and resources were identified to meet the objectives.
One of the resources used were exercise videos from the “SIT AND BE FIT” video series. These videos were disease specific and tailored to meet the unique needs of the patient’s chronic illness limitations. The patients performed the exercises in their own homes (often with the nurse) and practiced the exercises when it was convenient for them. Patients often commented that the exercises helped strengthen muscles, increased their sense of balance, and gave them more energy. They particularly likes the fact that they could plan their exercises around their daily schedule, pain medications, and treatments. The videos enhanced patient adherence to their exercise regimen because they were simple to perform (sitting or standing by a chair) and could be customized for more frail patients. When the patients were not “ready” to begin an exercise routine, the nurse and patient would discuss the potential benefits of exercise to improve their functional health and quality of life. They would then watch the video and discuss questions or challenges the patient saw to meeting the exercise goal. On subsequent visits the nurse and patient worked toward increasing their motivation to incorporate into their daily lives.
The nurses used a documentation database (Nurse Activity List) to capture the amount of times the videos were used. This data is preliminary and will be finalized in the next few months.
SIT AND BE FIT videotapes were used in a study by Dr. Gerald Eggert of Monroe County Long Term Care titles, “A Randomized Controlled Trial of Primary & Consumer-Directed Care for People with Chronic Illnesses”. This is a preliminary report of the study, provided to SIT AND BE FIT, 2003.
A Randomized Controlled Trial of Primary & Consumer-Directed Care for People with Chronic Illnesses (HFCA #95-C-90467/ 2-01)
The Medicare demonstration “A Randomized Controlled Trial of Primary & Consumer-Directed Care for People with Chronic Illnesses” (HCFA #95-C-90467/ 2-01) concluded June 30, 2002. The project tested the acceptability and effectiveness of three models of disease management and consumer-directed care. The objective of the models was to improve the health status and quality of life or reduce the rate of decline of high risk, functionally impaired Medicare patients living at home while at the same time minimizing, Medicare and total health care expenditures.
- Model 1: A Health Promotion Nurse (HPN) intervention that focused on empowering and teaching patients how to better manage their own health and interact more effectively with health care providers, through active partnership with Primary Care Physicians.
- Model 2: A Voucher that is expected to empower patients through their decisions to spend it on various health-related services including in-home workers, respite care, transportation, durable medical equipments and consumable care goods,
Preliminary findings indicate that a high degree of satisfaction among participants in the Voucher Group, significantly less changes in functional status for participants in the Nurse group, and overall reduction in Medicare and Medicaid care expenditures for the Nurse Group.
First, our findings indicate high satisfaction with the Voucher intervention among participants at 10 months. Participants (N=239) were asked to respond to a series of questions using a 5-point scale ranging from 1= “Not Helpful” to 5= “Completely Helpful”. High means scores were reported for satisfaction with the emotional support and encouragement from the Voucher Specialist (VS) (4.05); helpfulness of advice received from the VS (4:02); VS’s level of understanding (4:30); and, VS’s knowledge of the participant’s problems and needs (4:09).
Second, in our analysis at 22 months past baseline the HPN group experienced significantly less functional disability in activities of daily living than the control group – measured as both number of ADLs in which the participants reported difficulty (t=-3.89; p=.000), and the number of ADLs in which they reported being dependent (t=-2.67; p=.008). These analyses controlled for age, gender, ethnicity, marital status, education, income, study site, supplemental health insurance, Medicare HMO, interactions between voucher/nurse and site, and baseline ADL status.
Third, among the first 861 participants, who completed the 2 year intervention phase, the HPN group experienced substantially lower healthcare expenditures on average than the control group. Specifically, the HPN group reported mean total healthcare expenditures 22% lower than the control group ($11,791 per year versus $15,103). Medicare costs were 16% lower ($8,488 vs. $10,096) and Medicaid costs were 70% lower ($370 vs. $1,244). The reductions in Medicare and Medicaid were driven by large differences for nursing home ($1,922 vs. $4,826) and hospital inpatient ($4,118 vs. $4,490) expenditures. All of these results are unadjusted and were calculated from verified service use reported by Demonstration participants of their caregivers.
Results of the study need to be understood within the context of the health care environment in which they study was conducted. Therefore, we welcome your input as key informants to interpret results vis-a-vis changes in the health care environment, local trends, or unique characteristics in upstate New York that might have affected the health care delivery from 1998-2002.
Medicare Primary and Consumer-Directed Care (PCDC) Demonstration
Overview
The purpose of the Medicare PCDC Demonstration was to test the acceptability and effectiveness of a model of disease self-management/health promotion and a model of consumer-directed care. The objective of the models was to improve the health status and quality of life or reduce the rate of decline of high risk, functionally impaired Medicare patients living at home while at the same time minimizing inpatient hospital, Medicare, and total health care utilization and expenditures.
- Model 1: A Health Promotion Nurse intervention that focuses on empowering and teaching patients how to better manage their own health and interact more effectively with health care providers through active partnerships with Primary Care Physicians.
- Model 2: A Voucher that is expected to empower patients through their decisions to spend it on various health-related services including in-home workers, respite care, transportation, durable medical equipment, and consumable care goods.
Sample
To be eligible for the study, individuals had to need help with two activities of daily livin (ADLs) or three instrumental activities of daily living (IADLs); have had a hospital or nursing home admission or used Medicare home health care services during the past year or had two emergency department visits during the past six months; live in the community (in a private home or independent living setting); and, be enrolled in both Medicare Part A and Part B. Medicare beneficiaries were not eligible for the study if they were enrolled in a Medicare risk health maintenance organization (Medicare risk HMO), a Medicare hospice, the Medicare End Stage Renal Disease (ESRD) Program, the Program for All Inclusive Care for the Elderly (PACE), or a state Medicaid waiver (e.g., Nursing Home Without Walls) program, or if they were permanent residents of nursing homes, adult care facilities, assisted living facilities, or hospitals.
Baseline Characteristics
At baseline participants were on average 78 years old, were predominantly female, and most were Caucasian. About four in ten were married, lived alone, or had not graduated from high school. Nearly two-thirds reported an annual household income of less than $20,000. About 13% reported inadequate income for food and housing while one quarter indicated insufficient money for things they really need, such as clothing, medicine, home repairs, and transportation. The extent of depression and cognitive impairment was very high as was their functional impairment. According to the Geriatric Depression Scale-Short Form (Sheikh & Yesavage, 1986), 35% of Demonstration participants were mildly or moderately depressed and another 10% were severely depressed. One quarter of participants were classified as being cognitively impaired using the criteria of the Cognitive Performance Scale (Morris, et al., 1994). Nearly six in ten reported that they were impaired in at least one ADL while nearly all reported that they were impaired in at least one IADL. Fifty-eight percent of the sample reported fair or poor health, and 39% reported fair or poor satisfaction with their current life. The mean SF-36 (ware, et al., 1993, 2000) Physical Health Summary Score was 28 (the range is from 0 for worst possible health to 100 for best possible health) and the average Mental Health Summary Score was 48. At baseline 65% reported having hypertension, 60% hip or knee arthritis, 49% hand or wrist arthritis, 36% angina or coronary artery disease, 28% cognitive heart failure, 26% myocardial infarction, 38% other heart conditions, 28% chronic obstructive pulmonary disease, 27% stroke, 28% diabetes, and 21% cancer.
The Health Promotion Nurse (HPN) Intervention
Intervention Intervention Impacts Outcome Measures
Components* Special * Increased Empowerment * Increased Quality
Conference Visits (Vis-a-vis the Health of Life
with Primary Care Care System) * Increased Health
Providers * Increased Self-Efficacy Status and
* Health Behavior related to Self Management Function
Change Skill Development * Decreased
* Disease Self- Medicare and
Management Medicaid Use
* Patient Knowledge and Cost
and Skills * Decreased
* Dementia Care Depression
* Home VisitsThe Health Promotion Nurse (HPN) intervention is based on the logic that empowering and teaching older adults with chronic illness how to better manage their own health and to interact more effectively with health practitioners will result in improved health and functional outcomes. The HPN builds on the strengths of the patient and helps him/her develop new skills and personal resources needed to maximize health and manage chronic illness on a daily basis. The model is designed for a population of older adults exhibiting a wide range of chronic conditions. Most of the interaction between the HPNs and the participants occurred in the patient’s homes and over the telephone, supplemented by planned (four times over two years) physician-participant-family-HPN planning conferences in the primary care physicians’ offices.
Each consumer was randomly assigned to the Health Promotion Nurse intervention and assigned a Health Promotion Nurse. The level of help given was dependent upon the needs and preferences of the consumer, but at a minimum the HPN’s were required to have monthly contact with each consumer. Their caseload size was 65 consumers per nurse.
(1) Special Conference Visits with Primary Care Providers: In addition to the coaching of patients to better interact with the physician and his or her staff, the Demonstration focused onfacilitating better physician-patient-family communication through physician reimbursement for four physician-patient-family office planning conferences that were attended by the HPN. In addition, the HPN acted as a liaison among the physicians, their office staff, and the patients, helping to “troubleshoot” the resolution of emergent conditions affecting the patient’s health and well being.
(2) Health Behavior Change: The HPNs used the PRECEDE heath education planning model (Green & Kreuter, 1991) as the organizing framework for the application of behavior change. The PRECEDE framework identifies the predisposing, enabling, and reinforcing factors that affect health behavior, and incorporates both the Transtheoretical Model (TTM) of intentional behavior change developed by Prochaska and colleagues (1983; 1997) and the Health Belief Model (Becker, 1974). The TTM model, better known as the “stages of change” model, is based on the premise that people move through a series of stages in their attempts to change or adopt health behaviors.
(3) Disease Self-Management: Nurses from both sites collectively wrote Consumer Self-Care Strategies, a manual of care plans and strategies designed to promote self-care management for specific chronic illnesses and includes: Alzheimer’s disease, arthritis, diabetes, chronic obstructive pulmonary disease, cerebrovascular accident, diet/nutrition, congestive heart failure, hip fractures, medication compliance, fall prevention, vision problems, hearing deficits, hypertension, and incontinence.
(4) Patient Knowledge and Skills: All patients in the HPN group were given a copy of theHealthwise for Life handbook, an easy-to-use and inclusive manual that communicates how to respond to the presentation of disease symptoms, prevent illness, and enhance wellness. The HPN taught the patient how to use the Healthwise for Life handbook and often printed out additional disease-specific information from the Healthwise Knowledgebase, a comprehensive health information database available on the nurses’ laptops. Patients were also offered self-care, self-management, and exercise videos (SIT AND BE FIT). The SIT AND BE FIT exercise videos offered disease specific exercises that the patient could easily carry out in their home. The HPNs utilized a manual developed for the Medicare PCDC Demonstration outlining behavior change strategies and mechanisms as well as “coaching” techniques.
(5) Dementia Care: Approximately one quarter of the patients who received the HPN intervention had Alzheimer’s Disease or a related dementia. For these patients, goals and objectives were formulated to minimize behavioral and psychological symptom disturbances. The nurse and caregiver also targeted specific health behaviors and disease management strategies that promoted the physical health and well being of the dementia patient (e.g., the HPN educated the caregiver on strategies to achieve optimal glucose control for the dementia patient). In addition, the HPN worked with the caregiver on his or her own physical and mental health needs specifically targeting exercise, stress management, and health promotion.
(6) Home Visits: Visits to the patients home provided the nurse with additional information about the patient’s environment, family relationships, functional status in the home, and fostered the development of a “patient centered” relationship. This relationship was key to developing patient empowerment, disease management goals, and health promotion practices. Health Promotion Nurses visited at a minimum of once per month and increased the intensity of visits during acute exacerbations of illness of patient/caregiver need. The nurse was also available by phone between visits.
The Voucher InterventionIntervention Intervention Impacts Outcome Measures
Components* Home Visits * Increased Empowerment * Increased Quality
* Monetary Support (Vis-a-vis the Health of Life
* Voucher In-Home Care System) * Increased Health
Worker * Increased Self-Efficacy Status and
* Communication with related to Self Management Function
The Primary Care Skill Development * Decreased
Provider Medicare and
Medicaid Use
and Cost
* Decreased
DepressionThe Voucher intervention was designed to provide consumers with choice and control over the in-home services they receive. Flexibility allows consumers to design user-friendly, individually tailored service packages that met their unique needs and preferences. At the same time, the intervention recognizes that choice and control is bolstered by access to appropriate levels of staff assistance at key points in the decision-making process, as well as through on-going information and support as needed.
Each consumer randomly assigned to the Voucher intervention was assigned a Voucher Specialist. The level of help given was dependent upon the needs and preferences of the consumer, but at a minimum Voucher Specialists were required to have monthly contact with each consumer. Their caseload size was 100 consumers per Benefit Specialist.
The role of the Benefit Specialist fell into five main areas:
(1) Home Visits: One home visits the Voucher Specialists were available to provide the patient with general assistance and troubleshoot for environmental problems, safety issues, and the need for durable medical equipment or an in-home worker. They also provided suggestions for environmental modifications, networking with community resources, empowering the patient to use the voucher, and helped with the processing of voucher claims and taxes. Voucher Specialists visited on average once per month and were available by phone as needed.
(2) Monetary Support: Consumers assigned to the Voucher intervention received a maximum of $250 each month in the form of a Home and Community Care Benefit expanded beyond Medicare. Medicare beneficiaries were reimbursed 80 percent of the cost and could purchase items in the following categories: in-home worker, respite services, transportation, environmental modifications, adaptive and assistive equipment, durable medical equipment, consumable care goods, and medical supplies.
(3) Voucher In-Home Worker: As a key component of consumer-directed care, hiring in-home workers directly as domestic employees offered new challenge to consumers. Benefit Specialists were trained to assist consumers from start to finish through the process of hiring, paying, supervising, and (possibly) dismissing in-home workers.
(4) Communication with the Primary Care Provider: In order to maximize voucher use through a collaborative approach with the physician, a quarterly Snapshot Report was sent that informed him/her about the services the patient received through the Voucher Benefit (in-home worker services, environmental modifications, durable medical supplies, assistive/adaptive equipment, and consumable care products). The report also suggested specific areas of physician involvement that might facilitate voucher use.
Preliminary Results of the Medicare PCDC Demonstration
Preliminary findings indicate a high degree of satisfaction among participants in the Voucher Group, significantly less change in functional status for participants in the Nurse group, and overall reduction in Medicare and Medicaid care expenditures for the Nurse group.
First, our findings indicate high satisfaction with the Voucher intervention among participants at 10 months. Participants (N=239) were asked to respond to a series of questions using a 5-point scale ranging from 1- “Not Helpful” to 5= “Completely Helpful”. High means scores were reported for satisfaction with the emotional support and encouragement from the Voucher Specialist (VS) (4:05); helpfulness of advice received from the VS (4:03); VS’s level of understanding (4:30); and, VS’s knowledge of the participant’s problems and needs (4:09).
Second, in our analyses at 22 months post baseline the HPN group experienced significantly less functional disability in activities of daily living than the control group-measured as both number of ADLs with which the participants reported difficulty (t=-3.89; p=.000), and the number of ADLs in which they reported being dependent (t=-2.67; p=.008). These analyses controlled for age, gender, ethnicity, marital status, education, income, study site, supplemental health insurance, Medicare HMO, interactions between voucher/nurse and site, and baseline ADL status.
Third, among the first 861 participants, who completed the 2 year intervention phase, the HPN group experienced substantially lower healthcare expenditures on average than the control group. Specifically, the HPN group reported mean total healthcare expenditures 22% lower than the control group ($11,791 per year versus $15,103). Medicare costs were 16% lower ($8,488 vs. $10,096) and Medicaid costs were 70% lower ($370 vs. $1,244). The reductions in Medicare and Medicaid were driven by large differences for nursing home ($1,922 vs. $4,826) and hospital inpatient ($4,118 vs. $4,490) expenditures. All of these results are unadjusted and were calculated from verified service use reported by Demonstration participants or their caregivers.
Exercise
The Health Promotion Nurse (HPN) intervention is based on the logic that empowering and teaching older adults with chronic illness how to better manage their own health and to interact more effectively with health practitioners will result in improved health and functional outcomes. The HPN builds on the strengths of the patient and helps him/her develop new skills and personal resources needed to maximize health and manage chronic illness on a daily basis. The model is designed for a population of older adults exhibiting a wide range of chronic conditions. Most of the interaction between the HPNs and the participants occurred in the patient’s homes and over the telephone, supplemented by planned (four times over two years) physician-participant-family-HPN planning conferences in the primary care physician’s offices.
One of the greatest challenges to the health and well being of people over the age of 50 is physically inactivity. These risk factors are more pronounced in older adults that belong to ethnic groups, have multiple chronic conditions, low incomes, depressed, are socially isolated, or live in rural areas. Regular physical activity in these older adults can facilitate the maintenance of an independent lifestyle; increase muscle mass/strength, decrease falls, improve mental health, and prolong a productive life.
To help facilitate an increase in the study participant’s physical function and well being the HPN intervention placed a special focus on increasing physical exercise, activity, and fitness. The Health Promotion Nurses were certified as Fitness Specialists for Older Adults by the world-renowned Cooper Institute for Aerobics Research and received training in Tai Chi.
Using the PRECEDE health education model the nurse and patient identified the motivating factors, enabling resources, and reinforcing factors that impacted formulation of an activity goal. The nurse and patient then looked at the patient’s “readiness” to increase activity and begin an exercise regimen. Behavioral objectives were delineated and resources were identified to meet the objectives.
One of the resources used were exercise videos from “SIT AND BE FIT” video series. These videos were disease specific and tailored to meet the unique needs of the patient’s chronic illness limitations. The patients performed the exercises in their own homes (often with the nurse) and practiced the exercises when it was convenient from them. Patients often commented that the exercises helped strengthen muscles, increased their sense of balance, and gave them more energy. They particularly liked the fact, that they could plan their exercises around their daily schedule, pain medications, and treatments. The videos enhanced patient adherence to their exercise regimen because they were simple to perform (sitting or standing by a chair) and could be customized for more frail patients. When patients were not “ready” to begin an exercise routine, the nurse and patient would discuss the potential benefits of exercise to improving their functional health and quality of life. They would then watch the video and discuss challenges of questions the patient saw to meeting the exercise goal. On subsequent visits the nurse and patient worked towards increasing their motivation to incorporate exercise into their daily lives.
The nurses used a documentation database (Nurse Activity List) to capture the amount of times the videos were used. This data is preliminary and will be finalized in the next few months. *See the background paper regarding our result about functional status and health care utilization data in the nurse intervention participants.
References
Becker, M.H., ed. The Health Belief Model and Personal Health Behavior. Health Education Monographs, 2: 324-473, 1974.
Green, L.W., & Kreuter, M.W. Health Promotion Planning: An Educational and Environmental Approach (2nd ed). Mountain View , CA : Mayfield, 1991.
Morris, J.N., Fries, B.E., Mehr, D.R., Hawes, C., Phillips, C., Mor, V., & Lipsitz, L.A. MDS Cognitive Performance Scale. Journal of Gerontology (Med Sci), 49: M174-M182, 1994.
Prochaska, J.O., & DiClemente, C.C. Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change. Journal of Consulting and Clinical Psychology, 51(3): 390-395, 1983.
Prochaska, J.M. & Velicer, W.F. The Transtheoretical Model of Health Behavior. American Journal of Health Promotion, 12(1):38-48, 1997.
Sheikh J.I., & Yesavage, J.A. Geriatric Depression Scale (GDS). Recent Evidence and Development of a Shorter Version. Clinical Gerontologist, 5: 165-173, 1986.
Ware J.E., Snow, K.K., Kosinski, M. SF-36 Health Survey: Manual and Interpretation Guide. Lincoln , RI : QualityMetric Incorporated, 1993-2000.