I Am Able: Population Based Rehabilitation in a Family Health Team

Not Applicable

Completed

Interventions: Behavioral: Physiotherapy
Behavioral: Occupational Therapy
Behavioral: Capacity Building

Brief Summary: People who have long-term conditions such as heart disease, diabetes, arthritis etc. face challenges in staying active and able to participate in activities that are important to them. There is some research that suggests that a care model that focuses on physical functioning and helping patients to manage their own conditions will assist them to stay active and healthy longer. In this project, the investigators are testing whether physiotherapy and occupational therapy offered to groups of patients and information about rehabilitation offered to other members of the health care team can help people with chronic conditions to maintain their physical abilities.

Detailed Description: Participants older than 44, with at least one chronic disease, (n=60) will participate in a before-and-after study integrating a population based, rehabilitation-focused program targeting physical function into a Family Health Team. The program, delivered by a Physiotherapist and Occupational Therapist, will consist of comprehensive functional assessments and individualized self-management care plans; a rehabilitation based chronic disease self-management program; and on-line self-monitoring of physical function. Process and outcome measures will be administered at baseline and 4 months follow-up.

Recruitment & Eligibility

Inclusion Criteria

Exclusion Criteria

Arm && Interventions

Group	Intervention	Description
Intervention Group	Physiotherapy	Rehabilitation self-management group, on-line self monitoring of physical function, and organizational capacity building.
Intervention Group	Occupational Therapy	Rehabilitation self-management group, on-line self monitoring of physical function, and organizational capacity building.
Intervention Group	Capacity Building	Rehabilitation self-management group, on-line self monitoring of physical function, and organizational capacity building.

Primary Outcome Measures

Name	Time	Method
Physical Functioning Inventory (PFI)	4 months	The PFI is used to assess physical functioning in older adults. It contains 21 tasks from 4 subscales: activities of daily living, instrumental activities of daily living, mobility, moderate activities. A series of questions is used to determine whether the person experiences difficulty in completing a task, the level of difficulty they experience, and any changes to the method and/or frequency of task performance. The PFI is sensitive to steps in the natural history of functional decline that are often not assessed clinically. Range of scores: 0 (most difficulty); 100 (least difficulty).

Secondary Outcome Measures

Name	Time	Method
Self-rated Health	4 months
Health Care Utilization	4 months
Self-efficacy for Chronic Disease Scale	4 months
Rapid Assessment of Physical Activity	4 months
Grip Strength	4 months
Two Minute Walk Test	4 months
Patient Assessment of Chronic Illness Care	4 months
Primary Care Resources and Supports	4 months
Balance Screen	4 months
Eight Foot Walk Test	4 months