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

Study Overview
=================
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.

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

Conditions
-----------------
Chronic Conditions, Arthritis, Diabetes, Hypertension, Chronic Pain

Intervention / Treatment
-----------------
* Behavioral: Physiotherapy
* Behavioral: Occupational Therapy
* Behavioral: Capacity Building


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: 44 years and older 1 or more chronic conditions 3 visits to physician in the past year access or willingness to access email Exclusion Criteria: none

Ages Eligible for Study
-----------------
Minimum Age: 44 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Supportive Care
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention Group<br>Rehabilitation self-management group, on-line self monitoring of physical function, and organizational capacity building. | Behavioral: Physiotherapy<br>* group self-management classes<br>Behavioral: Occupational Therapy<br>* group self-management classes<br>Behavioral: Capacity Building<br>* workshops and case reviews with primary health care team members<br>|
| No Intervention: Case matched controls<br>Usual care in primary health care. | |

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Physical Functioning Inventory (PFI) | 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). | 4 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 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 |