NR 539 Week 8 Program Report for the Funder Example

Program Report for the Funder: Up and Steady's First Year, What Was Delivered, What Changed Among the People Visited, the Modest Share of That Change the Program Can Honestly Claim and the Case for Releasing Year Two

Student Name

College of Nursing, Chamberlain University

NR 539: Population Health II: Planning, Implementation, and Evaluation

Instructor Name

Month Day, Year

Program Report for the Funder: Up and Steady's First Year, What Was Delivered, What Changed Among the People Visited, the Modest Share of That Change the Program Can Honestly Claim and the Case for Releasing Year Two

Summary for the Funder

The state office on aging awarded our county $148,000 for Up and Steady, with the second year's $74,000 to be released on review of this report. In its first year, the program offered a home visit to every one of 172 older adults who had a lift-assist call, visited 124, modified 98 homes and enrolled 78 people in strength and balance classes. Among the first 81 people visited, 23% had another lift-assist call within six months, compared with 35% in a historical cohort of callers from the two years before the program. The program can honestly claim part of that difference, not all of it, and this report explains why. We request release of the second year's funding, with three changes described below.

What Was Delivered

Home visits. Of 172 older adults with a lift-assist call in the year, 124 accepted a visit, 72%. The share of visits within seven days of the call rose from 72% in the first six months to 86% in the second, after the ambulance service named a backup paramedic. Almost every visit included a complete fall risk screen and home hazard check.

Home modifications. Hazards needing modification were found in 101 homes, and the handyman program completed work in 98 of them, most often grab bars, night lights on the route to the bathroom and removal of loose rugs.

Primary care summaries. Summaries were sent for every person screened. Acknowledgment by clinics rose from 52% to 71% after the program lead visited the three clinics that had acknowledged few.

Classes. Two cohorts of strength and balance classes ran at three sites. Seventy-eight people enrolled and 55, or 71%, attended at least three-quarters of sessions.

What Changed

Repeat calls. The primary outcome asks how many people, once visited, called again for a lift. Full 12-month follow-up is available only for people visited early in the year, so this report uses six-month follow-up for the first 81 people visited. Twenty-three percent had another call within six months. The comparison group is every older resident whose first lift assist came during the 24 months before launch; tracked through the same records for the same six months, 35% of them called again.

Balance. Among the 55 class participants with both measurements, the median time on a standard standing and walking test improved from 13.4 to 11.3 seconds over 24 weeks.

County-wide calls. Across all of the county's older residents, lift-assist calls per month show no change that can yet be distinguished from ordinary variation. Twelve months of program data are too few for the time series analysis to show a change with confidence.

How Much of the Change the Program Can Claim

The program cannot claim the whole 12-point difference in repeat calls. Three things temper the claim. First, the people who accepted visits differed from those who declined: acceptance was lower among men living alone, who may be at higher risk of repeat falls. Some of the difference may reflect who accepted rather than what the program did. The historical cohort includes both kinds of people. When the comparison is restricted to people living with family, who accepted at similar rates to the cohort, the difference narrows to 8 points, 21% against 29%. Second, the numbers are small, and a difference of this size in groups of this size could partly reflect chance. Third, the first year included a mild winter, which may have reduced falls for everyone.

Two checks support the claim that at least part of the difference is real. Calls from the county's 55-to-64 age group, too young to qualify yet answered by the same crews, held steady, which makes a change in the ambulance service an unlikely explanation. And the historical cohort addresses regression to the mean, because its members qualified through the same kind of event, a call for a lift. The result is also consistent with published evidence: paramedic-led health promotion in Canadian social housing buildings lowered calls for ambulances in a randomized comparison (Agarwal et al., 2018), and pooled trials link exercise with fewer falls in people aged 60 and over who live at home (Sherrington et al., 2019).

Neither check removes the possibility that the people who accepted visits were simply more motivated to avoid falls. What can fairly be said is that people visited by the program were likely spared some repeat falls needing a crew, by somewhere between a few points and the full 12, and that the second year's data are needed to narrow that range.

Cost

The first year cost $73,400, within budget. That is about $590 for each person visited, or about $430 for each person reached by either a visit or a class. For comparison, a single ambulance response in our county is billed at several hundred dollars, and a fall-related hospitalization costs many times the program's cost per person. The program does not yet have evidence that it reduced hospitalizations, and this report does not claim savings. It notes only that if the program prevented even two hospital admissions a year among the people it visited, the savings to payers would exceed its annual cost, and that the second year's data will show whether admissions among people visited are lower than in the historical cohort. The funder should judge the program on the evidence of repeat calls and delivery, which is stronger, rather than on savings that have not been shown.

Year Two

We request release of the second year's $74,000 with three changes drawn from the first year's process evaluation. First, a shorter visit or telephone option for people who decline a full visit, aimed at men living alone. Second, a second volunteer driver for the farthest class site, where attendance was lowest. Third, completion of the outcome evaluation at 24 months, including 12-month follow-up for all people visited and the county-wide time series. The RE-AIM framework asks programs to report reach, effectiveness, adoption, implementation and maintenance (Glasgow et al., 1999). Year two will add evidence on maintenance: whether the ambulance service and the aging agency can sustain their roles, and whether the county commissioners will consider funding a third year.

References

Agarwal, G., Angeles, R., Pirrie, M., McLeod, B., Marzanek, F., Parascandalo, J., & Thabane, L. (2018). Evaluation of a community paramedicine health promotion and lifestyle risk assessment program for older adults who live in social housing: A cluster randomized trial. Canadian Medical Association Journal, 190(21), E638-E647. https://doi.org/10.1503/cmaj.170740

Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89(9), 1322-1327. https://doi.org/10.2105/AJPH.89.9.1322

Sherrington, C., Fairhall, N. J., Wallbank, G. K., Tiedemann, A., Michaleff, Z. A., Howard, K., Clemson, L., Hopewell, S., & Lamb, S. E. (2019). Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2019(1), Article CD012424. https://doi.org/10.1002/14651858.CD012424.pub2