National Exercise Referral Framework Draft 2 Consultation Presentation
Global Context
National Context National Physical Activity Plan
Physical Activity and Health
Physical Activity and Health Chronic Condition Risk Reduction* All-cause mortality 30% CVD, CHD, stroke 20-35% Diabetes 30-40% Hip fractures 36-68% Colon cancer 30% Breast cancer 30% Depression/dementia 20-30% Loss of function 20% * Adults meeting the recommended 30 min of PA on ≥5 d/ wk
Physical In activity is a global priority Global prevalence of physical in activity 31% Irish prevalence of physical in activity 60% As Presented by Prof. Fiona Bull, MBE at the NEHRF Expert Symposium in DCU on 19 th June, 2014
Risk Factors for Mortality 16 Global Mortality (%) 14 12 10 8 6 4 2 0 High Blood Tobacco Use Pressure High Blood Physical Glucose Inactivity WHO, 2009
The Toronto Charter for Physical Activity: A Global Call for Action The Seven Investments 1. A ‘whole of school’ approach to physical activity involves prioritizing: regular highly-active, physical education classes and providing suitable physical environments to support structured and unstructured physical activity throughout the day 2. Transport policies and systems that facilitate walking, cycling and public transport 3. Urban design regulations and infrastructure that ’ s provides for equitable and safe access for recreational physical activity and recreational or transport-related walking and cycling across the life course 4. Physical activity and NCD prevention integrated into primary healthcare systems by including physical activity as an explicit element of regular behavioural risk factor screening for NCD prevention, patient education and referral 5. Public education including mass media to raise awareness and change social norms on physical activity 6. Community-wide programmes involving multiple settings (cities, workplaces) and sectors that mobilise and integrate community engagement and resources 7. Sports systems and programmes that promote ‘sport for all’ and encourage participation across the life span
Physical Activity Pathways in Healthcare Model Brief advice (BA): This describes a short intervention (usually approx. 3 minutes) and involves opportunistic advice to raise awareness of, and assess a person’s willingness to engage in further discussion about, healthy lifestyle issues. It usually involves giving information about the importance of behaviour change and simple advice to support this behaviour change. Brief intervention (BI): Involves opportunistic advice, discussion, negotiation or encouragement. The intervention can vary from basic advice to more extended, individually-focused attempts to identify and change factors that influence activity levels. Exercise Referral (ER): This involves the ‘referral of a patient by a healthcare professional to a service offering an assessment of need, development of a tailored physical activity programme, monitoring of progress and a follow-up. Service here means i) a publically funded or privately operated service which may take place within a gym, leisure centre or at some other location and/or ii) an individual exercise professional operating an exercise referral service in a variety of settings.
• Evidence supports the effectiveness of brief advice and brief intervention by healthcare professionals to increase physical activity levels among the general population, and in particular inactive adults • Recommended by NICE
Evidence suggests ER is an effective targeted health intervention for specific patients, but it has limited evidence as an effective intervention for the general population
Recommendation 2: Policy makers and commissioners should fund exercise referral schemes for people who are sedentary or inactive and have existing health conditions or other factors that put them at increased risk of ill health if the scheme: • Incorporates behaviour change techniques • Collects a minimum set of data • Makes the data available to inform future practice
NERF Vision: Those living with NCDs or disability will enjoy more active and healthier lives Aim: To increase PA levels in individuals living with established NCD or disability Objectives: • To provide ER to quality, safe and effective supervised PA opportunities for those with an established NCD or disability • To develop the knowledge, attitude and skills of health professionals and PA service providers in relation to PA and its role for the primary and secondary prevention of NCDs • To develop a method for process and outcome evaluation of the NERF in order to determine its effectiveness over time
Target Population Category A Those with moderate to severe NCDs or disability that is significantly impacting on quality of life and health care utilization and that would benefit from regular physical activity. Category B Those with definite but mild NCDs or disability that is not (yet) significantly impacting on quality of life and/or health care utilization but that is likely to have a significant health impact in the future and that would benefit from regular physical activity. Category C Those who are inactive or sedentary or at risk of developing a NCD and who would benefit from regular physical activity
Participant Pathways A B C Brief Intervention Brief Advice Referral Referral High Level Supervision Medium Level Supervision Low Level Supervision Self-directed PA Programmes
Participant Pathways Category A A • Require a high level of supervision • Referral to a NERF designated high support centre, where accessible Referral • All can be prescribed home-based PA programmes by appropriately trained personnel • Participant transition to lower levels of supervision is recommended High Level Supervision
Participant Pathways Category B B • Require a medium level of supervision • Referral to a NEHRF approved exercise facility Referral or community-based PA programme • All can be prescribed home-based PA Medium Level Supervision
Participant Pathways Category C C • Require a low level of supervision • The NERF recommends brief advice and brief Brief Intervention intervention Low Level Supervision
Exercise Referral Pathways A B Referring Practitioner Exercise Feedback Referral Unit Service Provider
Referring Practitioner Referring practitioners may include, but is not restricted to, the following: • General practitioners • Hospital physicians and multidisciplinary colleagues • Primary care teams • Practice nurses • Clinical nurses specialists • Physiotherapists • Allied health professionals (e.g. occupational therapists) • Community care personnel (e.g. nurses, dieticians, pharmacists, social workers) • Mental health professionals
Roles & Responsibilties of Referring Practitioners 1.Patient 2. Screen Recruitment 3. Intervene • Exercise Referral 5. Follow-up / Review 4.Active Participation
Roles & Responsibilties of Referring Practitioners Intervene Active Participation Review Patient Recruitment Screen Reinforce & encourage to Assess current level of Opportunistic and routine continue to be more active physical activity. Data consultations recording & monitoring system Initiation via disease register Patient leaves pathway Purpose Meeting recommendations for health? To support delivery of ER within the healthcare system Yes Offer brief advice Target Audience: Category A and B No Patient leaves pathway INTERVENTION DELIVERY: Assess stage of behaviour Exercise Referral: change General Practitioners, Practice Nurses, Allied Health Pre-contemplation Professional etc Patient leaves pathway Patient sets goal and Contemplation/ becomes more active Preparation Assess suitability of participant Independent ‘free living’ Patient chooses to become based on inclusion /exclusion activity e.g. walking, cycling, active on their own guidelines and clinical gardening etc. judgement Absolute contraindication Exercise Referral to ER to exercise At 3, 6 and 12 months: high supervision centre or Review patient progress instructor Receives Exercise Category A Referral Exercise Referral to ER Category B Receives Exercise medium supervision Referral centre or instructor
Referring Practitioners Competencies/Training Requirements • An understanding of the NERF protocols and procedures • An understanding of both the benefits and risks of physical activity • Training in motivational interviewing to be able to determine the participant’s stage of behaviour change and facilitate behaviour change of potential candidates for the scheme Training Delivery Immediate Workforce Future Workforce • CPD • Integrated into the pre-service • Adapted HSELand Promoting curriculum on any vocational Physical Activity programme related to healthcare • Appropriately accredited • Easily accessible
Referring Practitioners Infrastructure and Resources • User-friendly electronic referral system • Where possible link to Healthlink • Referral handbook • Brief intervention pamphlets (for those in precontemplation)
Exercise Referral Pathways A B Referring Practitioner Exercise Feedb Referral Unit ack Service Provider
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