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National Exercise Referral Scheme
Falls Collaborative Presentation
Jeannie Wyatt-Williams
National Exercise Referral Coordinator
7th March 2012
In 2006 the Welsh Government (WG) commissioned a review of exercise referral schemes in Wales and agreed to establish a National Exercise Referral Scheme (NERS) alongside a randomised controlled trial (RCT).
Funding was given to all 22 Local Authorities (LA) in Wales to support a Coordinator and a number of exercise professionals (EP).
All EP’s were trained to meet recommended national standards.
Background
The RCT results revealed that participants in the scheme had higher levels of physical activity than the control group.
This was significant for patients referred for coronary heart disease risk factors; there were improvements in clients
with depression and anxiety
the economic evaluation demonstrated a cost per QALY of
£12,111.
For those who adhere to the full programme the
scheme was cost saving (£-367 per QALY).http://wales.gov.uk/about/aboutresearch/social/latestresearch/?lang=en
RCT results
In April 2008 the Minister for Health agreed to appoint a National Coordinator to be based in Welsh Local Government Association (WLGA) further develop and improve the scheme.
I was appointed in August 2008 and worked to develop protocols for standard delivery of physical activity for clients with specific chronic conditions; WG identified priority conditions.
These priority conditions have grown annually since 2009
Delivery for Chronic Conditions
The NERS Community Falls Prevention Intervention provides an opportunity for patients
to attend an evidence based exercise programme
designed to reduce the risk of falls, led by
qualified Postural Stability Instructors (PSI).
The scheme is based on best practice from
the UK, current evidence base and
operates to National Standards.
Introduction to Falls Prevention
The scheme has been supported by the WG, WLGA, Later Life Training (LLT), LA, Public Health Wales (PHW) and Local Health Boards (LHB).
The delivery of intervention is based on the 7 evidenced based components from the FaME trial
(Skelton and Dinan 2001/2 – published 2005) and the OTAGO Trials (Campbell et al 2002)
Introduction continued
The Royal College Physicians, National Falls and Bone Health Organisational Audit Executive Summary, March 2009 asks;
4.4.3 Does the intervention include a validated exercise programme delivered by appropriately trained healthcare professionals and/or exercise specialists:
Answer:
FaME and/or OTAGO+ level 4 Later Life PSI = YES
Therefore NERS Prehab =yes
Caution
No service in isolation can address Falls in Wales!
Introduction continued
To train EP to meet the LLT PSI Level 4 qualification.
To deliver an evidence based NERS Intervention
To offer a systematic and safety controlled system of referral to NERS Intervention.
To increase the patients strength, balance and co-ordination, wellbeing.
To decrease the patients social isolation and risk of fractures.
To increase the patients long term adherence to physical activity.
The principal aims
Areas delivering Prehab + referral rate
AREA REFERRALS
APRIL 2011-DEC 2011
AREA REFERRALS
APRIL 2011-DEC 2012
ANGLESEY 35 GWYNEDD 15
BRIDGEND 33 NEWPORT 13
CAERPHILLY 27 POWYS 7
CARMARTHEN 75 SWANSEA 24
CONWY 15 VALE OF GLAMORGAN
12
DENBIGH 7 WREXHAM 73
TOTAL AREAS 12 TOTAL REFERRALS
336
The other 4 areas have staff completing their qualification
Areas with qualified PSI’s
AREAS AREAS AREA
ANGLESEY DENBIGH POWYS
BLAENAU GWENT FLINTSHIRE RCT
BRIDGEND GWYNEDD SWANSEA
CAERPHILLY MERTHYR TORFAEN
CARMARTHEN NEWPORT VALE OF GLAMORGAN
CONWY PEMBROKESHIRE WREXHAM
Sample of Clinical Rehab Flow Chart
FRAT
QUESTIONNAIRE
PEOPLE AT
RISK OF / OR
HISTORY OF
FALLS
HEALTH CARE
PROFESSIONALS
SOCIAL CARE
PROFESSIONALS
NERS EXERCISE
PROFESSIONALS
AMBULANCE
SERVICE
GP’s
SELF REFERRAL
Entered onto a data
base.
Referred Multi factorial
Risk Assessment Team.
(MRA Team)
+ ve risk
of falls
Physio completes Database
Patient contacted and
invited for a Multi
factorial Risk
Assessment (MRA)
Designated NERS PSI
instructors &
Physiotherapist from
re-ablement team.
Joint working to
deliver MRA clinic in
community venue
G.P. for
medication
review
Optometrist
Care and repair
PSI Falls 48
week
Intervention
Low level Falls
Intervention
Physio led
Social Services
Home Safety
Check
Exit into
suitable
Community
based
Activities
Tai Chi
NERS
Walking
Clubs
R
e
f
e
r
r
a
l
s
b
a
s
e
d
o
n
a
s
s
e
s
s
m
e
n
t
f
i
n
d
i
n
g
s
NERS Prehab Intervention Flow Chart
Patient meets criteria and
agrees to referral to NERS
Falls Intervention
Ist Consultation
Completion of all tests
Explain Falls Diary
Referral to start 32 week
programme during weeks 1-4
Weeks 1-12 skilling up; requires 2 x PSI or 1
PSI +1 assistant
Weeks 12-32 training gains; requires PSI
plus 1 assistant
Weeks 33-48 maintenance; requires PSI plus
1 assistant. As NERS exit class
Suggested staffing local staff patient ratio to
be risk assessed
Proposed tests to be carried out at 1st consultationFalls Efficacy Scale (FES-1)
Functional Assessment (all 6 tests)
Health questionnaire If time constraints these can be sent out with appointment and returned at 1st consultation
SF12
CONFBal
Black fracture risk
Activity question: How active are they currently.
Please repeat the tests indicated at 32 and 48 weeks
Plus the following questions: on weeks 32 and 48
How active are they currently
How they are feeling?( ask weekly )
Have they noticed any changes?
Has their medication reduced?
Has their medical condition changed?
Are there any problems or issues about exercising?
Is there anything they can do now that they couldn’t do before?
Repeat the FRAT at week 48 to gauge reduced risk of Falls.
Discuss continuing exercise options in the community at week 32 and 48
Exit to suitable
community exercise
opportunities led by
REP’s registered
Community Instructor.
Issues/Benefits
Issues Benefits
Lack of additional funding to deliver additional conditions.
Agreed protocols meet
evidence base
Lack of multi factorial teams in place to assess clients and develop referral pathways.
Standardised delivery
Transport Rolling programme has now
been established in most areas
to avoid waiting times
Client exercise professional
ratio recommendations
Many areas working closely
with physiotherapists during
first skilling up phase
Integration of Health and the National Exercise Referral Scheme
in the Prevention and Management of Chronic Conditions
2. Health Education Programmes
1. Primary Care
3. Rehab Programmeswith
Specific Exercise Component
Generic Exercise Referral
Level 3 Instructors
SpecificExercise
ComponentLevel 4
Instructors
Gardening
Cycling
Yoga /Pilates
Obesity
Depression
Musculoskeletal
Impaired Glucose Tolerance
Expert Patient
Programme (EPP)
Condition Specific
Education
Mental Health
Falls
Back Pain / Chronic
Musculoskeletal
Jeannie Wyatt-Williams
Adapted from Bridgend’s Model
by Melanie Andrews
ABMU Health Board
Heart Failure
Stroke
Lifestyle /behaviour change advice and completion of risk assessment tool to ensure signposting to appropriate interventionLevel 2 Instructor
To deliver exit from NERS and entrance to community activity
Health
Interface
Exercise
Referral
Scheme
Exit routes
Mental Health
Obesity/ diabetes
Cancer
Thank you for listening
Jeannie Wyatt-Williams
National Exercise Referral Coordinator
