How functional fitness plans enhance preventive care of aging adults

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Primary care physicians can extend longevity and quality of life for older adults by conducting fall risk assessments and integrating functional fitness into their plans.As the population ages, medical practices have an opportunity to address these functional health needs through a team-based approach to geriatric care while also establishing a viable revenue model for fall prevention and fitness interventions.

By age 65, one in four Americans will experience functional decline in performing activities of daily living. Muscle composition changes over time, reducing the type II or fast-twitch muscle fibers that provide speed, power and quick reactions. Functional strength training helps older adults maintain or even improve their type II fibers, enhancing their stability and balance. Fall risk management (FRM) interventions can prevent early deaths from hip fractures or head trauma as well as fears that limit mobility and lead to social isolation.

Terrance Walless, DPT, MBA
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Physical activity in older adults (PAO) — the moderate- to high-intensity exercise recommended after age 65 — has been shown to slow the aging process and improve quality of life while enhancing heart health, mental health and many other aging issues. Resilience from strength training can help in managing conditions including arthritis, diabetes and heart disease. Exercise also reduces the risk of several types of cancer.

Functional fitness supports whole-person care

Medical practices and health plans increasingly evaluate physicians on FRM and PAO metrics, yet implementing fall risk and fitness programs remains a challenge, even in large health systems. Primary care physicians must address many issues during patient visits, and fall risk assessments can add to the physician’s heavy workload.

A path for fall prevention interventions may not always be clear either. Traditionally, primary care physicians refer patients to physical therapy after a fall occurs. Yet they are well positioned to take a more preventive approach by engaging community-based partners to implement initiatives such as Exercise Is Medicine (EIM) and the Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths & Injuries (STEADI) fall prevention program as part of a preventive care plan.

While older adults may not be mindful of their physical conditioning, they may be deeply investing in maintaining their independence and aging in place rather than moving into nursing homes. By establishing aging in place as a goal, physicians can start a discussion about whether a patient has fallen or feels unstable when walking. When taking vital signs, it is worthwhile to record and track how often and how much they exercise as well.

Managing functional health in older adults aligns with the 4M framework for age-friendly health systems, which focuses on meeting the unique needs of older adults:

• What matters: Learn patient goals and preferences.
• Medication: Ensure medicine is not causing dizziness or interfering with care.
• Mentation: Screen for fear of falling and mental health issues.
• Mobility: Encourage safe movement for the activities of daily living.

For instance, multiple medications may raise the risk of drug interactions causing balance issues. Declining eyesight can cause older adults to trip or miss key visual cues required to maintain balance. Referring an older adult for fall risk and fitness evaluations can help to proactively identify a range of issues that can interfere with activities of daily living and contribute to fall risk.

Beyond the time barrier: Building functional health into practices

Older patients often face more health concerns, and physicians may need to allow more time for their visits. Programs such as the Center for Better Aging at St. Bernard Hospital in Chicago’s underserved Englewood community are leading the way by scheduling hourlong intake sessions for comprehensive geriatric assessment and management. During these sessions, a collaborative team including a medical assistant, pharmacist, nurse physician and social worker assess the 4Ms, along with any need for durable medical equipment, nutritional aid or other resources.

Involving a larger care team will take pressure off the physician and ensure complete patient histories and medication lists. An extended appointment also helps assure patients and their caregivers contribute to, understand and actively participate in their care, which leads to better understanding and commitment to care plans.

Few practices will have resources for such exams outside of value-based programs such as Medicare and Medicaid’s capitated Programs of All-Inclusive Care for the Elderly (PACE). Yet fall risk and fitness assessments can be a billable service. Physicians can employ ICD-10 diagnostic codes for exercise counseling, along with other conditions such as hypertension, to support reimbursement.

The American College of Sports Medicine suggests appropriate diagnostic and billing codes that reflect the time and complexity of evaluation and monitoring (E&M). For example, billing code 99213 (established patient E&M visit) is appropriate if a physician spends over half of a 15-minute office visit in face-to-face counseling and care coordination with a patient.

Even without extensive resources, many practices will find value in making referrals for fall risk and fitness assessments. A fall risk assessment may consider not only mobility, balance and strength but also medication use, vision and hearing acuity, cognitive function and recent fall history. The assessment will recommend tailored exercise interventions, medication adjustments, changes in environment or other preventive measures.

Unmet needs for fall intervention

In communities with fewer practitioners or less ability to take routine checkups, physicians may consider expanding their outreach. For example, at senior center events on Chicago’s South Side, the Center for Better Aging collaborates with Smyl Fitness Rx to conduct fall risk assessments — a proactive step that identifies specific risk factors and provides valuable insights for older adults and their physicians.

Physicians should evaluate the efficacy of community wellness resources for clinical oversight, program design, access and engagement, tracking outcomes and quality indicators. For instance, a physician could collaborate with a local physical therapy practice to integrate a medically oriented gym to enhance design and delivery of exercise programs. While many health plans provide fitness membership benefits, these benefits often go underutilized among older adults.

Home exercise programs can also be a powerful option for patient adherence. Practices that develop their own home exercise programs can leverage reimbursement opportunities through remote therapeutic monitoring, either independently or in collaboration with partners.

Ultimately, functional health is a key driver of aging in place. Only 7,300 physicians in the United States are trained in geriatrics — one for every 10,000 older patients — and there is a significant need for primary care physicians to build their expertise in models of care to meet the needs of a skyrocketing older adult population.

Terrance Walless, DPT, MBA, is a board-certified geriatric clinical specialist physical therapist and the founder of Smyl Fitness Rx in Chicago, Illinois. He serves as a scientific reviewer for the National Institutes of Health Small Business Innovation Research program, where he contributes his expertise to the evaluation of innovative health care solutions.