ObjectiveFalls are a leading cause of injury death. Stepping On is a fall prevention program developed in Australia and shown to reduce falls by up to 31%. The original program was implemented in a community setting, by an occupational therapist, and included a home visit. The purpose of this study was to examine aspects of the translation and implementation of Stepping On in three community settings in Wisconsin.MethodsThe investigative team identified four research questions to understand the spread and use of the program, as well as to determine whether critical components of the program could be modified to maximize use in community practice. The team evaluated program uptake, participant reach, program feasibility, program acceptability, and program fidelity by varying the implementation setting and components of Stepping On. Implementation setting included type of host organization, rural versus urban location, health versus non-health background of leaders, and whether a phone call could replace the home visit. A mixed methodology of surveys and interviews completed by site managers, leaders, guest experts, participants, and content expert observations for program fidelity during classes was used.ResultsThe study identified implementation challenges that varied by setting, including securing a physical therapist for the class and needing more time to recruit participants. There were no implementation differences between rural and urban locations. Potential differences emerged in program fidelity between health and non-health professional leaders, although fidelity was high overall with both. Home visits identified more home hazards than did phone calls and were perceived as of greater benefit to participants, but at 1 year no differences were apparent in uptake of strategies discussed in home versus phone visits.ConclusionAdaptations to the program to increase implementation include using a leader who is a non-health professional, and omitting the home visit. Our research demonstrated that a non-health professional leader can conduct Stepping On with adequate fidelity, however non-health professional leaders may benefit from increased training in certain aspects of Stepping On. A phone call may be substituted for the home visit, although short-term benefits are greater with the home visit.

Falls among older adults result in substantial morbidity and mortality. Community-based programs have been shown to decrease the rate of falls. In 2007, the Centers for Disease Control and Prevention funded a research study to determine how to successfully disseminate the evidence-based fall prevention program (Stepping On) in the community setting. As the first step for this study, a panel of subject matter experts was convened to suggest which parts of the Stepping On fall prevention program were considered key elements, which could not be modified by implementers.MethodsOlder adult fall prevention experts from the US, Canada, and Australia participated in a modified Delphi technique process to suggest key program elements of Stepping On. Forty-four experts were invited to ensure that the panel of experts would consist of equal numbers of physical therapists, occupational therapists, geriatricians, exercise scientists, and public health researchers. Consensus was determined by percent of agreement among panelists. A Rasch analysis of item fit was conducted to explore the degree of diversity and/or homogeneity of responses across our panelists.ResultsThe Rasch analysis of the 19 panelists using fit statistics shows there was a reasonable and sufficient range of diverse perspectives (Infit MnSQ 1.01, Z score −0.1, Outfit MnSQ 0.96, Z score −0.2 with a separation of 4.89). Consensus was achieved that these elements were key: 17 of 18 adult learning elements, 11 of 22 programming, 12 of 15 exercise, 7 of 8 upgrading exercises, 2 of 4 peer co-leader’s role, and all of the home visits, booster sessions, group leader’s role, and background and training of group leader elements. The top five key elements were: (1) use plain language, (2) develop trust, (3) engage people in what is meaningful and contextual for them, (4) train participants for cues in self-monitoring quality of exercises, and (5) group leader learns about exercises and understands how to progress them.DiscussionThe Delphi consensus process suggested key elements related to Stepping On program delivery. These elements were considered essential to program effectiveness. Findings from this study laid the foundation for translation of Stepping On for broad US dissemination.

The Health Disparities Collaboratives (HDC) are the largest national quality improvement (QI) initiative in community health centers. This paper identifies the incentives and assistance personnel believe are necessary to sustain QI. In 2004, 1006 survey respondents (response rate 67%) at 165 centers cited lack of resources, time, and staff burnout as common barriers. Release time was the most desired personal incentive. The highest funding priorities were direct patient care services (44% ranked #1), data entry (34%), and staff time for QI (26%). Participants also needed help with patient self-management (73%), information systems (77%), and getting providers to follow guidelines (64%). Keywordsquality improvement; quality of care; disparities; community health center; vulnerable populations Quality improvement (QI) efforts can improve health care in the short-term (Chien et al., 2007), but little is known about how to sustain improvements over time. Most QI studies track changes in outcomes over relatively brief 1-2 year periods (Chien et al., 2007), but few examine (Landon et al., 2007;Chin et al., 2004). At the four-year follow-up period among patients with diabetes, clinical outcomes such as glucose and cholesterol control also improved . In addition, the HDC intervention has been generally very well-received by staff (Chin et al., 2004). While these early successes are promising, the impact of the HDC on the long-term health of patients will be significant only if current improvements are maintained or enlarged because of the natural history of many chronic diseases. NIH Public AccessThe need to maintain or enlarge improvements in care raises important questions regarding the sustainability of QI programs. In particular, little is known about what is required to sustain a QI collaborative at the organizational level (Ovretveit et al., 2002;Daniel et al., 2004;Mills & Weeks, 2004;Wilson et al., 2003). Some of the challenges of the HDC are probably common in other settings such as time burdens associated with data collection during initial HDC implementation (Chin et al., 2004). Other difficulties, including staff turnover, may be more severe in health centers (Chin et al., 2004). Enthusiasm for QI may be high when an intervention begins, but may wither once health care organizations confront the daily work and expense associated with the effort. While there are anecdotal reports of difficulties with sustaining QI activities, there are currently little data on important questions such as how much time the different tasks of quality improvement require, how much time devoted to the HDC is uncompensated, and whether participants are still enthusiastic several years after undertaking the initiative. In addition, it is unclear whether there is an economic business case for quality for outpatient facilities given that QI requires upfront personnel time and health centers may not receive the downstream financial benefits from prevented hospitalizations (Leatherman et al., 2003;Huang et al., 2008;Huang et ...

The study demonstrates how CDR provides enhanced documentation of risk factors to help steer prevention efforts regarding SUID deaths in a community and reaffirms infants in an unsafe sleep environment have an increased risk of death.

The Robert Wood Johnson Foundation's Finding Answers: Disparities Research for Change program funds evaluation of interventions to reduce racial and ethnic disparities in cardiovascular disease, depression, and diabetes. Of the 177 applications received in 2006, the most prevalent proposed interventions were patient or provider education (57 percent), community health workers (25 percent), case management (24 percent), integrated health care (24 percent), and cultural modification (24 percent). Policy interventions, including pay-for-performance (P4P) incentives, were lacking. The eleven grantees target patients, providers, patient-provider communication, health care organizations, and communities in innovative ways. We identify important future research questions.