exercise as medicine project

There is a growing body of evidence that highlights the positive effects of prescribing exercise as medicine.1

 

Project Introduction

North Coast Primary Health Network is pleased to announce a funding opportunity for General Practices, including Aboriginal Health Services interested in implementing evidence-based exercise interventions as part of comprehensive chronic disease management.

The aims of the program are twofold:
  • Improve physical function for older patients with selected chronic conditions
  • Test a model for resourcing general practices to implement effective strategies to assist patients overcome barriers to participating in exercise intervention
Participating practices will be provided with payments to support their work including:
  • Program establishment and setup
  • Service Delivery – fundholding to provide access to interventions when needed. Practices are encouraged to work with relevant allied health providers in their local area.
  • Outcome achievement – for improvement in the physical performance ability of participating patients as measured against a validated outcome measure.

Puthoff,M.L. (2008) Outcome measures in Cardiopulmonary Physical Therapy: Short Physical Performance Battery. The test is a simple test to measure lower extremity function using tasks that mimic daily activity

Patients are eligible to participate if they:
  • Aged over 50 years
  • Have one of three eligible conditions:
    • Painful Osteoarthritis of hip and knee
    • Chronic Obstructive Airway Disease (On stable Medications)
    • Chronic Heart Failure (On stable Medications)
  • Have a baseline Short Physical Performance Battery (SPPB) score of 0-9

Four practices will be selected to implement the program via an open expression of interest which will close on Monday 18 February 2019 at 8am.

Project Overview

General Practices are well placed to implement evidence based exercise interventions as part of comprehensive chronic disease management activity.

There is a growing body of evidence that highlights the positive effects of prescribing Exercise as Medicine1. Physical activity has been shown to reduce the risk of heart disease, stroke, diabetes, certain cancers, osteoporosis, cognitive decline, [hypertension and obesity], and even depression, at minimal cost and with virtually no side effects2.

The aging population and the rising rates of overweight and obesity are driving increasing rates of many long term conditions. Promotion of self-management, support with health coaching, group sessions and non-face to face support are all potentially effective and cost efficient methods to deliver exercise as evidence based therapy for many long term conditions.

North Coast Primary Health Network will provide funding to general practices who develop solutions to address local barriers to participating in activities that will improve physical function for older adults with COPD, CCF and/or Osteoarthritis.

The aims of the contract are twofold:

  • Improve physical function for older patients with selected chronic conditions
  • Test a model for resourcing general practices to implement effective strategies to assist patients overcome barriers to participating in exercise interventions

Practices will be contracted to implement Exercise as Medicine interventions. A wide variety of evidence based exercise interventions have been demonstrated to benefit patients in the eligible cohort. Practices are encouraged to set goals with patients and facilitate interventions that will support patients to achieve goals and maximise physical ability.

Eligibility and physical ability improvement will be measured using the Short Physical Performance Battery Test (SPPB) to measure and reward the outcome of improvement in physical ability. The test is a simple, validated test to measure lower extremity function using tasks that mimic daily activity3Click here to read article.

Patients are eligible to participate if they are:

  • Aged over 50 years
  • Have one of three eligible conditions:
    • Painful Osteoarthritis of hip or knee
    • Chronic Obstructive Airway Disease (on stable medications)
    • Chronic Heart Failure (on stable medications)
    • have a baseline SPPB score of 0-9

Practices will be required to capture patient data using ‘The Diary CarePro’, a tablet based or web accessed tool to record the patient’s type of service delivery for improving exercise and their progress SPPB scores.

Patients will have the right to view their record data via a patient facing App called “The Health Diary”. Patients will have the right to invite clinicians into their care team and to contribute relevant information to their individual record. Care providers are invited by the patient to have access to their individual record, allowing providers to see and add progress scores and view goals. This ensures patient consent for sharing information in their individual record.

The Diary CarePro is a stand alone, solution and will not interface with existing clinical information systems, meaning practice data integrity is assured. NCPHN will never see private patient information. Practices will be able to view identified data for individual patients as well as dashboards which track progress of their whole cohort. All data is stored securely and is compliant with Australian Information Privacy Standards.

NCPHN will provide practices with data enabled, customised iPADs, free of charge as well as training and support to adopt the system.

For more information please download the following resources:

 

Practices selected to participate in the program will be required to enter into a formal Service Agreement with NCPHN and fulfil the requirements outlined in the Statement of Works.

Practices participating in the program are required to capture outcomes data in ‘the Diary Care Pro’ and support patients to adopt ‘the HealthDiary’ as described in ‘Patient Outcomes Monitoring’ above.

The PHN is providing funding for the following components:

Fee Payable to the Contractor (Ex GST)Phase and date
$ 4,000On return of contract, to support planning and preparation.
$2,000Education/ Orientation session completed
$48,966

 Service Delivery-Paid in 6 monthly instalments, Within 21 days of  acceptance of  progress report

Payment 1    $ 8,000
Payment 2    $ 8,000
Payment 3  $ 8,160
Payment 4  $ 8,160
Payment 5  $ 8,323
Payment 6  $8,323

Variable

$175 per patient who have demonstrated a minimum improvement in the SPPB score of 2 points at two time points 6 or more months apart

Automated- paid 6 monthly

Incentive payments will be capped at 100 patients per practice in any one reporting period

 

$4,897Final Report accepted

Practices selected for the program will be provided with the following support from the PHN:

  • Access to mentoring to support design of practice level program (NCPHN facilitated)
  • Orientation and training of the team delivering the program (NCPHN facilitated)
  • Software and data enabled iPADs for tracking of outcomes and performance reporting (NCPHN facilitated). Practices will have access to a helpdesk to support them to adopt the software
  • Payments as outlined above

Practices will be selected through an open expression of interest process, where they will provide information on practice capability and maturity, characteristics and estimated size of planned cohort (including Aboriginality), willingness to engage with the PHN and comply with reporting requirements.

To complete the EOI process, practices will be required to register via Tenderlink and upload all required documents. 

To complete the application process, the following documents will need to be submitted:

  • Completed EOI Application
  • Practice Accreditation Certificate
  • Insurances – Practice Indemnity and Public Liability
  • Letter of support from Practice Owner or Authorised Person

NCPHN will contract four suitable practices to implement this activity

  • Selection of practices will be made by a selection panel which will include an academic, Exercise as Medicine steering group member, Allied health professional (member of NCPHN Clinical Council), Director of Integration NNSW, NCPHN Clinical Advisor (not from a practice submitting application).
  • Expressions of interest must only be submitted via Tenderlink.
  • Expressions of Interest will close on Monday 18th February at 8 am. Successful applicants will be advised prior to the end of March 2019.
  • Selected practices will be provided with three-year contracts that are subject to meeting minimum implementation requirements.
  • Successful practices will complete their preparation and commence service delivery by June 2019.

A series of initial FAQs are published below.

All new enquiries, and requests for clarification or additional information from interested parties can made in writing via the Tenderlink “Online Forum” at www.tenderlink.com/ncphn

Enquiries must not be addressed to Staff or Board members of NCPHN.

Interested parties are strongly encouraged to register at Tenderlink to ensure they receive responses to any new FAQ’s.

Download project overview
(4 pages)
Exercise as Medicine FAQs

Contract Related

All the information you require to make a decision is available on this webpage. You can also attend one of the webinar briefing sessions for general practices. Two sessions are scheduled with details published on the website. For additional questions you will need to follow the link to the Tenderlink site and post your questions via the forum.

Yes, this program is open to organisations providing general practice services including Aboriginal Health Services.

You must maintain 25 patients in order to receive the service delivery funding for that    period. Your contract will be reviewed and may end if patient numbers remain less than 25.

Practices are responsible to keep data up to date as payments are made on these. Outcomes reports will be automated and provided to NCPHN. These will be based on de- identified patient information collected by ‘The Diary’ tablet record of patient progress.

NCPHN will provide tablets, mobile enablement when needed and training to practices free of charge.

Automated reports of outcomes measures will be provided to NCPHN on the first trading day of each calendar month, based on the previous calendar months data.

Practices are responsible for maintaining data completeness. No late data will be considered.

All NCPHN contractors require Professional Indemnity and Public Liability Insurance. Additionally, all NSW employers, by law, require Workers Compensation Insurance.

If selected, you will need to demonstrate that your practice has $10 million Indemnity Insurance and $20 million public liability insurance. This is easy to do by contacting your insurance company and requesting a certificate of currency.

For more information about our insurance requirements visit https://ncphn.org.au/professional-indemnity-and-public-liability-insurance

All Expressions of Interest will be evaluated by a selection panel that will be comprised of:

  • NCPHN GP Clinical advisor,
  • Allied health professional from NCPHN clinical council,
  • Academic with exercise science skills and knowledge,
  • NCPHN director

Payments

Only patients who have demonstrated a minimum improvement in the SPPB score of 2 at two time points, six or more months apart, will be eligible for the outcome payment.

Patient improvement is the key to this program. It is the volume of patients that will really drive the incentives. Each payment period requires measurements that demonstrate a minimum improvement in the SPPB score of 2 at two time points, six or more months apart.

A patient that improves by at least two points in a six month period would trigger a payment. A new baseline will be set with each payment. If the same patient improves by a further 2 points in the following 6 months, the practice will be eligible for another payment.

There is no penalty, but you won’t meet the criteria for outcomes payments. Some patient scores may fall for a range of reasons. Practices will be encouraged to measure regularly, so patients can see changes, though payment will be based only on the net change over 6 months. If it takes 9 months to achieve at least two points of improvement, then a payment will be triggered then.

The service delivery funding can be used at the practice’s discretion. If all funds are not utilised the practice can keep the remaining funds. Practices would be encouraged to utilise any leftover funds to increase the number of patients in the program, which will increase their access to additional outcomes payments.

You must maintain a minimum of 25 patients. There is no maximum, but outcomes payments will be capped at 100 in any 6 month payment period.

Measurements

A meaningful functional improvement at 6 months is a worthy health outcome.

Participants are encouraged to measure as often as they want – the tools chosen are aimed at guiding care and motivating to patients. Regular measure of, and feedback to patients about their progress, is an important aspect of motivation and engagement.

The minimum re-measure will be 3 monthly. If there have been no measures in a 6 month period the patient will be regarded as inactive and will not count towards the minimum of 25 patients that the practice needs to have participating.

Patient selection is the practice’s responsibility.

You can re-measure them when they are well. After 6 months, payment will be triggered whenever the patient achieves a minimum of 2 points of improvement.

QoL measures would be good, but not as directly responsive to exercise intervention as a function measure. An implementation team may wish to use QoL measures, or other measures as well as the program specified function measure. Outcome payments will be based on the net change in the specified function score over 6 months.

No. NCPHN will only pay based on the SPPB scores. During the orientation period, the care team will be trained to complete the SPPB consistently.

Clinical

Outcomes payments will only be made for eligible patients, however practices have the discretion to include anyone who would benefit in their local program.

When initially diagnosed CCF and COPD patients often go through a phase of medication titration before settling on a stable medication regimen. Functional improvement is often seen in this period. This program is to pay for the additional functional improvement that can be attained through the exercise therapy rather than the initial medication stabilisation.

Sick day actions plans are encouraged as part of standard care, and these should continue where applicable.

The tests represent activities of daily living that are of real-life value. If you are better at doing sit to stand, or timed up and go, it has benefits no matter how it was achieved.

QoL of life measures would be good, but not as directly responsive to exercise intervention as a function measure. An implementation team may wish to use QoL measures, or other measures as well as the program specified function measure. Outcome payments will be based on the net change in the specified function score over 6 months.

Yes, patients can be enrolled or discharged from the program at any time.

This depends on the types of patients you enrol and the types of interventions you arrange.

We would not expect every patient to show an improvement in the function score, but enough of them should show an improvement to make the whole program worthwhile.

Some patients are likely to get clinical benefit from exercise therapy without showing improvement in SPPB score, e.g those that would otherwise have deteriorated, while others will show improvement in their function score with very little input.

Types of interventions can be adapted to the practice systems and individual patients, eg one on one, group, free community services, allied health services. It is likely that having a range (“menu”) of options will make it easier for your patients to find something that suites them well.

Technical Solution

Outcomes reports will be automated and will be based on de-identified patient information collected by ‘The Diary CarePro’ tablet based record of patient progress, and provided to NCPHN.

NCPHN will provide tablets, mobile enablement when needed and training to practices free of charge.

Patients will have access to their own Health Diary where they can view their goals, progress against the measures and contribute relevant information (for example weight or exercise patterns)

Each practice will be provided with a number of data enabled iPads free of charge to use with the program. It is also possible to enter data via a web portal if needed.

NCPHN wanted a solution that could be easily used by multidisciplinary teams who may not be working under the same roof or in the same practice. We worked with vendors to evaluate a range of technical solutions to collect outcomes measures. After careful evaluation the Diary Care Pro (Professionals) and Heath Diary were selected.

The solution is not complicated, it is easy to adopt by patients and professionals. Both Diary and CarePro were developed with working groups comprised of a full range of computer literacy, from those who have never used a smart device or tablet, to those who were power users.

The Diary application was tested with a diverse group of members at a YMCA in the United States (US). They were all members of a wellness program who were tasked with achieving one health goal over 30 days to start their program. Only one of the users chose not to participate in the test. The group were primarily senior (aged 55+). The group preferred the iPad over the iPhone when working on health goals.

Recently a user feedback experience was conducted in Mackay with our support of the solution. Nearly 90% of the participants reported wanting to continue using the product after the experience. The ages ranged from 27 – early 80’s with 50% of them having no previous experience with an iOS device. The Diary CarePro was developed with a work Care Management Team in a US Accountable Care Organisation. Every step of development of the initial product was tested fully for usability prior to the product being released. The product became an integral part of the team process and field care managers actually stopped using their desktop computers. An internal time study showed a 50% gain in efficiency over their paper-based system.

In the Mackay hospital/clinic, the staff members and patients were able to use the hardware and software with minimal training. Prior experience with technology was not found to be a barrier in use of the solution in the hospital/clinic settings.

The solution provides a systematic way to record patient consent to participate in the program and share data with the use of The Diary and CarePro. The Diary is built on a framework that puts the patient in control of their data. The Diary has a patented permissions system allowing patients to select which data elements can or cannot be viewed or modified, at a granular level.

Every Diary account also has a file folder to hold any documents, including any paper signed documents that can be scanned with the device and placed in the file folder for all users with permissions to view. Each user will be utilising an Apple iPad with core accessibility features built into the platform to ensure usability regardless of hearing, sight or motor skill requirements. For more information, please explore Apple Accessibility.

You may be surprised to see how many of them have a suitable device they can use to view their progress. Patients should be encouraged to view their record on their own device if they have them, however practices will be provided with an iPAD that patients can log onto when they visit the practice.

This will be helpful when they want to include another team member in their diary – for example their physiotherapist). This device will have automated log outs so that no other patients can view an individual’s data.

In addition, interested patients can view their results via a web portal where they will have a login if needed.

Qualitative reporting will be included in the reporting system. This will be from a general practice perspective initially. The Diary Pro does have the capacity to undertake patient surveys, this could be included at a later date.

Download FAQs (6 pages)

IMPORTANT INFORMATION
All additional enquiries and requests for clarification or further information must be made in writing via the Tenderlink “Online Forum”. Enquiries must not be addressed to Staff or Board members of NCPHN.