QUERI – Quality Enhancement Research Initiative

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Veterans' Perspectives

Optimizing Function and Independence for VA Inpatients

HSR&D’s monthly publication Veterans’ Perspectives highlights research conducted by QUERI (Quality Enhancement Research Initiative) investigators, showcasing the importance of research for Veterans – and the importance of Veterans for research. Our May issue features Optimizing Function and Independence QUERI and the expansion of the STRIDE program, funded by QUERI. QUERI is VA’s national program focused on improving Veteran health by ensuring that research evidence from the academic shelf gets into the hands of Veterans and their providers in routine care. STRIDE is a supervised walking program that helps hospitalized older Veterans improve their mobility and functional independence.

In the May 2018 Issue:

Background

What is STRIDE?

STRIDE is a supervised walking program that helps hospitalized older Veterans improve their mobility and functional independence.

Immobility during hospitalization leads to loss of muscle mass, de-conditioning, and overall weakness; in turn, this contributes to inpatient complications such as functional decline and falls, longer hospital stays, higher rates of discharge to skilled nursing facilities, and increased risk of readmission to the hospital. More than one-third of adults older than age 70 are discharged from the hospital with a major new disability that was not present before the onset of acute illness. At least half of the time, the associated illness is not a clearly disabling condition, like hip fracture or stroke, but rather a medical condition such as pneumonia or heart failure. Further, one year following discharge, more than half of older adults with hospital-associated disability do not recover to their pre-illness functional status, resulting in higher rates of nursing home placement and death.

Immobility during hospitalization is a key contributor to hospital-associated disability. While fewer than 5% of patients have physician orders for bed rest, hospitalized older adults spend only 4% of their time standing or walking. Older Veterans are especially vulnerable to the adverse physical effects of immobility and their resultant consequences. The hazards of immobility in the hospital have been recognized for more than two decades, but there are currently no VA-system wide approaches to address this important gap in clinical care.

The STRIDE program

VA Stride Program STRIDE is a supervised walking program for hospitalized older adults designed to address the important clinical problem of immobility during hospitalization and its negative consequences, including hospital-associated disability. In this way, STRIDE aims to reduce preventable harm to hospitalized Veterans. STRIDE consists of a one-time gait and balance assessment conducted by a physical therapist, followed by daily supervised walks by a therapy or nursing assistant for the duration of the hospital stay.

Program evaluation has demonstrated high satisfaction among Veteran participants and reduced need for post-acute institutional care. The multidisciplinary approach to the program’s development resulted in several features that make STRIDE different from other hospital mobility programs. The goals of the STRIDE program are to:

  • Improve the function of hospitalized older Veterans and decrease immobility, and its associated consequences, by incorporating supervised walking into their care.
  • Increase independence and improve quality of life for Veterans, and promote the Veteran’s ability to remain in the most independent and least restrictive living environment.
  • Improve VAMC inpatient quality of care; for example, Strategic Analytics for Improvement and Learning (SAIL) measures focused on length of stay and Veteran experience.

Impacts

VA Stride Program High participation and satisfaction in STRIDE during the first year of implementation at the Durham VA Health Care System highlight the gap in care filled by the program. During the first five months of the program – managed by the Durham Geriatrics Research Education and Clinical Center (GRECC), 92 older adults participated. A significant proportion of STRIDE patients had functional deficits at baseline: 50% used an assistive device for walking, and 45% reported at least one fall in the previous three months. STRIDE walks lasted for 10 minutes, on average, and 90% of patients reported feeling better after their walk.

To examine program effectiveness, STRIDE participants were compared with individuals referred but not enrolled (because program was at capacity or they refused). STRIDE participants and individuals receiving usual care had similar demographic and clinical characteristics. STRIDE participants had shorter hospitalizations (4.7 days compared to 5.7 days) and were less likely to be discharged to a nursing home (92% discharged to home compared to 74%).1,2,3  

Implementation at multiple sites

As part of Optimizing Function and Independence QUERI goals, STRIDE will be implemented at a total of eight VAMCs across the country by the end of 2018. The Durham Center of Innovation for Health Services Research in Primary Care will study the roll-out of STRIDE at these sites, specifically examining the implementation process and patient functional outcomes.

Veteran and Provider Perspectives

The Optimizing Function and Independence QUERI team has heard positive feedback about STRIDE from both patients and staff involved in the program at Durham. A sampling of their comments include:

"Well, [STRIDE has] done a lot for me. I reckon the main thing...is putting my life back together. 'Cause if I had kept on sitting out there at home like that, you know, it wouldn't have been long, I would have been gone from here..."

STRIDE patient 1:

  • On participating in STRIDE walks: “…at first it was kinda like I really didn’t wanna be bothered with it, you know, and then afterwards… I was looking for them. At 10 and then at 2 o’clock, I was actually looking for them to go on the walk… Now I just take the walks on my own.”
  • On the impact of STRIDE: “I think it’s helped tremendously as far as keeping the blood flow going, keeping me active while I’m in the hospital. I think that’s the goal, is to keep you active while you’re here, especially when you stay for a while ‘cause you could lose sight of being active really quick. So the STRIDE program really helps that, staying active.”

STRIDE patient 2:

  • “Well, [STRIDE has] done a lot for me. I reckon the main thing… is putting my life back together. ‘Cause if I had kept on sitting out there at home like that, you know, it wouldn’t have been long, I would have been gone from here…”
  • What would you tell a new patient asked to go for a walk for STRIDE? “I would tell them that’d be the best thing they could do.”

STRIDE walking staff member:

  • “When I started with the program I just fell right into it, because as a Veteran I was able to help the Veterans in regards to assisting them with walking. Not just walking, just to listen to them because the Veterans love someone to listen because they have a lot of good stories.”


References

  1. Wang V, Allen K, Van Houtven C, et al. Supporting teams to optimize function and independence in Veterans: A multi-study program and mixed-methods protocol. Implementation Science. 2018;13:58.
  2. Hastings S, Sloane R, Morey M, et al. Assisted early mobility for hospitalized older Veterans: Preliminary data from the STRIDE program. Journal of the American Geriatric Society. 2014;62:2180-2184.
  3. Hastings S, Vaughn C Stevens, et al. Research and operations: Joining forces to improve care for Veterans. North Carolina Medical Journal. 2015;76:315-319.