Physical therapists who provide care in the home healthcare practice setting commonly encounter adults over the age of 65 who have experienced at least one fall. Various screening and intervention strategies including the Centers for Disease Control and Prevention (CDC) Stopping Elderly Accidents, Death and Injuries initiative are available to home healthcare physical therapists (CDC, 2017). The Otago Exercise Program (OEP), originally developed and tested in clinical trials at the University of Otago Medical School in New Zealand, is another such program (The National Council on Aging, 2018). It is encompassed as a recommendation within the CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults (Stevens & Burns, 2015). The OEP is a home-based individually tailored strength and balance retraining program. Prior evidence has demonstrated the effectiveness of the OEP in reducing falls in the elderly, including those over 80 years of age (Kyrdalen et al., 2014).

The OEP is currently being utilized as an intervention in the research study titled "Prevention Focused Home-Based Physical Therapy Utilizing Community Partnership Referrals" conducted through Oakland University in Auburn Hills, MI, by Dr. Sara Arena and Dr. Chris Wilson. Michael Colling, DPT, a home healthcare physical therapist with Residential Home Care, serves as a data collector for the study. A component of his preparatory training included completing The Otago Exercise Program: Falls Prevention Training (Carolina Geriatric Education Center, n.d.). The course educates physical therapists, physical therapy assistants, and other healthcare providers on the OEP components and how to utilize the program in daily practice. After using the program as a research data collector, Colling saw significant value in the program benefits to both the research participants and within the population he served in his daily home healthcare practice. He reached out to his home healthcare agency supervisor to facilitate utilization of this program by more clinicians at his agency.

His communication to his supervisor in support of the OEP was as follows: "There is really nothing new or different that is done with a patient, exercise-wise, with the OEP; however, it gives a great framework in which to operate and organizes what exercises and balance activities I give my patient. It also uses several outcome measures we already utilize including the Timed Up and Go, Chair Sit to Stand, and the 4 Test Balance Scale, as well as strength and gait assessments. There are six basic components: 1) warm up, 2) strengthening with or without weights, 3) balance exercise, 4) walking, 5) sit to stand, and 6) stairs (if applicable). The program itself can be modified to meet patient' functional levels, whether high or low, and challenges them accordingly. The exercise framework lends itself to a natural progression with limited repetitive documentation which is helpful to support the skilled and medically necessary care being provided."

Colling provides the following example of how it impacted the care of one of his patients: "I have been providing care to a patient with congestive heart failure for the past two weeks using the OEP model and am observing great progress in the patient's function. The intervention begins with a warm up and then goes into strengthening exercise (initially without and then with weights). Balance exercise started with semi-tandem supported activities, but have progressed to unsupported semi-standing and supported tandem stance. We incorporate stairs into the care plan as the patient's laundry is in the basement and there are three steps to enter and exit the home. We conclude our sessions with indoor and outdoor ambulation, weather permitting.

The patient is so pleased at what she is now able to do and reports her confidence is building every day. Her significant other has also noticed improvement in her function and independence. An added benefit of the OEP is that I can immediately introduce balance activities into the plan of care for even lower functioning patients as the lowest level standing exercise asks them to hold a static stance with their feet together for ten seconds. Patients also appreciate when I instruct them to do the exercise portion three times a week, but walking every day. This plan doesn't seem overwhelming and empowers patients to be compliant with the prescribed program."

The agencies response has been positive and his employer is now offering employee reimbursement to take the $35 The Otago Exercise Program: Falls Prevention Training, which is an online course and provides continuing education credits (Carolina Geriatric Education Center, n.d.). Additionally, the agency has started to incorporate the OEP into patient care pathways. Michael does note that the evidence-based OEP utilizes a 1 year protocol timeframe inclusive of five visits during the first 8 weeks, eight telehealth encounters, and then a 6- and 12-month follow-up visits. Although current insurance reimbursement models may limit the ability of home healthcare agencies to carry out the complete yearlong program, the initial 4- to 8-week program is a natural fit for use in a home healthcare encounter

For more information on the OEP, the National Council on Aging Otago Exercise Program: Program Information and Guidance website (https://www.ncoa.org/resources/otago-exercise-program-program-information-guidan, n.d.) or the Otago Exercise Programme to Prevent Falls in Older Adults (Campbell & Robertson, 2003) may be useful resources.

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