HHS Public Access Author manuscript Author Manuscript
J Frailty Aging. Author manuscript; available in PMC 2017 May 26. Published in final edited form as: J Frailty Aging. 2017 ; 6(1): 2–5. doi:10.14283/jfa.2017.1.
PUBLIC HEALTH IMPACT OF FRAILTY: ROLE OF PHYSICAL THERAPISTS A.M. GUSTAVSON1, J.R. FALVEY1, C.M. JANKOWSKI2, and J.E. STEVENS-LAPSLEY1,3 1Physical
Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
Author Manuscript
2College
of Nursing, University of Colorado, Aurora, CO, USA
3Geriatric
Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO, USA
Abstract
Author Manuscript
Frailty is an emerging and immediate public health concern given the growing aging population. The condition of frailty is characterized by a reduction in physiologic reserve, which places frail older adults at considerable risk for further functional decline, hospitalization, institutionalization, and death. Recent research suggests that frailty may be reversible, which could result in significant improvement in public health. Thus, a strong impetus exists to develop strategies for frail older adults that achieve the Triple Aim through better promotion of population health, optimization of patient experiences, and delivery of high-quality care at minimal cost. Physical therapists often treat frail older adults, yet how physical therapists can contribute to preventing or reversing frailty in healthcare settings has not been described, and may potentially influence patient outcomes and healthcare spending. Therefore, the purpose of this publication is to outline the potential role of physical therapists in achieving the Triple Aim for the frail older adult population.
Keywords Rehabilitation; frail older adults; frail elderly; physical therapy specialty; triple aim
Introduction Author Manuscript
The prevalence of frailty is anticipated to dramatically increase in the United States as the percent of older adults rises (1, 2), with current estimates of frailty across communitydwelling older adults varying between 4–59% (3). Frail older adults are characterized as having a loss of physiologic reserve that results in an inability to maintain homeostasis in the presence of external stressors (e.g., surgery, falls, or illness) (2, 4, 5). Reduced physiological reserve may manifest in higher rates of hospitalization, institutionalization, disability, and mortality (4). As a result, older adults with greater indices of frailty accrue 22–46% higher
Corresponding author: Jennifer E. Stevens-Lapsley, University of Colorado, 13121 East 17th Avenue, Aurora, CO 80045, Office: (303) 724-9170, Fax: (303) 724-9016, [email protected]. Conflict of Interest Disclosure: None
GUSTAVSON et al.
Page 2
Author Manuscript
healthcare costs following hospitalization compared to those with minimal frailty (6). In addition, frailty has a negative impact on both physical and mental quality of life (QOL) (7). Thus, the need to identify frailty early and intervene in a timely manner is an emerging public health concern because of the impending, exponential growth of the aging population and the subsequent increase in healthcare burden (8). Healthcare providers are being challenged to achieve the Triple Aim of improving population health, reducing per capita costs, and optimizing patient experience for frail older adults (9).
Author Manuscript
In 2012, the International Association of Gerontology & Geriatrics and The World Health Organization developed a consensus statement that promotes frailty screening as a strategy for identifying vulnerable, frail older adults and initiating interventions to allow “aging in place” (10, 11). However during patient visits in primary care, providers rarely perform a comprehensive screen for frailty indicators, such as assessment of muscle weakness or slowness of gait, due to growing administrative burden limiting patient contact time (12, 13). Physical therapists (PTs) are ideally positioned to identify frailty in geriatric healthcare settings, because they are often the first-line providers for treatment of frailty-associated functional impairments such as slowness of gait, fatigue, and weakness. However, the potential impact and contribution of PTs to the public health aspect of frailty has not been fully realized, which leads to a gap in understanding of how and when to utilize physical therapy services for frail older adults. Therefore, the purpose of this publication is to highlight the potential role and value of PTs in promoting population health, reducing healthcare costs, and improving outcomes for frail older adults (Figure 1).
Improving Population Health Author Manuscript Author Manuscript
Improving the health of the frail older adult population, as part of the Triple Aim, can be achieved through early identification and timely treatment of unmet, yet addressable, clinical needs (9, 14). Currently there is a paucity of population analyses to characterize frail older adults and subsequently identify high-risk patients, track population outcomes over time, and promote longitudinal monitoring of cost or utilization trends (14, 15). Standardizing the screening tools for frailty used by PTs and other healthcare providers could be an impactful first step towards gathering quality data to identify high-risk patients and populate outcomes databases for clinical, research, and policy analyses. For example, the physical therapy profession is developing a Physical Therapy Outcomes Registry, which focuses on enhancing patient care and improving practice through objective demonstration of the value of physical therapy services (16). Physical therapy practices can also contract with companies such as Focus on Therapeutic Outcomes Inc.® (FOTO) for data management and analysis (17). Additionally, on a wider interdisciplinary scale, sections of the National Institutes of Health have begun to promote standardized data collection across research projects and data sharing to promote greater collaboration through larger data sets (18). These initiatives could lead to greater accuracy and earlier identification of pre-frail or frail patients at the highest risk for adverse events and increased healthcare utilization. Large data collection can also help researchers and healthsystems identify characteristics responders to interventions designed to prevent, treat, or reverse frailty, which would more accurately characterize who to target with interventions. Additionally, a database consisting of clinical outcomes and frailty assessments may enable providers, clinical researchers, and policy J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 3
Author Manuscript
makers to study cost-effectiveness of physical therapy interventions for frail older adults and, subsequently, inform health policy regarding reimbursement and payment reform across healthcare settings. Unmet needs born out of lack of screening and early identification lead to risk for and greater prevalence of adverse events in the frail older adult population. Thus, initiating timely intervention to reduce or reverse frailty severity for these older adults is critical. PTs, as trained exercise interventionists, are ideally positioned to improve population health through delivery of safe and evidence-based rehabilitation for older adults with frailty. Consequently, PTs may be the first providers to recognize this risk and can intervene early through physical therapy interventions and referrals to other healthcare providers.
Reducing Per Capita Costs Author Manuscript
Reducing per capita costs of high-quality care is a second essential step to achieving the Triple Aim for the frail older adult population. PTs can help achieve this step through timely initiation of exercise interventions and development of preventative programs (9, 14). Physical therapy research and clinical data could help optimize identification and initiation of physical therapy interventions to improve physical function, and to initiate referrals to other healthcare providers. Physical function is a robust risk factor for hospitalization in older adult populations (19). In fact, previous studies have shown that low physical function is associated with greater risk for hospitalization and death (20). Thus, including physical therapy services in the care of frail older adults has the potential to reduce costs, because risk factors for costly rehospitalization and institutionalization - such as gait speed, weakness, and dependence with activities of daily living (21, 22) - are potentially modifiable through physical therapy interventions (23, 24).
Author Manuscript Author Manuscript
Furthermore, the early identification of frailty provides opportunities for prevention efforts, including population and patient-level education, motivational interviewing, and an emphasis on patient self-management that can in turn reduce costs (23). PTs can provide patient education on the safe use of assistive devices, equipment for a fall-proof home, appropriate exercise prescription, and recommendations for appropriate home health care assistance given the extent of mobility or activities of daily living limitations (23). PTs can also engage the patient and caregivers in problem-solving self-management needs. For example, PTs can teach patients and caregivers how to monitor and report mobility-related warning signs such as declines in gait speed or new impairments in daily activities (23). Patient self-monitoring, early detection of new or worsening impairments, and communication with the PTs or other providers of the interdisciplinary care team can potentially mitigate costly, avoidable rehospitalizations and institutionalization.
Optimizing Patient Experience Optimizing the patient experience is the third critical component of the Triple Aim and can be achieved through PT-initiated programs to support wellness while aging. Additionally, PTs often work collaboratively with other healthcare disciplines to develop coordinated, interdisciplinary, patient-centered care plans for frail older adults, which can include
J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 4
Author Manuscript Author Manuscript
wellness components and a holistic approach to care. Patient experiences and outcomes are better when healthcare teams work together (23, 25–29), which may in turn decrease healthcare utilization (23, 30). Perhaps the quintessential role of PTs in optimizing patient experiences is through promotion of “aging in place.” To achieve this, PTs can work with patients and caregivers to develop health and wellness educational materials to improve home safety and maintain independence; these materials could include strategies for maintaining function, improving physical activity, and reducing falls risk for frail older adults. Although integrating wellness into physical therapy to improve QOL is a growing area of the profession, it is currently not the standard of care and may be a gap in physical therapy curricula and reimbursement policies. Maintaining QOL for frail older adults is important to the patient as well as the health system’s perspective. For example adverse, costly, and oftentimes life-changing outcomes in older adults who are frail—such as mortality, falls, hospitalization, and institutionalization–are intricately linked with QOL (7, 31–35). Numerous studies have shown an inverse relationship between frailty and QOL at a single point in time, with a faster decline in QOL in those with frailty indicators (7, 31, 32). Therefore, frailty is a clear example of a condition that is conducive to a patient-centered, holistic approach to care (36) as awareness, prevention, early detection, and rapid intervention may help frail older adults “age in place” (10) with an improved QOL.
Physical Therapy Research and Initiatives through a Public Health Lens
Author Manuscript
Public Health will likely play an increasing role in achieving the Triple Aim through prevention and management of frail older adults (improve population health) to promote quality of life (optimize patient experience) at lower costs (reduce per capita costs). However, the integration and assessment of physical therapy services in this realm has not been adequately studied. Physical therapy services can potentially reduce healthcare costs when examined through a Public Health lens (37). For example, the increasing demand for high-quality, cost-saving healthcare delivery has stimulated cost-effectiveness and economic analyses of physical therapy (6) for arthritis and back pain exercise interventions; hip protector studies; and continence training (38). However no studies have specifically looked at the cost-effectiveness of physical therapy services and outcomes in the frail older adults population. Physical therapy interventions alone may be insufficient to reverse frailty and reduce costs; however an interdisciplinary approach that includes PTs is likely a costeffective strategy to treat frail older adults. Thus, cost-effectiveness research is greatly needed to assert the value of physical therapy in promoting optimal outcomes in the frail older adult population and subsequently achieving improved population health at lower healthcare costs, while also enhancing patient experiences.
Author Manuscript
Traditionally, physical therapy knowledge has been built on quantitative studies, with a paucity of patient-centered research (39), which hinders the ability to assess the patient experience arm of the Triple Aim. Qualitative research in physical therapy offers the opportunity to identify novel factors and challenges to health care delivery that includes the frail patient and caregivers in the decision-making process (39). Comparative effectiveness research of existing interventions would provide a risk to benefit profile that PTs, as part of an interdisciplinary team, and patients could use to make informed health care decisions (9). The Patient Centered Outcomes Research Initiative (PCORI) has bolstered enthusiasm for J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 5
Author Manuscript
investigations about informed health care decision-making. The mission of PCORI is to “[help] people make informed healthcare decisions, and [improve] healthcare delivery and outcomes, by producing and promoting high-integrity, evidence-based information that comes from research guided by patients, caregivers, and the broader healthcare community” (40). Physical therapists have been awarded more than 28 million U.S. dollars of PCORI funding to analyze outcomes in real-world settings, with patient involvement early in the process (41). Nonetheless, a notable gap remains to involve frail older adults in the clinical decision process, which likely impacts patient experiences and subsequent outcomes across the spectrum of healthcare settings.
Conclusions
Author Manuscript
In the context of interdisciplinary healthcare teams and patient-centered care approaches, understanding the value of PTs in achieving the Triple Aim for the frail older adult population is important to the future of healthcare (Figure 1). However, a major gap exists in understanding the potential cost-savings of physical therapy services, as well as the role of PTs in improving patient experiences and outcomes in the frail older adult population. Overall, the use of rehabilitative approaches to care for the frail older adult population has strong potential to improve functional status and QOL, while concurrently reducing rates of disability, rehospitalization, institutionalization, and healthcare costs.
Acknowledgments
Author Manuscript
Funding: This research was funded in part by the Florence P. Kendall Doctoral Scholarship and the Promotion of Doctoral Studies I from the Foundation for Physical Therapy; the Fellowship for Geriatric Research from the Academy of Geriatric Physical Therapy; the Integrative Physical of Aging Training Grant T32AG000279; R25 CA160013; the University of Colorado Cancer Center the Rehabilitation Research& Development Small Projects in Rehabilitation Research I21 RX002193-01 from the U.S Department of Veteran Affairs; and the Rehabilitation Research& Development Merit Award I01 RX001978-01 from the U.S Department of Veteran Affairs. The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.
References
Author Manuscript
1. Bonar SK, Tinetti ME, Speechley M, Cooney LM. Factors associated with short- versus long-term skilled nursing facility placement among community-living hip fracture patients. J Am Geriatr Soc. 1990; 38:1139–44. [PubMed: 2172352] 2. 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:M146–56. [PubMed: 11253156] 3. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of Frailty in CommunityDwelling Older Persons: A Systematic Review. J Am Geriatr Soc. 2012; 60:1487–92. [PubMed: 22881367] 4. Partridge JS, Harari D, Dhesi JK. Frailty in the older surgical patient: a review. Age Ageing. 2012; 41:142–7. [PubMed: 22345294] 5. Morley JE. Developing novel therapeutic approaches to frailty. Curr Pharm Des. 2009; 15:3384–95. [PubMed: 19860686] 6. Comans TA, Peel NM, Hubbard RE, Mulligan AD, Gray LC, Scuffham PA. The increase in healthcare costs associated with frailty in older people discharged to a post-acute transition care program. Age Ageing. 2016; 45:317–20. [PubMed: 26769469] 7. Kojima G, Iliffe S, Jivraj S, Walters K. Association between frailty and quality of life among community-dwelling older people: a systematic review and meta-analysis. J Epidemiol Commun Health. in press. J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 6
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
8. Cesari M, Prince M, Thiyagarajan JA, et al. Frailty: An Emerging Public Health Priority. J Am Med Dir Assoc. 2016; 17:188–92. [PubMed: 26805753] 9. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008; 27:759–69. [PubMed: 18474969] 10. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013; 14:392–7. [PubMed: 23764209] 11. Romero-Ortuno R, Walsh CD, Lawlor BA, Kenny RA. A frailty instrument for primary care: findings from the Survey of Health, Ageing and Retirement in Europe (SHARE). BMC Geriatr. 2010; 10:57. [PubMed: 20731877] 12. Stalenhoef PA, Huijnen LG, Schonck RS, Knottnerus JA, van der Horst FG, Crebolder HF. [Home visits by community health nurses can contribute to the family practitioner’s knowledge of elderly patients]. Nederlands tijdschrift voor geneeskunde. 1996; 140:2464–7. [PubMed: 8999348] 13. De Lepeleire J, Degryse J, Illiffe S, Mann E, Buntinx F. Family physicians need easy instruments for frailty. Age Ageing. 2008; 37:484. author reply -5. [PubMed: 18515292] 14. Steifel, M., Nolan, KA. Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Serieswhite paper2012 15. Kindig DA. Managing population health. Physician Exec. 1997; 23:34–9. 16. The Physical Therapy Outcomes Registry Is Totally Into You. Profession in Transformation: American Physical Therapy Association; 2015. http://www.apta.org/ProfessionInTransformation/ Knowledgeable/PTOR/. Accessed November 9, 2016 17. Research Using FOTO Data: Focus on Therapeutic Outcomes Inc. Available from: http:// www.fotoinc.com/science-of-foto/citations-for-foto-database. Accessed October 26, 2016 18. NINDS Common Data Elements: National Institute of Neurological Disorders and Stroke. Available from: https://www.commondataelements.ninds.nih.gov/#page=Default. Accessed October 26, 2016 19. Cesari M, Kritchevsky SB, Penninx BW, et al. Prognostic value of usual gait speed in wellfunctioning older people–results from the Health, Aging and Body Composition Study. J Am Geriatr Soc. 2005; 53:1675–80. [PubMed: 16181165] 20. Volpato S, Cavalieri M, Sioulis F, et al. Predictive value of the Short Physical Performance Battery following hospitalization in older patients. J Gerontol A Biol Sci Med Sci. 2011; 66:89–96. [PubMed: 20861145] 21. Hoyer EH, Needham DM, Miller J, Deutschendorf A, Friedman M, Brotman DJ. Functional status impairment is associated with unplanned readmissions. Arch Phys Med Rehab. 2013; 94:1951–8. 22. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014; 9:277–82. [PubMed: 24616216] 23. Falvey JR, Burke RE, Malone D, Ridgeway KJ, McManus BM, Stevens-Lapsley JE. Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Phys Ther. 2016; 96:1125–34. [PubMed: 26939601] 24. Falvey JR, Mangione KK, Stevens-Lapsley JE. Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift. Phys Ther. 2015; 95:1307–15. [PubMed: 25908526] 25. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Managed Care. 2011; 17:41–8. 26. Polnaszek B, Mirr J, Roiland R, Gilmore-Bykovskyi A, Hovanes M, Kind A. Omission of Physical Therapy Recommendations for High-Risk Patients Transitioning From the Hospital to Subacute Care Facilities. Arch Phys Med Rehab. 2015; 96:1966–72.e3. 27. Dossa A, Bokhour B, Hoenig H. Care transitions from the hospital to home for patients with mobility impairments: patient and family caregiver experiences. Rehab Nurs. 2012; 37:277–85. 28. Russell D, Rosati RJ, Andreopoulos E. Continuity in the provider of home-based physical therapy services and its implications for outcomes of patients. Phys Ther. 2012; 92:227–35. [PubMed: 22074941]
J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 7
Author Manuscript Author Manuscript Author Manuscript
29. Greysen SR, Hoi-Cheung D, Garcia V, et al. «Missing pieces»–functional, social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. J Am Geriatr Soc. 2014; 62:1556–61. [PubMed: 24934494] 30. Browne K, Roseman D, Shaller D, Edgman-Levitan S. Analysis & commentary. Measuring patient experience as a strategy for improving primary care. Health Affairs. 2010; 29:921–5. [PubMed: 20439881] 31. Lee IC, Chiu YH, Lee CY. Exploration of the importance of geriatric frailty on health-related quality of life. Psychogeriatr. in press. 32. Kojima G, Iliffe S, Morris RW, Taniguchi Y, Kendrick D, Skelton DA, et al. Frailty predicts trajectories of quality of life over time among British community-dwelling older people. Qual Life Res. in press. 33. Bilotta C, Bowling A, Nicolini P, Case A, Pina G, Rossi SV, et al. Older People’s Quality of Life (OPQOL) scores and adverse health outcomes at a one-year follow-up. A prospective cohort study on older outpatients living in the community in Italy. Health Qual Life Outcomes. 2011; 9:72. [PubMed: 21892954] 34. Tsai SY, Chi LY, Lee CH, Chou P. Health-related quality of life as a predictor of mortality among community-dwelling older persons. Eur J Epidemiol. 2007; 22:19–26. [PubMed: 17216549] 35. Chida Y, Steptoe A. Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosom Med. 2008; 70:741–56. [PubMed: 18725425] 36. Bergman H, Ferrucci L, Guralnik J, Hogan DB, Hummel S, Karunananthan S, et al. Frailty: an emerging research and clinical paradigm–issues and controversies. J Gerontol A Biol Sci Med Sci. 2007; 62:731–7. [PubMed: 17634320] 37. Winslow C-EA. The Untilled Field of Public Health. Modern Medicine. 1920; 2:183–91. 38. Peterson LE, Goodman C, Karnes EK, Chen CJ, Schwartz JA. Assessment of the quality of cost analysis literature in physical therapy. Phys Ther. 2009; 89:733–55. [PubMed: 19556332] 39. Richardson B, Lindquist I. Metasynthesis of qualitative inquiry research studies in physiotherapy. Physiother Res Int. 2010; 15:111–7. [PubMed: 20183861] 40. Patient-Centered Outcomes Research Institute: About Us. 2016. Available from: http:// www.pcori.org/about-us. Accessed November 9, 2016 41. Health Care Headlines. PT in Motion; 2015. Available from: http://www.apta.org/PTinMotion/ News/2015/2/25/PCORI/. Accessed October 26, 2016
Author Manuscript J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 8
Author Manuscript Author Manuscript
Figure 1.
Schematic regarding the role of physical therapists in achieving the Triple Aim with respect to the treatment and management of the frail older adult
Author Manuscript Author Manuscript J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
J Frailty Aging. Author manuscript; available in PMC 2017 May 26. Published in final edited form as: J Frailty Aging. 2017 ; 6(1): 2–5. doi:10.14283/jfa.2017.1.
PUBLIC HEALTH IMPACT OF FRAILTY: ROLE OF PHYSICAL THERAPISTS A.M. GUSTAVSON1, J.R. FALVEY1, C.M. JANKOWSKI2, and J.E. STEVENS-LAPSLEY1,3 1Physical
Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
Author Manuscript
2College
of Nursing, University of Colorado, Aurora, CO, USA
3Geriatric
Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO, USA
Abstract
Author Manuscript
Frailty is an emerging and immediate public health concern given the growing aging population. The condition of frailty is characterized by a reduction in physiologic reserve, which places frail older adults at considerable risk for further functional decline, hospitalization, institutionalization, and death. Recent research suggests that frailty may be reversible, which could result in significant improvement in public health. Thus, a strong impetus exists to develop strategies for frail older adults that achieve the Triple Aim through better promotion of population health, optimization of patient experiences, and delivery of high-quality care at minimal cost. Physical therapists often treat frail older adults, yet how physical therapists can contribute to preventing or reversing frailty in healthcare settings has not been described, and may potentially influence patient outcomes and healthcare spending. Therefore, the purpose of this publication is to outline the potential role of physical therapists in achieving the Triple Aim for the frail older adult population.
Keywords Rehabilitation; frail older adults; frail elderly; physical therapy specialty; triple aim
Introduction Author Manuscript
The prevalence of frailty is anticipated to dramatically increase in the United States as the percent of older adults rises (1, 2), with current estimates of frailty across communitydwelling older adults varying between 4–59% (3). Frail older adults are characterized as having a loss of physiologic reserve that results in an inability to maintain homeostasis in the presence of external stressors (e.g., surgery, falls, or illness) (2, 4, 5). Reduced physiological reserve may manifest in higher rates of hospitalization, institutionalization, disability, and mortality (4). As a result, older adults with greater indices of frailty accrue 22–46% higher
Corresponding author: Jennifer E. Stevens-Lapsley, University of Colorado, 13121 East 17th Avenue, Aurora, CO 80045, Office: (303) 724-9170, Fax: (303) 724-9016, [email protected]. Conflict of Interest Disclosure: None
GUSTAVSON et al.
Page 2
Author Manuscript
healthcare costs following hospitalization compared to those with minimal frailty (6). In addition, frailty has a negative impact on both physical and mental quality of life (QOL) (7). Thus, the need to identify frailty early and intervene in a timely manner is an emerging public health concern because of the impending, exponential growth of the aging population and the subsequent increase in healthcare burden (8). Healthcare providers are being challenged to achieve the Triple Aim of improving population health, reducing per capita costs, and optimizing patient experience for frail older adults (9).
Author Manuscript
In 2012, the International Association of Gerontology & Geriatrics and The World Health Organization developed a consensus statement that promotes frailty screening as a strategy for identifying vulnerable, frail older adults and initiating interventions to allow “aging in place” (10, 11). However during patient visits in primary care, providers rarely perform a comprehensive screen for frailty indicators, such as assessment of muscle weakness or slowness of gait, due to growing administrative burden limiting patient contact time (12, 13). Physical therapists (PTs) are ideally positioned to identify frailty in geriatric healthcare settings, because they are often the first-line providers for treatment of frailty-associated functional impairments such as slowness of gait, fatigue, and weakness. However, the potential impact and contribution of PTs to the public health aspect of frailty has not been fully realized, which leads to a gap in understanding of how and when to utilize physical therapy services for frail older adults. Therefore, the purpose of this publication is to highlight the potential role and value of PTs in promoting population health, reducing healthcare costs, and improving outcomes for frail older adults (Figure 1).
Improving Population Health Author Manuscript Author Manuscript
Improving the health of the frail older adult population, as part of the Triple Aim, can be achieved through early identification and timely treatment of unmet, yet addressable, clinical needs (9, 14). Currently there is a paucity of population analyses to characterize frail older adults and subsequently identify high-risk patients, track population outcomes over time, and promote longitudinal monitoring of cost or utilization trends (14, 15). Standardizing the screening tools for frailty used by PTs and other healthcare providers could be an impactful first step towards gathering quality data to identify high-risk patients and populate outcomes databases for clinical, research, and policy analyses. For example, the physical therapy profession is developing a Physical Therapy Outcomes Registry, which focuses on enhancing patient care and improving practice through objective demonstration of the value of physical therapy services (16). Physical therapy practices can also contract with companies such as Focus on Therapeutic Outcomes Inc.® (FOTO) for data management and analysis (17). Additionally, on a wider interdisciplinary scale, sections of the National Institutes of Health have begun to promote standardized data collection across research projects and data sharing to promote greater collaboration through larger data sets (18). These initiatives could lead to greater accuracy and earlier identification of pre-frail or frail patients at the highest risk for adverse events and increased healthcare utilization. Large data collection can also help researchers and healthsystems identify characteristics responders to interventions designed to prevent, treat, or reverse frailty, which would more accurately characterize who to target with interventions. Additionally, a database consisting of clinical outcomes and frailty assessments may enable providers, clinical researchers, and policy J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 3
Author Manuscript
makers to study cost-effectiveness of physical therapy interventions for frail older adults and, subsequently, inform health policy regarding reimbursement and payment reform across healthcare settings. Unmet needs born out of lack of screening and early identification lead to risk for and greater prevalence of adverse events in the frail older adult population. Thus, initiating timely intervention to reduce or reverse frailty severity for these older adults is critical. PTs, as trained exercise interventionists, are ideally positioned to improve population health through delivery of safe and evidence-based rehabilitation for older adults with frailty. Consequently, PTs may be the first providers to recognize this risk and can intervene early through physical therapy interventions and referrals to other healthcare providers.
Reducing Per Capita Costs Author Manuscript
Reducing per capita costs of high-quality care is a second essential step to achieving the Triple Aim for the frail older adult population. PTs can help achieve this step through timely initiation of exercise interventions and development of preventative programs (9, 14). Physical therapy research and clinical data could help optimize identification and initiation of physical therapy interventions to improve physical function, and to initiate referrals to other healthcare providers. Physical function is a robust risk factor for hospitalization in older adult populations (19). In fact, previous studies have shown that low physical function is associated with greater risk for hospitalization and death (20). Thus, including physical therapy services in the care of frail older adults has the potential to reduce costs, because risk factors for costly rehospitalization and institutionalization - such as gait speed, weakness, and dependence with activities of daily living (21, 22) - are potentially modifiable through physical therapy interventions (23, 24).
Author Manuscript Author Manuscript
Furthermore, the early identification of frailty provides opportunities for prevention efforts, including population and patient-level education, motivational interviewing, and an emphasis on patient self-management that can in turn reduce costs (23). PTs can provide patient education on the safe use of assistive devices, equipment for a fall-proof home, appropriate exercise prescription, and recommendations for appropriate home health care assistance given the extent of mobility or activities of daily living limitations (23). PTs can also engage the patient and caregivers in problem-solving self-management needs. For example, PTs can teach patients and caregivers how to monitor and report mobility-related warning signs such as declines in gait speed or new impairments in daily activities (23). Patient self-monitoring, early detection of new or worsening impairments, and communication with the PTs or other providers of the interdisciplinary care team can potentially mitigate costly, avoidable rehospitalizations and institutionalization.
Optimizing Patient Experience Optimizing the patient experience is the third critical component of the Triple Aim and can be achieved through PT-initiated programs to support wellness while aging. Additionally, PTs often work collaboratively with other healthcare disciplines to develop coordinated, interdisciplinary, patient-centered care plans for frail older adults, which can include
J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 4
Author Manuscript Author Manuscript
wellness components and a holistic approach to care. Patient experiences and outcomes are better when healthcare teams work together (23, 25–29), which may in turn decrease healthcare utilization (23, 30). Perhaps the quintessential role of PTs in optimizing patient experiences is through promotion of “aging in place.” To achieve this, PTs can work with patients and caregivers to develop health and wellness educational materials to improve home safety and maintain independence; these materials could include strategies for maintaining function, improving physical activity, and reducing falls risk for frail older adults. Although integrating wellness into physical therapy to improve QOL is a growing area of the profession, it is currently not the standard of care and may be a gap in physical therapy curricula and reimbursement policies. Maintaining QOL for frail older adults is important to the patient as well as the health system’s perspective. For example adverse, costly, and oftentimes life-changing outcomes in older adults who are frail—such as mortality, falls, hospitalization, and institutionalization–are intricately linked with QOL (7, 31–35). Numerous studies have shown an inverse relationship between frailty and QOL at a single point in time, with a faster decline in QOL in those with frailty indicators (7, 31, 32). Therefore, frailty is a clear example of a condition that is conducive to a patient-centered, holistic approach to care (36) as awareness, prevention, early detection, and rapid intervention may help frail older adults “age in place” (10) with an improved QOL.
Physical Therapy Research and Initiatives through a Public Health Lens
Author Manuscript
Public Health will likely play an increasing role in achieving the Triple Aim through prevention and management of frail older adults (improve population health) to promote quality of life (optimize patient experience) at lower costs (reduce per capita costs). However, the integration and assessment of physical therapy services in this realm has not been adequately studied. Physical therapy services can potentially reduce healthcare costs when examined through a Public Health lens (37). For example, the increasing demand for high-quality, cost-saving healthcare delivery has stimulated cost-effectiveness and economic analyses of physical therapy (6) for arthritis and back pain exercise interventions; hip protector studies; and continence training (38). However no studies have specifically looked at the cost-effectiveness of physical therapy services and outcomes in the frail older adults population. Physical therapy interventions alone may be insufficient to reverse frailty and reduce costs; however an interdisciplinary approach that includes PTs is likely a costeffective strategy to treat frail older adults. Thus, cost-effectiveness research is greatly needed to assert the value of physical therapy in promoting optimal outcomes in the frail older adult population and subsequently achieving improved population health at lower healthcare costs, while also enhancing patient experiences.
Author Manuscript
Traditionally, physical therapy knowledge has been built on quantitative studies, with a paucity of patient-centered research (39), which hinders the ability to assess the patient experience arm of the Triple Aim. Qualitative research in physical therapy offers the opportunity to identify novel factors and challenges to health care delivery that includes the frail patient and caregivers in the decision-making process (39). Comparative effectiveness research of existing interventions would provide a risk to benefit profile that PTs, as part of an interdisciplinary team, and patients could use to make informed health care decisions (9). The Patient Centered Outcomes Research Initiative (PCORI) has bolstered enthusiasm for J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 5
Author Manuscript
investigations about informed health care decision-making. The mission of PCORI is to “[help] people make informed healthcare decisions, and [improve] healthcare delivery and outcomes, by producing and promoting high-integrity, evidence-based information that comes from research guided by patients, caregivers, and the broader healthcare community” (40). Physical therapists have been awarded more than 28 million U.S. dollars of PCORI funding to analyze outcomes in real-world settings, with patient involvement early in the process (41). Nonetheless, a notable gap remains to involve frail older adults in the clinical decision process, which likely impacts patient experiences and subsequent outcomes across the spectrum of healthcare settings.
Conclusions
Author Manuscript
In the context of interdisciplinary healthcare teams and patient-centered care approaches, understanding the value of PTs in achieving the Triple Aim for the frail older adult population is important to the future of healthcare (Figure 1). However, a major gap exists in understanding the potential cost-savings of physical therapy services, as well as the role of PTs in improving patient experiences and outcomes in the frail older adult population. Overall, the use of rehabilitative approaches to care for the frail older adult population has strong potential to improve functional status and QOL, while concurrently reducing rates of disability, rehospitalization, institutionalization, and healthcare costs.
Acknowledgments
Author Manuscript
Funding: This research was funded in part by the Florence P. Kendall Doctoral Scholarship and the Promotion of Doctoral Studies I from the Foundation for Physical Therapy; the Fellowship for Geriatric Research from the Academy of Geriatric Physical Therapy; the Integrative Physical of Aging Training Grant T32AG000279; R25 CA160013; the University of Colorado Cancer Center the Rehabilitation Research& Development Small Projects in Rehabilitation Research I21 RX002193-01 from the U.S Department of Veteran Affairs; and the Rehabilitation Research& Development Merit Award I01 RX001978-01 from the U.S Department of Veteran Affairs. The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.
References
Author Manuscript
1. Bonar SK, Tinetti ME, Speechley M, Cooney LM. Factors associated with short- versus long-term skilled nursing facility placement among community-living hip fracture patients. J Am Geriatr Soc. 1990; 38:1139–44. [PubMed: 2172352] 2. 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:M146–56. [PubMed: 11253156] 3. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of Frailty in CommunityDwelling Older Persons: A Systematic Review. J Am Geriatr Soc. 2012; 60:1487–92. [PubMed: 22881367] 4. Partridge JS, Harari D, Dhesi JK. Frailty in the older surgical patient: a review. Age Ageing. 2012; 41:142–7. [PubMed: 22345294] 5. Morley JE. Developing novel therapeutic approaches to frailty. Curr Pharm Des. 2009; 15:3384–95. [PubMed: 19860686] 6. Comans TA, Peel NM, Hubbard RE, Mulligan AD, Gray LC, Scuffham PA. The increase in healthcare costs associated with frailty in older people discharged to a post-acute transition care program. Age Ageing. 2016; 45:317–20. [PubMed: 26769469] 7. Kojima G, Iliffe S, Jivraj S, Walters K. Association between frailty and quality of life among community-dwelling older people: a systematic review and meta-analysis. J Epidemiol Commun Health. in press. J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 6
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
8. Cesari M, Prince M, Thiyagarajan JA, et al. Frailty: An Emerging Public Health Priority. J Am Med Dir Assoc. 2016; 17:188–92. [PubMed: 26805753] 9. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008; 27:759–69. [PubMed: 18474969] 10. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013; 14:392–7. [PubMed: 23764209] 11. Romero-Ortuno R, Walsh CD, Lawlor BA, Kenny RA. A frailty instrument for primary care: findings from the Survey of Health, Ageing and Retirement in Europe (SHARE). BMC Geriatr. 2010; 10:57. [PubMed: 20731877] 12. Stalenhoef PA, Huijnen LG, Schonck RS, Knottnerus JA, van der Horst FG, Crebolder HF. [Home visits by community health nurses can contribute to the family practitioner’s knowledge of elderly patients]. Nederlands tijdschrift voor geneeskunde. 1996; 140:2464–7. [PubMed: 8999348] 13. De Lepeleire J, Degryse J, Illiffe S, Mann E, Buntinx F. Family physicians need easy instruments for frailty. Age Ageing. 2008; 37:484. author reply -5. [PubMed: 18515292] 14. Steifel, M., Nolan, KA. Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Serieswhite paper2012 15. Kindig DA. Managing population health. Physician Exec. 1997; 23:34–9. 16. The Physical Therapy Outcomes Registry Is Totally Into You. Profession in Transformation: American Physical Therapy Association; 2015. http://www.apta.org/ProfessionInTransformation/ Knowledgeable/PTOR/. Accessed November 9, 2016 17. Research Using FOTO Data: Focus on Therapeutic Outcomes Inc. Available from: http:// www.fotoinc.com/science-of-foto/citations-for-foto-database. Accessed October 26, 2016 18. NINDS Common Data Elements: National Institute of Neurological Disorders and Stroke. Available from: https://www.commondataelements.ninds.nih.gov/#page=Default. Accessed October 26, 2016 19. Cesari M, Kritchevsky SB, Penninx BW, et al. Prognostic value of usual gait speed in wellfunctioning older people–results from the Health, Aging and Body Composition Study. J Am Geriatr Soc. 2005; 53:1675–80. [PubMed: 16181165] 20. Volpato S, Cavalieri M, Sioulis F, et al. Predictive value of the Short Physical Performance Battery following hospitalization in older patients. J Gerontol A Biol Sci Med Sci. 2011; 66:89–96. [PubMed: 20861145] 21. Hoyer EH, Needham DM, Miller J, Deutschendorf A, Friedman M, Brotman DJ. Functional status impairment is associated with unplanned readmissions. Arch Phys Med Rehab. 2013; 94:1951–8. 22. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014; 9:277–82. [PubMed: 24616216] 23. Falvey JR, Burke RE, Malone D, Ridgeway KJ, McManus BM, Stevens-Lapsley JE. Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Phys Ther. 2016; 96:1125–34. [PubMed: 26939601] 24. Falvey JR, Mangione KK, Stevens-Lapsley JE. Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift. Phys Ther. 2015; 95:1307–15. [PubMed: 25908526] 25. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Managed Care. 2011; 17:41–8. 26. Polnaszek B, Mirr J, Roiland R, Gilmore-Bykovskyi A, Hovanes M, Kind A. Omission of Physical Therapy Recommendations for High-Risk Patients Transitioning From the Hospital to Subacute Care Facilities. Arch Phys Med Rehab. 2015; 96:1966–72.e3. 27. Dossa A, Bokhour B, Hoenig H. Care transitions from the hospital to home for patients with mobility impairments: patient and family caregiver experiences. Rehab Nurs. 2012; 37:277–85. 28. Russell D, Rosati RJ, Andreopoulos E. Continuity in the provider of home-based physical therapy services and its implications for outcomes of patients. Phys Ther. 2012; 92:227–35. [PubMed: 22074941]
J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 7
Author Manuscript Author Manuscript Author Manuscript
29. Greysen SR, Hoi-Cheung D, Garcia V, et al. «Missing pieces»–functional, social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. J Am Geriatr Soc. 2014; 62:1556–61. [PubMed: 24934494] 30. Browne K, Roseman D, Shaller D, Edgman-Levitan S. Analysis & commentary. Measuring patient experience as a strategy for improving primary care. Health Affairs. 2010; 29:921–5. [PubMed: 20439881] 31. Lee IC, Chiu YH, Lee CY. Exploration of the importance of geriatric frailty on health-related quality of life. Psychogeriatr. in press. 32. Kojima G, Iliffe S, Morris RW, Taniguchi Y, Kendrick D, Skelton DA, et al. Frailty predicts trajectories of quality of life over time among British community-dwelling older people. Qual Life Res. in press. 33. Bilotta C, Bowling A, Nicolini P, Case A, Pina G, Rossi SV, et al. Older People’s Quality of Life (OPQOL) scores and adverse health outcomes at a one-year follow-up. A prospective cohort study on older outpatients living in the community in Italy. Health Qual Life Outcomes. 2011; 9:72. [PubMed: 21892954] 34. Tsai SY, Chi LY, Lee CH, Chou P. Health-related quality of life as a predictor of mortality among community-dwelling older persons. Eur J Epidemiol. 2007; 22:19–26. [PubMed: 17216549] 35. Chida Y, Steptoe A. Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosom Med. 2008; 70:741–56. [PubMed: 18725425] 36. Bergman H, Ferrucci L, Guralnik J, Hogan DB, Hummel S, Karunananthan S, et al. Frailty: an emerging research and clinical paradigm–issues and controversies. J Gerontol A Biol Sci Med Sci. 2007; 62:731–7. [PubMed: 17634320] 37. Winslow C-EA. The Untilled Field of Public Health. Modern Medicine. 1920; 2:183–91. 38. Peterson LE, Goodman C, Karnes EK, Chen CJ, Schwartz JA. Assessment of the quality of cost analysis literature in physical therapy. Phys Ther. 2009; 89:733–55. [PubMed: 19556332] 39. Richardson B, Lindquist I. Metasynthesis of qualitative inquiry research studies in physiotherapy. Physiother Res Int. 2010; 15:111–7. [PubMed: 20183861] 40. Patient-Centered Outcomes Research Institute: About Us. 2016. Available from: http:// www.pcori.org/about-us. Accessed November 9, 2016 41. Health Care Headlines. PT in Motion; 2015. Available from: http://www.apta.org/PTinMotion/ News/2015/2/25/PCORI/. Accessed October 26, 2016
Author Manuscript J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
GUSTAVSON et al.
Page 8
Author Manuscript Author Manuscript
Figure 1.
Schematic regarding the role of physical therapists in achieving the Triple Aim with respect to the treatment and management of the frail older adult
Author Manuscript Author Manuscript J Frailty Aging. Author manuscript; available in PMC 2017 May 26.
