Activating older adults with serious mental illness for collaborative primary care visits.

OBJECTIVE: Persons with serious mental illness frequently receive inadequate medical care and are more likely to experience difficulty navigating the health care system compared with the general population. To address this gap in quality, we developed a program of peer co-led collaborative activation training for primary care (CAT-PC) designed to improve "patient activation" and person-centered care in primary care visits for middle-aged and older adults with serious mental illness and cardiovascular risk. This report presents pilot study feasibility and participant outcomes for CAT-PC. METHOD: A pre-post pilot evaluation of CAT-PC included N = 17 adults (age ≥ 50) with serious mental illness and cardiovascular health risk conditions, and N = 6 primary care providers. CAT-PC consists of 9 weekly peer co-led patient education and skills training sessions and a 45-min video-based training for primary care providers. Pre-post measures included the Patient Activation Measure (PAM), Perceived Efficacy in Patient-Physician Interactions (PEPPI), Autonomy Preference Index (API) for preferred role in primary care encounters, and Social Skills Performance Assessment (SSPA) role-play test for medical visits. RESULTS: All 17 participants attended 5 or more sessions. Post-intervention improvement was found for patient activation and simulated performance of medical visit communication skills. Trends were observed for improved self-efficacy in provider interactions and greater preference for a more collaborative role in decision-making. CONCLUSIONS AND IMPLICATIONS: CAT-PC is a brief, peer co-led education and skills training intervention potentially improving patient activation in primary care encounters and providing an important missing component in emerging models of "patient-centered behavioral health homes" for this high-risk group.

A sustainable primary care system: lessons from the Netherlands.

The Dutch primary care system has drawn international attention, because of its high performance at low cost. Primary care practices are easily accessible during office hours and collaborate in a unique out-of-hours system. After the reforms in 2006, there are no copayments for patients receiving care in the primary care practice in which they are registered. Financial incentives support the transfer of care from hospital specialists to primary care physicians, and task delegation from primary care physicians to practice nurses. Regional collaborative care groups of primary care practices offer disease management programs. The quality assessment system and the electronic medical record system are predominantly driven by health care professionals. Bottom-up and top-down activities contributed to a successful Dutch primary care system.

Explaining the ineffectiveness of a Tai Chi fall prevention training for community-living older people: a process evaluation alongside a randomized clinical trial (RCT).

The results of a randomized clinical trial (RCT) on the effects of a Tai Chi fall prevention in community-living older people with a high risk of falling in the Netherlands showed no beneficial effects on falls and secondary outcomes (e.g., balance, fear of falling). The aim of this study is to provide insight in process-related factors that may have influenced the effectiveness of the intervention. The intervention consisted of Tai Chi Chuan (TCC) training for 1 h twice a week for 13 weeks. We used self-administered questionnaires and registration forms to collect data from participants and instructors. We analyzed quantitative data by means of descriptive statistics and categorized qualitative data based on the content of the answers given. Of the participants, that started the program 89 (79%) completed the intervention, but a minority of 47% attended 80% of more of the lessons. All participants and instructors were positive about the program and most participants reported benefits from the intervention. Suggestions for improvements mainly relate to adjustments of training aspects. The main process-related factors that may be have influenced the lack of beneficial effects on falls and secondary outcomes are the relatively high withdrawal and the low adherence rates.

The effects of Tai Chi on fall prevention, fear of falling and balance in older people: a meta-analysis.

OBJECTIVE: Tai Chi (TC) is an exercise training that is becoming increasingly popular as an intervention for single fall prevention. This meta-analysis was performed to evaluate the efficacy of TC on fall rate, fear of falling and balance in older people. METHODS: Randomized controlled trials published between 1988 and January 2009 were included. In the Netherlands (2009) we used random effects models for the analyses, with data reported as incidence rate ratios (IRR) for falls and standardized mean differences (SMD) for fear of falling and balance. RESULTS: Nine trials (representing 2203 participants) were included in the analyses. Compared with exercise controls, TC participants showed significant improvements in fall rates (2 trials included, IRR: 0.51, 95% CI 0.38-0.68) and static balance (2 trials included, SMD: 0.47, 95% CI 0.23-0.72). Compared with non-exercise controls, no improvement was found for TC participants in fall rates (5 trials, IRR: 0.79, 95% CI 0.60-1.03) or static balance (2 trials, SMD: 0.30, 95% CI -0.50-1.10), but a significant improvement was found for fear of falling (SMD: 0.37, 95% CI=0.03-0.70). CONCLUSIONS: Currently there is insufficient evidence to conclude whether TC is effective in fall prevention, decreasing fear of falling and improving balance in people over age 50 years.

Lack of effect of Tai Chi Chuan in preventing falls in elderly people living at home: a randomized clinical trial.

OBJECTIVES: To evaluate the effectiveness of Tai Chi Chuan in fall prevention in elderly people living at home with a high risk of falling. DESIGN: Randomized controlled trial. SETTING: Two industrial towns in the western part of the Netherlands. PARTICIPANTS: Two hundred sixty-nine elderly people (average age 77) living at home with a high risk of falling. INTERVENTIONS: The intervention group received Tai Chi Chuan training for 1 hour twice a week for 13 weeks; the control group received usual care. Both groups received a brochure containing general information on how to prevent fall incidents. MEASUREMENTS: Primary outcome was the number of falls over 12 months. Secondary outcomes were balance, fear of falling, blood pressure, heart rate at rest, forced expiratory volume during the first second, peak expiratory flow, physical activity, and functional status. RESULTS: After 12 months, no lower fall risk in the Tai Chi Chuan group was observed than in the control group (adjusted hazard ratio=1.16; 95% confidence interval=0.84-1.60), and there were no significant intervention effects on the secondary outcome measures. CONCLUSION: These results suggest that Tai Chi Chuan may not be effective in elderly people at a high risk of falling who live at home.

Effects of exercise programs on falls and mobility in frail and pre-frail older adults: A multicenter randomized controlled trial.

OBJECTIVES: To determine the effects of moderate intensity group-exercise programs on falls, functional performance, and disability in older adults; and to investigate the influence of frailty on these effects. DESIGN: A 20-week, multicenter randomized controlled trial, with 52-week follow-up. SETTING: Fifteen homes for the elderly. PARTICIPANTS: Two hundred seventy-eight men and women (mean age +/- standard deviation, 85+/-6y). INTERVENTIONS: Two exercise programs were randomly distributed across 15 homes. The first program, functional walking (FW), consisted of exercises related to daily mobility activities. In the second program, in balance (IB), exercises were inspired by the principles of Tai Chi. Within each home participants were randomly assigned to an intervention or a control group. Participants in the control groups were asked not to change their usual pattern of activities. The intervention groups followed a 20-week exercise program with 1 meeting a week during the first 4 weeks and 2 meetings a week during the remaining weeks. MAIN OUTCOME MEASURES: Falls, Performance Oriented Mobility Assessment (POMA), physical performance score, and the Groningen Activity Restriction Scale (GARS) (measuring self-reported disability). RESULTS: Fall incidence rate was higher in the FW group (3.3 falls/y) compared with the IB (2.4 falls/y) and control (2.5 falls/y) groups, but this difference was not statistically significant. The risk of becoming a faller in the exercise groups increased significantly in the subgroup of participants who were classified as being frail (hazard ratio [HR] = 2.95; 95% confidence interval [CI], 1.64-5.32). For participants who were classified as being pre-frail, the risk of becoming a faller decreased; this effect became significant after 11 weeks of training (HR = .39; 95% CI, .18-.88). Participants in both exercise groups showed a small, but significant improvement in their POMA and physical performance scores. In the FW group, this held true for the GARS score as well. Post hoc analyses revealed that only the pre-frail participants improved their POMA and physical performance scores. CONCLUSIONS: Fall-preventive moderate intensity group-exercise programs have positive effects on falling and physical performance in pre-frail, but not in frail elderly.

The effect of Tai Chi Chuan in reducing falls among elderly people: design of a randomized clinical trial in the Netherlands [ISRCTN98840266].

BACKGROUND: Falls are a significant public health problem. Thirty to fifty percent of the elderly of 65 years and older fall each year. Falls are the most common type of accident in this age group and can result in fractures and subsequent disabilities, increased fear of falling, social isolation, decreased mobility, and even an increased mortality. Several forms of exercise have been associated with a reduced risk of falling and with a wide range of physiological as well as psychosocial health benefits. Tai Chi Chuan seems to be the most promising form of exercise in the elderly, but the evidence is still controversial. In this article the design of a randomized clinical trial is presented. The trial evaluates the effect of Tai Chi Chuan on fall prevention and physical and psychological function in older adults. METHODS/DESIGN: 270 people of seventy years and older living at home will be identified in the files of the participating general practitioners. People will be asked to participate when meeting the following inclusion criteria: have experienced a fall in the preceding year or suffer from two of the following risk factors: disturbed balance, mobility problems, dizziness, or the use of benzodiazepines or diuretics. People will be randomly allocated to either the Tai Chi Chuan group (13 weeks, twice a week) or the no treatment control group. The primary outcome measure is the number of new falls, measured with a diary. The secondary outcome measures are balance, fear of falling, blood pressure, heart rate, lung function parameters, physical activity, functional status, quality of life, mental health, use of walking devices, medication, use of health care services, adjustments to the house, severity of fall incidents and subsequent injuries. Process parameters will be measured to evaluate the Tai Chi Chuan intervention. A cost-effectiveness analysis will be carried out alongside the evaluation of the clinical results. Follow-up measurements will be collected at 3, 6 and 12 months after randomization. DISCUSSION: As far as we know this is the first trial in Europe considering Tai Chi Chuan and fall prevention. This project will answer a pragmatic research question regarding the efficacy of Tai Chi Chuan regarding fall reduction.