Ron Stock

Tai Chi and Postural Stability in Patients with Parkinson's Disease

BACKGROUND Patients with Parkinsons disease have substantially impaired balance, leading to diminished functional ability and an increased risk of falling. Although exercise is routinely encouraged by health care providers, few programs have been proven effective. METHODS We conducted a randomized, controlled trial to determine whether a tailored tai chi program could improve postural control in patients with idiopathic Parkinsons disease. We randomly assigned 195 patients with stage 1 to 4 disease on the Hoehn and Yahr staging scale (which ranges from 1 to 5, with higher stages indicating more severe disease) to one of three groups: tai chi, resistance training, or stretching. The patients participated in 60-minute exercise sessions twice weekly for 24 weeks. The primary outcomes were changes from baseline in the limits-of-stability test (maximum excursion and directional control; range, 0 to 100%). Secondary outcomes included measures of gait and strength, scores on functional-reach and timed up-and-go tests, motor scores on the Unified Parkinsons Disease Rating Scale, and number of falls. RESULTS The tai chi group performed consistently better than the resistance-training and stretching groups in maximum excursion (between-group difference in the change from baseline, 5.55 percentage points; 95% confidence interval [CI], 1.12 to 9.97; and 11.98 percentage points; 95% CI, 7.21 to 16.74, respectively) and in directional control (10.45 percentage points; 95% CI, 3.89 to 17.00; and 11.38 percentage points; 95% CI, 5.50 to 17.27, respectively). The tai chi group also performed better than the stretching group in all secondary outcomes and outperformed the resistance-training group in stride length and functional reach. Tai chi lowered the incidence of falls as compared with stretching but not as compared with resistance training. The effects of tai chi training were maintained at 3 months after the intervention. No serious adverse events were observed. CONCLUSIONS Tai chi training appears to reduce balance impairments in patients with mild-to-moderate Parkinsons disease, with additional benefits of improved functional capacity and reduced falls. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00611481.).

A randomized controlled trial of patient-reported outcomes with tai chi exercise in Parkinson's disease.

A previous randomized, controlled trial of tai chi showed improvements in objectively measured balance and other motor‐related outcomes in patients with Parkinsons disease. This study evaluated whether patient‐reported outcomes could be improved through exercise interventions and whether improvements were associated with clinical outcomes and exercise adherence. In a secondary analysis of the tai chi trial, patient‐reported and clinical outcomes and exercise adherence measures were compared between tai chi and resistance training and between tai chi and stretching exercise. Patient‐reported outcome measures were perceptions of health‐related benefits resulting from participation, assessed by the Parkinsons Disease Questionnaire (PDQ‐8) and Vitality Plus Scale (VPS). Clinical outcome measures included motor symptoms, assessed by a modified Unified Parkinsons Disease Rating Scale–Motor Examination (UPDRS‐ME) and a 50‐foot speed walk. Information on continuing exercise after the structured interventions were terminated was obtained at a 3‐month postintervention follow‐up. Tai chi participants reported significantly better improvement in the PDQ‐8 (−5.77 points, P = 0.014) than did resistance training participants and in PDQ‐8 (−9.56 points, P < 0.001) and VPS (2.80 points, P = 0.003) than did stretching participants. For tai chi, patient‐reported improvement in the PDQ‐8 and VPS was significantly correlated with their clinical outcomes of UPDRS‐ME and a 50‐foot walk, but these correlations were not statistically different from those shown for resistance training or stretching. However, patient‐reported outcomes from tai chi training were associated with greater probability of continued exercise behavior than were either clinical outcomes or patient‐reported outcomes from resistance training or stretching. Tai chi improved patient‐reported perceptions of health‐related benefits, which were found to be associated with a greater probability of exercise adherence. The findings indicate the potential of patient perceptions to drive exercise behavior after structured exercise programs are completed and the value of strengthening such perceptions in any behavioral intervention.

Developing a Senior Healthcare Practice Using the Chronic Care Model: Effect on Physical Function and Health-Related Quality of Life

An ambulatory senior health clinic was developed using the chronic care model (CCM), with emphasis on an interdisciplinary team approach. To determine the effect of this care model approach in a nonprofit healthcare system, an observational, longitudinal panel study of community‐dwelling Medicare beneficiaries was performed to examine the effect on physical function and health‐related quality of life (HRQL). Participants in the study were recruited from a community sample of 6,864 eligible Medicare beneficiaries. Informed consent and baseline data were obtained from 1,709 individuals (recruitment response rate=25%) and complete data across 30 months from 1,307 (completion response rate=76%). Participants receiving care in the CCM‐based senior healthcare practice (n=318) were compared with patients of primary care physicians supported by care managers (n=598) and a group without care managers (n=391). Self‐reported data were collected over the telephone to measure physical function and HRQL at baseline and 6, 18, and 30 months. A multiple group mixture growth model was used to analyze physical function and HRQL across the 30 months. Physical function and HRQL mean scores decreased across time in all participants and were moderately correlated at each wave (correlation coefficient=0.74–0.79). Two latent growth classes were identified. In class 1, physical function decreased, and HRQL remained stable across time. In class 2, physical function and HRQL decreased in parallel. Ninety‐seven percent of intervention group patients were in class 1, and 99% of patients in comparison groups 1 and 2 were in class 2. Despite physical function decline, patients in a senior health clinic care model maintained HRQL over time, whereas patients receiving traditional care had physical function and HRQL decline. An interdisciplinary team CCM approach appears to have a positive effect on HRQL in this population.

Developing a comprehensive interdisciplinary Senior healthcare practice

The PeaceHealth Senior Health and Wellness Center (SHWC) provides primary care coordinated by geriatricians and an interdisciplinary office practice team that addresses the multiple needs of geriatric patients. The SHWC is a hospital outpatient clinic operated as a component of an integrated health system and is focused on the care of frail elders with multiple interacting chronic conditions and management of chronic disease in the healthier older population. Based on the Chronic Care Model, the SHWC strives to enhance coordination and continuity along the continuum of care, including outpatient, inpatient, skilled nursing, long‐term care, and home care services. During its development, a patient‐centered approach was used to identify senior service needs. The model emphasizes team development, integration of evidence‐based geriatric care, site‐based care coordination, longer appointment times, “high touch” service qualities, utilization of an electronic medical record across care settings, and a prevention/wellness orientation. This collection of services addresses the interrelationships of all senior issues, including nutrition, social support, spiritual support, caregiver support, physical activity, medications, and chronic disease. The SHWC provides access in an environment sensitive to the special needs of seniors, with a staff trained to meet those needs. The SHWC business model attempts to improve access and quality of care to seniors in a mostly noncapitated healthcare setting, while also attempting to remain financially viable.

Implementing an Evidence‐Based Fall Prevention Program in an Outpatient Clinical Setting

To investigate the dissemination potential of a Tai Ji Quan–based program, previously shown to be efficacious for reducing risk of falls in older adults, through outpatient clinical settings.

Using an electronic prescribing system to ensure accurate medication lists in a large multidisciplinary medical group

BACKGROUND Although medication safety has largely focused on reducing medication errors in hospitals, the scope of adverse drug events in the outpatient setting is immense. A fundamental problem occurs when a clinician lacks immediate access to an accurate list of the medications that a patient is taking. Since 2001, PeaceHealth Medical Group (PHMG), a multispecialty physician group, has been using an electronic prescribing system that includes medication-interaction warnings and allergy checks. Yet, most practitioners recognized the remaining potential for error, especially because there was no assurance regarding the accuracy of information on the electronic medical record (EMR)-generated medication list. PeaceHealth developed and implemented a standardized approach to (1) review and reconcile the medication list for every patient at each office visit and (2) report on the results obtained within the PHMG clinics. METHODS In 2005, PeaceHealth established the ambulatory medication reconciliation project to develop a reliable, efficient process for maintaining accurate patient medication lists. Each of PeaceHealths five regions created a medication reconciliation task force to redesign its clinical practice, incorporating the systemwide aims and agreed-on key process components for every ambulatory visit. RESULTS Implementation of the medication reconciliation process at the PHMG clinics resulted in a substantial increase in the number of accurate medication lists, with fewer discrepancies between what the patient is actually taking and what is recorded in the EMR. DISCUSSION The PeaceHealth focus on patient safety, and particularly the reduction of medication errors, has involved a standardized approach for reviewing and reconciling medication lists for every patient visiting a physician office. The standardized processes can be replicated at other ambulatory clinics-whether or not electronic tools are available.

State-Level Design: The Coordinated Care Model

Abstract Oregon’s means to achieving the “triple aim” was to fundamentally change how health care is delivered and Coordinated Care Organizations (CCOs) were created as the vehicle to make that happen. This chapter describes the theory behind CCOs and details the five critical elements upon which they were founded: local accountability, a global budget, flexibility in the use of services and health care dollars, coordinated care, and metrics. In addition, it outlines the progress to date and concludes with a discussion of lessons learned.

Chapter 12 – The Oregon Transformation Center: How and Why a State Agency Can Support Change

Provides background and overview of the Oregon Transformation Center, a new office created with the Oregon Health Authority designed to serve as a hub for innovation and to support the spread of learning the implementation of the Coordinated Care Model. The Transformation Center was part of Oregon’s effort to support change and circumvent the usual challenges of dissemination of change in health care. This chapter provides information on early implementation, organizational structure and staff roles, activities and future planning, and considers key lessons learned and implications for the development of transformation centers in other states.Abstract Provides background and overview of the Oregon Transformation Center, a new office created with the Oregon Health Authority designed to serve as a hub for innovation and to support the spread of learning the implementation of the Coordinated Care Model. The Transformation Center was part of Oregon’s effort to support change and circumvent the usual challenges of dissemination of change in health care. This chapter provides information on early implementation, organizational structure and staff roles, activities and future planning, and considers key lessons learned and implications for the development of transformation centers in other states.

Emerging Models to Prepare the Workforce for Health System Change

Critical to health care reform is recruiting and training a multiprofessional workforce working together collaboratively with individuals, families, and communities using an interprofessional team approach. This chapter characterizes how Oregon has approached the recruitment and retention of health care professionals to meet the demand, now and into the future, as well as providing the competency training for a new system of care. Three workforce training interventions that have emerged as catalysts to implementation of health reform in Oregon are described in the final section of this chapter: (1) the Clinical Innovation Fellows Program; (2) the Traditional Health Workers Program; and (3) the Patient-Centered Primary Care Home Program.