CHAPTER ONE: INTRODUCTION -...

IMPLEMENTATION OF HOME EXERCISE PROGRAM

Implementation of Home Exercise Program in Home Health Care:

A Practice Policy to Improve Activity Level in Patients with Hypertension

Blessing Isiguzo, BSN-RN, DNP-Student

Maryville University

Submitted in partial fulfillment of the requirements for the Doctor of Nursing Practice Degree

Capstone Chair: Dr. Boniface Stegman, PhD

Capstone Committee Members: Dr. Campbell-O’Dell, DNP, Chi Ochiobi, MSN, FNP-C Marvin Alexander, BS, LPT

Date of Submission: November 20, 2017


TABLE OF CONTENTS

ABSTRACT....................................................................................................................................3

CHAPTER ONE: INTRODUCTION..........................................................................................4PURPOSE.......................................................................................................................................5BACKGROUND..............................................................................................................................5SIGNIFICANCE TO NURSING..........................................................................................................7SIGNIFICANCE TO HEALTHCARE..................................................................................................8IMPLICATION TO ADVANCED PRACTICE NURSING.......................................................................8PRACTICE SUPPORT FOR PROJECT................................................................................................9BENEFIT OF PROJECT TO PRACTICE...........................................................................................10

CHAPTER TWO: LITERATURE REVIEW...........................................................................11SEDENTARY LIFESTYLE IN THE ELDERLY POPULATION............................................................12EFFECTS OF INCREASED ACTIVITY ON HYPERTENSION.............................................................13THE IMPACT OF A HEP ON THE ELDERLY.................................................................................14THE ROLE OF HOME HEALTH IN IMPROVING ACTIVITY LEVEL................................................16LITERATURE CRITIQUE...............................................................................................................19STRENGTHS................................................................................................................................19WEAKNESSES.............................................................................................................................20GAPS...........................................................................................................................................21LIMITATIONS..............................................................................................................................21CONCEPTS AND DEFINITIONS.....................................................................................................22THEORETICAL FRAMEWORK.......................................................................................................23

CHAPTER THREE: METHODS AND DESIGN....................................................................24METHODOLOGY..........................................................................................................................25NEEDS ASSESSMENT..................................................................................................................25STUDY DESIGN...........................................................................................................................26DATA COLLECTION INSTRUMENTS.............................................................................................28RESOURCES................................................................................................................................29BUDGET......................................................................................................................................30TIMELINE....................................................................................................................................30PROTECTION OF HUMAN SUBJECTS...........................................................................................31CONTEXT....................................................................................................................................31INTERVENTIONS..........................................................................................................................32STUDY OF INTERVENTIONS........................................................................................................32MEASURES..................................................................................................................................33ETHICAL CONSIDERATIONS........................................................................................................33

CHAPTER FOUR: LIMITATIONS, RESULTS, AND DISCUSSIONS...............................34LIMITATIONS OF STUDY.............................................................................................................34RESULTS AND ANALYSIS............................................................................................................35DISCUSSION................................................................................................................................40STRENGTHS OF THE STUDY........................................................................................................40

CHAPTER FIVE: CONCLUSION............................................................................................41

REFERENCES............................................................................................................................43


Abstract

Activity level influences the health of an individual especially older adult as supported by many

pieces of literature. Many older adults in home health live a sedentary lifestyle engaging in little

daily activity insufficient to support cardiovascular health. This lifestyle is a phenomenon of

concern to health professionals as inactivity precedes many health conditions including

hypertension (HTN). Typically, home health nursing services include; skilled nurse for teaching

on a disease, medication management, and wound care. There is usually no inclusion of home

exercise training program for patients diagnosed with HTN only except for those with

musculoskeletal events. Thus, patients with either a musculoskeletal pathology or

neuromuscular deficits are the only ones who have exclusively received some home exercise

program (HEP), which should be provided for patients with high blood pressure as well. The

purpose of this scholarly project is to propose the implementation of a HEP for patients with

HTN in home health care to increase their activity level, which will consequently help in

managing their HTN more efficiently. This research is a quantitative study that examined the

effects and relationship between a HEP and activity level in older adults. Pre-and Post HEP

activity levels were measured using the rapid assessment (RAPA) questionnaire and statistically

analyzed. Results from statistical analysis of this research showed that Post-HEP activity levels

were higher than Pre-HEP activity levels and participants indicated that they enjoyed the HEP,

would continue to engage in the HEP and will recommend it to others. In conclusion, HEP

increases the activity level of older adults in home health, reduces sedentary lifestyle, and

therefore, is beneficial in the management of HTN in older adults.

Keywords: Home exercise program, activity level, sedentary lifestyle, home health

Running head: IMPLEMENTATION OF HOME EXERCISE PROGRAM

CHAPTER ONE: INTRODUCTION

Many older adults in home health live a sedentary lifestyle. This lifestyle is a

phenomenon of concern to health professionals as inactivity precedes many health conditions

including HTN. Many elderly patients in home health with HTN live a sedentary lifestyle with

little daily activity level insufficient to support cardiovascular health. In 2007, 54.1% of the U.S.

non-institutionalized older adults were inactive, compared to 32.9% of people aged 18-24

(Douma et al., 2017). Typically, nursing services provided in home health care include; skilled

nurse for teaching on a disease, medication management, and wound care. There is usually no

inclusion of home exercise training program for patients diagnosed with HTN except for those

with musculoskeletal events. Instead, current efforts to achieve better blood pressure control

lean towards using widely available fixed-dose combination pharmacotherapy. For instance, for

patients requiring multiple medications such as thiazide diuretics, for patients with difficult-to-

control HTN (i.e., uncontrolled on ≥3 BP medications), as well as aldosterone antagonist for

resistant HTN (Fontil, 2017). Consequently, most of the homebound patients with HTN depend

solely on pharmacotherapy and poor dietary management. The problem of inactivity not only

exacerbates HTN in these patients but also, predisposes them to excessive dependence on

antihypertensive pharmacotherapy. A study noted that since aging often results in a decrease in

cardiorespiratory fitness (CRF), older adults might be more susceptible to not meeting the

recommendation of the required amount of physical activity needed to maintain good health

(Aspvik, 2016, p.2). From this writer’s experience, home health agencies have not fully

exploited the benefits of exercise in older adults who dominate the percentage of their patients.

The focus of home health care has continually been directed towards skilled nurse teaching for

wound care, skilled nurse teaching, and intravenous therapy. Patients with either a

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musculoskeletal pathology or neuromuscular deficits are the only ones who have exclusively

received physical therapy with some HEP which should also be provided for patients with high

blood pressure as well.

Purpose

The purpose of this scholarly project is to introduce and implement a HEP for patients

with HTN in home health care to increase their activity level, which will consequently help in

managing their HTN more efficiently. The introduction of a HEP with the collaboration of the

patients, there is a high tendency that they will adhere to the prescribed activity level. Thus, this

project will generate a more active elderly population in home health care, which will reduce

dependency on pharmacotherapy and foster physiological and psychological well being.

Background

Inactivity and sedentary lifestyle of the elderly population are not only peculiar to the

United States. There is an indication that despite compelling scientific evidence and

recommendations from the government about the required level of daily physical exercise,

epidemiological surveys indicate that approximately 20% of older people in the Netherlands can

be considered inactive (Fleuren et al., 2012, p. 2). Ironically, the standard of care for the

management of HTN in home health patients in the United States has not implicitly included an

exercise program. However, lifestyle factors including regular exercise are vital modifiable

determinants of HTN. Engaging in activity as little as one day per week is as efficient or more

effective than pharmacotherapy for reducing all-cause mortality with HTN (Pescatello,

MacDonald, Lamberti, & Johnson, 2015). It is unusual for exercise to be viewed as a daunting

task more so by the older adults who have many comorbidities and degenerative conditions of

aging including skeletal muscle weakness. There may also be issues with endurance with

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activity, which makes it more difficult for older adults to participate in an exercise activity.

However, with the introduction of various exercise programs into the daily routine of this

population, inactivity can be significantly reduced. A study discovered that increased amounts

of physical activity with an emphasis on increased time in moderate to vigorous activity should

be recommended to promote a favorable metabolic health profile in senior women (Nilsson,

Wahlin-Larsson, & Kadi, 2017, p.9). Another study reported that there is substantial evidence

for the benefits of exercise in improving functional mobility in chronically ill populations

(Graham, & Connelly, 2013, p.333) seen in home health. Most elderly patients lack the

confidence to embark on a daily exercise activity due to many factors including fear of fall or

chronic pain from arthritis or degenerative joint diseases.

Furthermore, inactivity of older adults can be attributed to their stereotypes and

dependency on caregivers, which denies the opportunity to use and improve on residual

musculoskeletal function. It has been argued that dependence can be accompanied by a

perceived loss of confidence and self-esteem, as well as negative perceptions about one’s health

(Coudin, & Alexopoulos, 2010, p.519). To make the situation much more complicated, taxing

effort to follow up with physicians’ regular visits to evaluate blood pressure logs, a determinant

factor for pharmacotherapy adjustment becomes jeopardized. HEP implemented in clinical

practice for home health patients will significantly foster confidence in mobility and compliance

in an exercise program. Research supports the idea that HEP is effective on and necessary for

achieving compliance with an exercise program (Ozdemir, & Tosun, 2017). With the support of

the registered nurse and physical or occupational therapist, the initial training on body

movements and range of motion exercises will encourage older adults to appreciate the

feasibility and benefits of increased activity level on their general health. Ozdemir and Tosun,

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(2017) discovered a positive effect of a HEP in improving the physical activity level of home

health patients. The study concluded that exercise programs, during home visits conducted after

hip replacement, promote bodily functions and quality of life. Home health agencies must create

and enhance accessibility to exercise plans to eliminate barriers to physical activity (Watson et

al., 2016) to help home health adults with chronic illnesses such as HTN begin and maintain a

more active lifestyle.

Significance to Nursing

Fostering the delivery of holistic and natural therapeutic care, embedded in the nursing

model of care is a high relevance of this project to nursing. This assertion supports the fact that

exercise therapy goes beyond cardiac improvements as it equally promotes psychological and

mental well being. Research has shown that exercise benefits both the physical health and

mental well-being of older persons, which in turn improves their functional independence and

quality of life (Marquard, Stolee, Zaza, & Schuehlein, 2012, p.351). However, a challenge

exists in the implementing an exercise program concerning compliance and sedentary attitude of

older adults to a recommended exercise routine. Nevertheless, with the collaboration of physical

and occupational therapists, registered nurses can adopt a practice change and embrace a culture

and attitude towards mobility improvement and rehabilitation using simple ways to build

mobility exercises into daily patient routines (Mowat, & Parsons, 2016). Thus, establishing a

regular exercise program as a standard of care for home health patients suffering from HTN is

quite remarkable, and nurses are at the forefront of making this happen. Nursing can achieve this

practice policy change by using a multidisciplinary approach liaising with other healthcare teams

to ensure effective implementation. Nurses as patients’ advocates are empowered with the skills

and knowledge of collaboration to improve outcomes.

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Significance to Healthcare

From the healthcare perspective, the importance of this project is that through the

standardization of exercise therapy for elderly home health patients with HTN, there will be a

reduction in healthcare costs. This cost reduction will emanate from multiple hospitalizations

due to complications of uncontrolled HTN such as CVA, CHF, renal disease and myocardial

infarction. There is estimation that from 2010 to 2030, the total direct costs attributed to HTN

are projected to triple from US$130.7 to US$389.9 billion (Pescatello, MacDonald, Lamberti, &

Johnson, 2015). Also, the indirect costs due to lost productivity will almost double from

US$25.4 to US$42.8 billion. In a century driving towards a proactive health prevention and

promotion approach versus reactive approach, a plan to sustain the activity level of the older

adults with compromised physiological functions will be of great benefit to patients’ outcomes.

In home health, “the Balanced Budget Act of 1997 (BBA) established new reimbursement

systems in the Medicare home health fee-for-service benefit. Reimbursements were reduced to

1993 levels, and per-beneficiary capitated limits were introduced for the first time” (Davitt,

2009, p.291). The effect of this payment cut is that home health agencies must strive to keep

patients out of the hospital and one major way to do that is to increase the activity level of

patients to promote general health reducing exacerbation of their disease process. A key to

managing HTN in outpatient settings such as home health will be to “increase community/school

opportunities for physical activity” (Dunphy, Winland-Brown, Porter, & Thomas, 2015, p.442).

Implication to Advanced Practice Nursing

Concerning advanced practice nursing, this project is a proposition towards health

promotion, which is a major part of advanced nursing practice. In as much as the benefits of

exercise and increased activity level can be used for HTN management, it goes further to prevent

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other cardiovascular and metabolic conditions, thus, serving as a health promotion strategy.

Therefore, the implication is that advanced practice nurses will need to start adding home

exercise therapy for elderly home health patients with HTN. Advanced practice nurses are

strategically placed to manage older adults with chronic diseases such as cardiovascular

conditions including HTN, and the treatment of heart disease requires a multidisciplinary team-

based care approach that includes exercise training to improve patients’ functional status

(Mendes et al., 2016, p. 2). Consequently, advanced practice nurses can make a tremendous

impact in improving home health patients’ outcomes through increased activity level by

prescribing and authorizing a strategically developed HEP for home health patients including but

not limited to patients with uncontrolled blood pressure. Any licensed clinician who makes

home visits including nurses, physical or occupational therapist may provide home exercise

training.

Practice Support for Project

Home health managers, supervisors, and administrators are much concerned with the rate

of hospital admission of patients and will be eager to embrace a practice policy that will deter

inpatient admission. The reason is not far-fetched because, in the home health process, hospital

admissions count against the institution’s rating and drops outcome measurement scores.

Furthermore, within the Houston area, there are several agencies with intense competition for

quality of care and outcome improvements. Thus, there is practice support for this scholarly

project as the manager of clinical operations at Humana at Home Agency has given full approval

for this project and has also indicated interest to adopt the project’s proposal. Professional

colleagues including managers, nurses, and physical therapists have shown keen interest and

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willingness to assist in the project. A licensed physical therapist at the organization has agreed

to be part of the DNP scholarly project committee and has provided excellent input.

Benefit of Project to Practice

Historically, the fee for service payment method was the reimbursement process in home

health care. However, with the advent of management of scarce public funds in joined with

healthcare reforms in the United States aimed at a value-based approach, there has been a shift to

a prospective payment method which requires the managing a patient with a fixed amount of

resources over a given period. Home health agencies do not typically provide routine exercise

programs for elderly patients with HTN, and the consequence of sedentary lifestyle manifests in

frequent hospitalization emanating from ineffective chronic disease management. Frequent

hospitalization not only reduces outcome measures but also attracts lower reimbursement from

Medicare and increases the cost of patient care. This project will be beneficial in improving

managing of these chronic diseases such as HTN through the inherent benefits of increased

activity level by introducing a HEP. The implementation and adoption of this practice process of

increased activity level through a current HEP for patients with HTN in home health will

improve patient outcomes scores, agency census, reimbursement, revenue, and rating while

reducing patient hospitalization and cost of care. Furthermore, keeping hospital admission rate

at a minimum will increase job security and staff retention because home health census and

revenue drive employment and retention of staff. Additionally, recurrent nurse turnover due to

low patient registration and lack of full-time positions in home health and reduction in mortality

rate attributed to better management of chronic illnesses will be an added benefit to home health

agencies. This century has brought several clinical and financial challenges to the home health

industry forcing many institutions to shut their doors. A practice policy change such as

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increasing activity level of patients will preserve many home health agencies. In the home health

agency this writers works, there is frequent hospitalization from preventable conditions such as

HTN management. This project will prevent and reduce re-hospitalization, which will increase

agency revenue and patient satisfaction scores.

CHAPTER TWO: LITERATURE REVIEW

The purpose of this project is to increase the activity level of older adults with HTN in

home health care through the implementation of a HEP. Many elderly patients in home health

do not engage in an adequate activity level to promote their health which leads to poor control of

their chronic illnesses especially HTN. This sedentary lifestyle is a remarkable phenomenon that

has not been addressed by home health care services provided for patients suffering from HTN.

Consequently, this project aims at reducing blood pressure and better control of HTN using a

naturalistic approach. The research questions addressed in this study are: (a) In home health

patients with HTN, age 65 and older, how does HEP compare to no HEP affect activity level? (b)

Is it feasible for home health agencies to plan and implement a HEP for patients with HTN?

These questions will help this writer stay focused on the proposed practice change to introduce a

HEP for patients with HTN in home health. Strategic methods for the research history

concentrated on peer-reviewed journals and articles to ensure reliability and validity of findings.

Empirical studies were electronically obtained from reputable journals and reports. Maryville

University Library was used to retrieve information from sites such as CINAHL, PubMed,

PsycINFO, Medline, Cochrane library, and EBSCOhost. Words such as hypertension, activity

level, older adults, home health, sedentary lifestyle, and home exercise program were used in the

search. Also, the ancestry approach was used whereby the researcher used references cited in

articles to track down other related studies. Using advanced search modifiers such as publication

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date, healthcare, or filters narrowed the search results. This increased the number of relevant

articles retrieved and reduced the bulk of irrelevant materials.

Sedentary Lifestyle in the Elderly Population

A sedentary lifestyle is a common problem in the older population, and many articles

examined by this writer supported this fact. Aging is often accompanied by a sedentary lifestyle,

Lira, (2011). Despite the much-advertised benefits of physical activity through regular exercise,

many people in the United States especially older adults remain sedentary (Jing et al., 2015). To

further substantiate the prevalence of inactivity in older adults, it is noted that although physical

activity is a key factor for healthy aging, many older people lead a sedentary lifestyle, (Wolff,

Warner, Ziegelmann, and Wurm, 2014). Inactivity in the older adult population is not only

peculiar to the United States. There is documentation that even though the government of the

Netherlands has encouraged increased activity level in older adults, epidemiological surveys

indicate that approximately 20% of seniors in the Netherlands are considered inactive by the

government (Fleuren et al., 2012, p. 2). In South America, a Brazilian population study verified

that an age was associated with living a sedentary life and that prevalence rates of sedentary were

31.8% in adults and 58% in the elderly (Rossi et al., 2013). It is also determined from research

that older adults often form the most sedentary segment of the population of any given

community, (Brookfield et al., 2015).

An interesting fact about sedentary lifestyle of the elderly population is that many older

adults wrongfully believe that they are old and should not routinely engage in physical activities

to avoid injury and preserve energy. Also, issues with comorbidities such as HTN may be

perceived as a reason to remain inactive. However, even though aging is objectively linked to

negative aspects, such as a decline in health status, several negative views are misconceptions of

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old age or obsolete perspectives on aging, (Wolff, Warner, Ziegelmann, and Wurm, 2014).

Furthermore, a comparative analysis study of a cross-section of individuals from different age

groups discovered the highest level of inactivity among older adults (Bernaards, Hildebrandt, and

Hendriksen, 2016). This discovery is not different from what this writer has observed from

several home visits as many older adults sit or lie down doing nothing, watching TV, playing

cards or reading papers. Caregivers worsen the situation by not allowing the elderly patients

perform the little activities of daily living (ADL’s), which they can do on their own. It is also

noted that lack of physical activity relates to the increased likelihood of elderly individuals

becoming dependent leading to a more sedentary lifestyle (Rossi et al., 2013).

Effects of Increased Activity on Hypertension

Increased activity level has substantial benefits in the management of HTN. Several

studies and literature have reported positive effects of increased activity through regular exercise

in the control of high blood pressure. On the one hand, it is demonstrated that regular aerobic

exercise reduces blood pressure (Pagonas et al., 2014). In the same direction, a meta-analysis

cohort study discovered that physical activity is a cost-effective way to decrease blood pressure

since it possesses the potential for having a significant public health impact (Yurong, Liwei, &

Gang, 2011). It is also noted that engaging in exercise as little as one day per week is as efficient

or more effective than other measures for reducing all-cause mortality with HTN, (Pescatello,

MacDonald, Lamberti, & Johnson, 2015). Evidence from a study performed in 2012, noted that

exercise coaching on how to increase an activity level yielded good blood pressure control

(Samadian, Dalili, & Jamalian, 2016). Engaging in walking or relaxing with some bouts of

activity leads to a reduction in blood pressure (Alparslan & Akdemir, 2010). Another real fact

about exercise is that it can be used in conjunction with other lifestyle modifications to control

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high blood pressure. For example, a study with its sizeable population-based sample provides

evidence that regular exercise is an essential non-pharmacological approach in the prevention of

high BP in non-obese adolescents if used with other lifestyle modifications (So et al., 2013).

To further stress the benefit of increased activity level on HTN, a study noted that blood

pressure reduction is linked to increased physical activity even in patients who do not have high

blood pressure (Yurong, Liwei, & Gang, 2011). Based on the benefits of exercise, a health

promotion modality designed to incorporate a feasible exercise routine will be a desirable

proactive approach to prevent uncontrolled HTN and associated effects. Some health

organizations support this by providing physical activity recommendations for blood pressure

control in individuals with HTN. For example, the American Heart Association (AHA)

recommends an average forty minutes of moderate to the vigorous physical activity about four

times a per week for blood pressure reduction (AHA, 2017). Similarly, the World Health

Organization (WHO) recommends at least 150 minutes of weekly moderately intense physical

activity or at least 75 minutes of vigorous exercise or an equivalent combination of both (WHO,

2017). These recommendations are in line with the fact that repeated bouts of physical activity

are a good strategy for lowering blood pressure, (Samadian, Dalili, & Jamalian, 2016). Frequent

exercise and movement of the body improve the function of the heart and its valves. This

improvement in heart function allows for better blood circulation in the body with less resistance

to prevent HTN.

The Impact of a HEP on the Elderly

For older adults, the home emerges as a primary site for active or sedentary behavior

(Brookfield et al., 2015) since they spend most of the time at home. Unfortunately, healthcare

providers do not consider recommending exercise to older adults with HTN despite its good

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benefits in lowering blood pressure in patients with chronic HTN. From this writer’s experience,

a HEP will be useful to home health patients who are homebound and unable to commute to the

gymnasium for regular workouts, like the younger adults who are active with less comorbid

conditions. Also, most seniors that this writer encounter in home health are retired and do not

have the opportunity to engage in many physical activities as would someone who regularly goes

to work. This lack of opportunity constitutes a barrier to meeting adequate daily activity level.

The good news is that a HEP designed by home health for this population solves this barrier and

tendency for inactivity. However, this is just one speck of sand out of a desert.

Research supports a positive impact on enhanced functional ability in subjects enrolled in

an exercise program, supporting the idea that HEP can be beneficial to this patient population

(Roriquez-Larrat et al., 2017). This increased functional status apparently increases

physiological functioning, which improves blood pressure control and management especially in

the older population with chronic HTN. Lack of exercise and sedentary lifestyle contributes to

the risk of developing HTN (Yurong, Liwei, & Gang, 2011). A HEP performed on routine basis

eventually becomes part of a daily routine for the elderly which improves the efficacy of its

therapeutic effects. In another direction, being able to practice a HEP removes the fear to engage

in an activity necessary to improve functional status. Participation in a regular exercise training

program is a cost-effective intervention with known health benefits to improve health (Zaleski,

2016, p.98) including proper management of chronic conditions such as HTN. Frequent practice

of a HEP will apparently build confidence in the elderly individual, remove fears, and prejudices

about engaging in a HEP. Overcoming this barrier and getting the older adults acquainted with

the exercise program is a breakthrough for achieving the positive impact of HTN control.

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An exercise program prescribed for older adults will also foster the involvement of older

adults in the management of their health. A HEP puts the elder adult at the forefront of their

hypertensive management keeping them active rather than passive in health promotion and

maintenance. Research supports this idea that involving older adults in an exercise program for

rehabilitation could be an efficient way of maintaining or regaining functional autonomy (Rossi

et al., 2013). Therefore, HEP has a significant impact on the elderly patient’s ability to foster

their HTN management through their active involvement in the process. By engaging in the

prescribed HEP, older adults can understand the relationship between the effects of their

adherence to a HEP and their HTN control.

The Role of Home Health in Improving Activity Level

It is estimated that by 2017, the US would have more individuals on the planet who are

over 65 than under the age of 5 years old for the first time in history (Abyad, 2017).

Unfortunately, a higher proportion of this population lives a sedentary lifestyle as mentioned

earlier. To worsen the situation, only 32% of clinicians deliver exercise counseling or education

to older adults during an office visit (Zaleski, 2016, p. 98). Home health agencies play essential

roles geared towards improving the activity level of older patients. Implementation of a HEP is a

vital role of home health agencies in promoting the activity level of older adults. Obviously,

elderly patients usually are unable to plan and develop a HEP on their own without expertise

involvement. Therefore, home-focused care such as a HEP is fixated on the patient, offering

comprehensive, modern, and individualized practice to look after individuals with actual and

impairing conditions (Abyad, 2017, p.20). Research also determined that older adults were more

likely to start and continue an exercise program if health professionals recommended it (De

Groot & Fagerstrom, 2011). The findings suggest that all local health practitioners in a

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community actively inform and educate older adults regarding the health benefits gained, and

how to initiate exercise groups in their local community in other to improve their health

condition especially with the management of HTN. Consequently, pioneering the

implementation of a HEP to enhance the activity level of older adults is a significant role of

home health. Providers including clinicians in home health should consider physical activity as

an essential measure for the prevention, treatment, and control of HTN (Yurong, Liwei, & Gang,

2011). Thus, active implementation strategies are required to influence the multiple factors

associated with innovation in health-promoting practices (Martinez et al., 2017, p.11) such as a

HEP designed by home health clinicians. To effect the implementation of a HEP in home health,

Zaleski, et al., (2016) suggested the use of initiatives such as the American College of Sports

Medicine (ACSM) Exercise is Medicine campaign. Their study showed that actions such as these

increase exercise participation six-fold when compared to adults not receiving exercise

counseling.

Another critical role of home health towards improving activity level in older adults is the

involvement of family members and caregivers. To build robust implementation strategies, there

is need to identify factors that determine a change in practice, namely, barriers and enablers of

change (Martinez et al., 2017). From this writer’s experience, family members and caregivers

have a significant influence on patients’ participation and compliance with any treatment plan.

Consequently, home health agencies have a huge role to investigate the type of support system

the patients’ have at home during the time of establishing a HEP. Family members and

caregivers should be involved in the HEP training teaching them to encourage and monitor

compliance with the exercise program. Including family members and caregivers in the

establishment of a HEP will also create a favorable view of aging and the need for exercise and

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increased activity level for the older population. A positive outlook on aging can be improved

by an intervention such as the HEP and is associated with an increase in physical activity over a

period (Wolff, Warner, Ziegelmann, & Wurm, 2014). Concerning caregivers and family

members, home health agencies can delegate the recording and tracking of the daily performance

of the implemented HEP performed by the older adults to be evaluated by home health clinicians

during follow-up visits. This approach will be useful for home health agencies to assess the

therapeutic effects of the HEP in increasing the activity level and better blood pressure control.

Besides, such information will be necessary for re-evaluation and modification of the HEP.

Home health agencies also serve as change agents in the move to increase the activity level

of older adults. Elderly patients seen in home health are not aware of some simple exercises they

can perform at home which will be beneficial towards their hypertensive management as a

lifestyle modification. In most cases, older adults view exercise as an intensive outdoor activity,

which they are incapable of participating. Fortunately, home health plays vital roles in enabling

older adults to take part in a routine exercise plan, a significant and inexpensive lifestyle

modification for HTN. It is a known fact by health care providers that lifestyle modification

such as regular exercise program is a definite strategy to maintain and control blood pressure

(Pescatello, MacDonald, Lamberti, & Johnson, 2015). Thus the use of regular exercise should

be strictly implemented in patients with HTN. Clinicians in home health are in good position to

achieve this through ensuring proper communication between providers and the patients.

Home modification is another significant role of home health towards improving the

activity level of older adults in their homes. Obstacles in the house due to the home arrangement

and fixtures such as stairways or furniture arrangements and their location create a significant

barrier for older adults to perform any form of physical activity in the home (Brookfield et al.,

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2015). Home health clinicians are well positioned to help in adequately arranging the house to

promote safety during home visits. They can do this in various ways such as removing throw

rugs, encouraging adequate lighting, clearing pathways and establishing a safe designated area to

perform required HEP. From this writer’s experience, involving older adults in a change process

and showing them the feasibility, safety, and benefits of the process will yield compliance. This

is because the assurance of safety and the feasibility of performing a prescribed HEP motivates

the patients. In sum, assessment of a patients’ condition, living environment, comorbidities,

capabilities, development of a HEP followed with consistent feedback and evaluation, are critical

roles played by home health in increasing the activity level of older adults. Home health

agencies will play a useful role by making sure that each patient diagnosed with HTN has a

planned exercise program. Properly educating patients will go a long way to ensure that the plan

goes well with the establishment of a HEP. From this writer’s experience, patients build trust

with home care staff, which is good for compliance. Patients are more likely to listen to and

follow instructions provided to them by a clinician they know and have developed trust over

time. Thus, developing an expertise modality on the implementation of a behavior modification

such as a HEP for home health older adults with high blood pressure problem is very important.

Literature Critique

Strengths

There are several strengths present in the literature used in this project. For example,

many of the literature including Alparslan, and Akdemir, (2010); Bernaards, Hildebrandt, and

Hendriksen, (2016); Fleuren et al., 2012; Rodriguez-Larrad, (2017); and Wolff, Warner,

Ziegelmann, and Wurm, (2014) all used rigorous and reliable recruitment and data collection

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method. This makes them useful and applicable to this project. The randomized controlled trials

utilized by most of the literature make it possible for use and generalizability of findings.

Furthermore, research methodology including reliable statistical data analysis is another

strength of the studies presented in the literature. The one-way analysis of variance for repeated

measures (ANOVA), the Bonferroni multicomparison test, SPSS for Windows using correlates

and regression coefficient and meta-analysis are some of the reputable data analysis methods

found in the research which enhanced the validity and applicability to this project which will

analyze the effects of a HEP on activity level. Variables controlled in the literature especially

age, sedentary work, and chronic diseases were important considerations that fit specifically into

this project. In addition, the use of prospective data and objective accelerometer physical

activity monitoring in some of the literature such as Jing et al., (2015) and Lira et al., (2011)

strengthened the literature applicability to this project as older adults involved in this project will

have a pre and post implementation physical activity assessment. This project deals with human

subjects and most the literature presented is approval from an institutional review board. Also,

all literature used in this project are within the last ten years.

Weaknesses

There were some weaknesses determined from the literature review. These shortcomings

were mainly in the aspect of method and research process. One major weakness is in the area of

small sample size as is evident in Pagonas, (2014) and De Groot, and Fagerstrom, (2011). This

affects the generalizability of literature inferences on effects of increased activity level in older

adults with a planned HEP. Self-selection bias is another weakness of the literature such as the

literature presented by Wolff, Warner, Ziegelmann, and Wurm, (2014). Lack of direct

supervision of subjects in some literature presented is also a weakness applicable to this project.

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Lack of direct supervision of participants to ensure prescribed activity was carried out as seen in

some of the literature such as Alparslan, & Akdemir, (2010) is another weakness in the literature

presented. This is relevant to this project because an accurate assessment of the performance of

the HEP along with a comparison of the difference in activity level pre and post implementation

is a critical element in the project.

Gaps

Concerning gaps in the literature, some of the articles examined such as Fleuren et al.,

(2012) did not focus on older adults in their experimental study which can negatively affect the

strength of this study which deals mainly with an effect of a practice change on the elderly.

Some articles did not mention what statistical data that was used which presents a significant gap

in the reliability of usage in this project. Also, not controlling for pre-existing conditions as

found in some articles such as the Rodriguez-Larrad et al., (2017) and the Ziegelmann, and

Wurm, (2014) is another noticeable gap in literature since comorbidities can affect activity level

in older adults.

Limitations

Limitations of the literature review also exist. Some literature presented reported being

limited by the lack of data on visit-to-visit variability restricted by the variable duration of the

exercise period (8–12 weeks) (Pagonas, et al., 2014, p.370). Age of literature is also a limitation

for the applicability and reliability of this project finding as few articles such as the Alparslan,

and Akdemir, (2010) utilized materials more than ten years old. Inconsistent use of standard

measurement for an important variable such as blood pressure readings is an obvious limitation

in literature presented. For example, blood pressure measurement was done once in one of the

literature presented which is misleading due to the possibility of the white coat effect (So et al.,

21


2013). Conflict of interest in some of the literature presented is another limitation. For example,

in one of the studies, the former leader of the research subjects had personal involvement with

the previous joint project (De Groot & Fagerstrom, 2011). Proper use and definition of

terminology constitute another concerning the contextual applicability of definitions. For

example, it was reported that the definition of physical frailty used in one of the studies might

not be generalizable to other interpretations (Jing et al., 2015), which is a limitation concerning

applying the concept of inactivity in older adults in this project.

Concepts and Definitions

Pertinent concepts utilized in this project have been defined to foster understanding.

Physical Activity – Physical activity is defined as any movement of the body that

causes the use of energy and may be in different forms. These events may be in

sports, at home or due to activities required for the job (Umaporn et al., 2017).

Exercise – The WHO defines exercise as a particular type of physical activity that

is purposefully initiated with a goal to promote the physical well being of an

individual (WHO, 2017).

Home Exercise Program (HEP) – This is a systematically planned exercise

routine designed for the home. It includes repetitive body movements, a range of

motion, extension, flexion, rotation, bending, sitting, and standing. HEPs are less

expensive and integrate more readily into the patient’s lifestyle (Spafford, Oakley,

& Beard, 2014).

Hypertension – HTN is defined as blood pressure with a systolic value of 140 or

greater or systolic reading of 90 or higher. However, the joint national

commission (JNC) 8 in its recent publication defined HTN for people 60 years or

22


older to be below 160 systolic or below 90 diastolic as long as they do not have

diabetes or kidney disease (Krader, 2014).

Sedentary Lifestyle – Sedentary behavior refers to any waking activity

characterized by low energy expenditure (1.0 to 1.5 basal metabolic rate) and a

sitting or reclining posture, (Rodriguez-Larrad et al., 2017). Sedentary lifestyle

involves a consistent engagement in inactivity.

Theoretical Framework

The health promotion model (HPM) is a nursing theory founded by Nola Pender, first

published in 1982 and revised in 1996. The theory defined health as a continuum condition of

health rather than a mere absence of a disease. Thus, its approach is geared towards improving

an individual’s health thereby preventing the occurrence of a disease. According to Nursing

Theory, (2016), the HPM has five major elements including person, environment, nursing,

health, and illness, and is based on some assumptions including;

i. People have the capacity for reflective self-awareness, including assessment of

their competencies.

ii. People interact with their environment, transforming it and themselves over time.

iii. Nurses and other health professionals form an important aspect of people’s

interaction with their environment.

iv. Self-initiated reconfiguration of the interactive patterns between people and their

environments is necessary for a change in behavior.

Also, Nursing Theory, (2016) reported the HPM has the following theoretical proposition

which forms an integral part of its foundation:

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i. Individual’s behavior and their way of life have a significant effect on how they

respond to situations or accept change for improving their health condition.

ii. People commit to engaging in acts from which they anticipate deriving personally

valued benefits.

iii. Barriers can constrain commitment to action.

The elements and assumptions of this theory appropriately fit into this project, which

practically harnesses the clinician with the patient as the patient interacts with confronting issues

such as HTN, sedentary lifestyle and inactivity. This project aims at using home health

clinicians to teach and encourage HEP to patients in their homes to increase their activity level to

manage their HTN better. The process involves interaction between the elements of the person,

environment, illness, and health. Teaching HEP to home health patients will increase activity

level and enhance patient’s belief in the benefit of the program, which improves self-awareness

and enactment of the health-promoting behavior, which are part of the assumptions and

propositions of the HPM. Furthermore, individualized planned HEP pioneered by home health

nurses will enhance patient’s ability and exercise competence. This enhancement will create

confidence and compliance, a significant element of the theoretical framework of the HPM.

CHAPTER THREE: METHODS AND DESIGN

The purpose of this research is to determine the relationship between HEP and activity

level in older adults. This project will introduce and implement a HEP for home health patients

with HTN to help manage this condition. A HEP structurally planned to suit the ability of

elderly individuals in their home will be beneficial in reducing sedentary behavior. Also, this

project will lead to a practice policy change utilizing home health clinicians as change agents to

tackle inactivity in older adults. The recommendation of this project will include implementing a

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HEP for patients diagnosed with HTN to foster and improve their activity level to prevent

complications of HTN. This chapter presents the methods used in this research study including

needs assessment, design, data collection instruments, analysis plan, resources, budget, timeline,

protection of human subjects, context, interventions, a study of interventions, measures, and

ethical considerations.

Methodology

The variables examined in this project are HEP and activity level. This study will explore

the relationship between the two variables that impact practice and patient outcomes. Pre-study

physical activity level assessment will be conducted, a HEP introduced, and a post-study

physical activity level obtained. Pre and post-study activity levels will be comparatively

analyzed using statistical data to determine the effect of the HEP on activity level. Finally, a

quantitative survey of intent to continue the HEP will be conducted and statically analyzed.

Survey questionnaires will be used to obtain responses from participants.

Needs Assessment

The majority of home health patients including those at Humana at Home Agency are

older adults, and in addition to lower physical activity levels, more inactivity exists in this

population (Douma, 2017). From previous experience, HTN a is a common comorbidity in

home health care including Humana at Home Agency, and poor management of HTN leads to

hospitalization which negatively affects insurance companies’ assessment of the quality of care

provided by home health agencies. The Centers for Medicare & Medicaid Services (CMS) for

example, considers acute care hospitalization (ACH) during home health episode to be one of the

key quality measures for care given to homebound Medicare patients (Schade & Brehm, 2010)

which also determines reimbursement. Because many older adults in home health are not

25


physically active, they battle with poor HTN control and subsequent acute care hospitalization

which costs the home health agency money through insurance penalties attributed to poor quality

of care. As health care costs continue to escalate in the United States, many stakeholders

including Humana at Home Agency have focused on identifying effective methods for enhancing

the quality of care while reducing unnecessary health care costs (Zillich, 2014). Thus, there is a

great need for a sustainable strategy to increase the activity level of older adults to which comes

with many benefits such as proper HTN control. A HEP is an excellent strategy towards this

venture. Typically, Humana at Home Agency delivery process for patients admitted with HTN

does exclude a HEP. There is need to implement a HEP, a lifestyle modification and naturalistic

approach to better manage high blood pressure in the elderly patients through increased activity

level. Thus, information obtained from this project will be used to propose a practice policy

chance based on established literature on the effects of a HEP on activity level. Consequently,

project findings will help improve patient outcome and quality of care provided in home health.

Study Design

This project is a single group descriptive quantitative correlational study focused on

examining the relationship between a HEP on the activity level of older adults in home health

care. The setting will be home health care in patients’ homes, which may include independent

living or boarding homes. The sample size will be twenty (20) consisting of older adults, male

and female of all races. The inclusion criteria will include age between 65 and 88, diagnosis of

HTN, ability to give consents and follow commands. The rationale for the inclusion criteria is

that subjects within the specified age range will foster the generalization of findings to older

adults. Ensuring that participants have received a HEP is pertinent in to demonstrate the

relationship between a HEP and activity level. Also, ability to demonstrate good cognitive status

26


is necessary to ensure that research questionnaires are completed correctly and objectively. In

addition, this protects the subjects’ interest by ensuring they are not vulnerable due to cognitive

impairment common in this age group. The exclusion criteria include cognitive disability, have

not received a HEP and age less than 65. The justification for the exclusion criteria is that

disorientation, impaired cognitive status or no recent record of receiving a HEP will result in

incorrectly completed questionnaires, which will skew the results and jeopardize the reliability

and validity of research findings. The steps in the project are:

i. Week 1: The researcher will provide recruitment flyer to participants and explain

research to participants using a script during a routine home health visit. There will be no

further communication regarding the project with the potential participants after sharing

of the flyer and explaining the research. Additional communication will be up to the

participant to contact the researcher on the number provided on the flyer.

ii. Week 2 - After interested participants contact the researcher, the researcher will set up a

time to meet with participants in their place of residence to complete the research

questionnaires. There will be a total of three questionnaires that will be completed

(RAPA-Pre, RAPA-Post, and Post-HEP survey). The researcher will explain the entire

research process to participants, obtain informed consents and explain the Rapid

Assessment Physical Assessment (RAPA) Tool. Each participant will undergo a

cognitive test involving a clock draw test to ensure cognitive competence. The researcher

will provide each participant with two copies of the RAPA assessment questionnaire to

be completed by the participants, one copy will be to record activity level before

receiving HEP and the second copy will be to record activity level after they received a

HEP. The participants will be asked to recall their level of activity before they started the

27


HEP, fill out the first RAPA form, then consider their current level of activity following

the HEP and fill out the second RAPA form. Participants may complete the

questionnaires at this time or within one week of providing the questionnaire. Completed

questionnaire will be placed in a sealed envelope and collected by the researcher in a

locked box. The post research survey questionnaire Instruments will also be provided to

participants, and they will complete it after completing the two RAPA questionnaires.

Completion of questionnaires is all that participants will do as they will document their

activity level before they received a HEP and after they received a HEP. They must have

received and completed a HEP already before being recruited for the research.

iii. Week 3 – The researcher will conclude the collection of all completed RAPA

questionnaires and begin analysis of data.

iv. Week 4 – The researcher will introduce the research results and the practice policy

change to Humana at Home Agency to the Manager of Clinical Operations.

v. Week 5 - After the Introduction of the policy change, Humana at Home will begin to

include a HEP to the plan of care of patients with HTN. The HEP will be provided

during routine visits at no additional or out of pocket cost to the patients.

Data Collection Instruments

The data collection instruments for this project will include the University of Washington

RAPA questionnaire, informed consents, eligibility screening questionnaire, participants de-

identified data sheet, script to verify participants orientation and cognitive status, and a post-

research survey. The RAPA is a 9-item, self-administered questionnaire used to assess and

monitor physical activity levels of adults aged 50 years and older (Silva, Queirós, Alvarelhão, &

Rocha, 2014). The choice of the RAPA tool based on the fact that a validation study among

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older adults with the RAPA showed a positive correlation with physical activity level on the

physical activity surveys. Community health activities model program for Seniors (CHAMPS),

the patient-centered assessment and counseling for exercise (PACE), and the behavioral risk

factor surveillance system (BRFSS) are some of the surveys (Vega-López, Chavez, Farr, &

Ainsworth, 2014).

Informed consents are provided based on Maryville University guidelines. The

researcher developed other data collection instruments used in this project. These include an

eligibility screening questionnaire with specific questions about inclusion and exclusion criteria

such as HTN, age, having received a HEP within the last month, and ability to follow commands.

Also, a script to verify participants’ cognitive status with cognitive questions and a clock draw

test was also developed by the researcher. Other instruments developed by the researcher

include participant’s de-identified data sheet that is properly structured to contain only age and

gender with a unique identifier code to protect participants’ confidentiality. The post research

survey sheet is designed to get feedback from participants on the HEP they received before this

study and will be analyzed to assess the feasibility of the project recommendations to determine

participants’ intent to practice HEP routinely.

Resources

This project utilized several resources to accomplish the process. The researcher

collaborated with an experienced licensed physical therapist with inputs on the effectiveness of a

properly structured HEP for the older adults. Humana at home is the agency that is used for

recruitment of older adults for participation in this project. Electronic media was extensively

used to extract pertinent information such as literature review from Maryville University Library,

29


statistics modalities, exercise recommendations, and physical assessment tools. This project

funding is from researcher’s funds and student loans.

Budget

Based on the items and resources needed for this project, a budget is developed.

1. Human resources (Staff and Others) - $200

2. Research expenses (Printing of tools, field expenses, gas, etc.) - $400

3. Meetings/Consultations for dissemination - $300

4. Printing of the report - $200

5. Capital (computers, office set up, data analysis software) - $300

6. Overhead (electricity and rent) - $200

Total Budget Amount - $1,700

This budget is justified based on many factors. For example, expenses will involve

human resource utilization by the consultation of a licensed physical therapist and the

manager of clinical operations for organizational approval and recruitment of subjects.

Costs will also include statistical software, printing of research materials and capital

expenses.

Timeline

The planned timeline needed to complete this project is:

1. Obtaining institutional review board (IRB) approval – 2 Weeks

2. Implementation – 1 Weeks

3. Analysis – 1 Weeks

4. Writing the final report – 2 Weeks

30


From the projected timeline, the project duration is 6 weeks from getting IRB approval to

drafting the final report. This projection will enable the researcher plan appropriately to

ensure success in the process.

Protection of Human Subjects

This research is a practice change based project that involves human subjects with a risk

of breach of confidentiality. Consequently, strategies have been adequately mapped out to

protect participants and minimize this risk. For example, ensuring that data collected is de-

identified data, coded and recorded in a password-protected electronic device and stored in a

locked cabinet of a locked private office of the researcher will mitigate the issue of breach of

confidentiality. Interviews will occur in a private and secure area. Also, the researcher will

destroy all data by shredding and deletion from electronic device hard drives not later than one

year after completion of the project. Finally, there will be no obligation and exercise of power or

duress, and participation is exclusively voluntary and non-punitive with the right to withdraw

any time as clearly stated in the consent form. Participants will be screened to ensure stable

cognitive status using the orientation script developed by the researcher and a clock draw test.

Context

To achieve the affordable care act’s (ACA’s) goal in the reduction of healthcare

expenses and improve the quality of home health, the Medicare payment advisory commission

(Med- PAC) recommended a home health financial incentive program. This program penalizes

home health agencies (HHAs) with frequent preventable hospitalization of home health patients

due to poor management of diseases such as HTN (Chen, Carlson, Popoola, & Suzuki, 2016).

Since many home health agencies including Humana at Home Agency are Medicare financed

organizations, sedentary lifestyle and subsequent poor management of HTN leading to inpatient

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stay result in significant loss of revenue. This approach is a remarkable contextual relevance of

this project, which aims at increasing activity levels of older adults through the implementation

of a HEP to better manage HTN and prevent specialized acute care. From experience, an

essential factor in home health organizational dynamics and collaboration is that there are

multidisciplinary employees such as physical therapists and home health aides who can assist in

the maintenance of a HEP for patients with HTN to ensure feasibility of the practice change.

The sustainability of the HEP will improve home health systems performance as will be

evidenced by increased activity level and good HTN control. This improvement in the standard

of care will invariably produce similar outcomes if adopted by other home health agencies since

the population type, operational guidelines, and the process is identical and regulated by the

same licensing and federal agencies.

Interventions

This project will introduce a practice change to manage HTN in older adults better. The

proposal of this project is to recommend a HEP as a standard of care for all older adults with

HTN in home health. The mechanism by which HEP intervention is expected to produce a

change in healthcare systems performance is by increasing activity level of older adults which

will reduce the risk of physical frailty and promotes health benefits including better quality of

life and reduced risk of chronic disease exacerbation (Jing et al., 2015). Specific teams involved

in this project and process of implementation is nursing and physical therapy.

Study of Interventions

The approach chosen to assess the impact of the interventions proposed by this project is

data collection and assessment of pre-and post-HEP activity level using the RAPA questionnaire,

a reliable physical activity evaluation tool. Evaluation of participant’s views on the intervention

32


will also be examined. The use of peer-reviewed literature to investigate established associations

between sedentary lifestyle, inactivity and HTN control will also be explored. This information

will help the researcher confer inference on the likelihood of associating the outcome of the

study to HEP. The association of the study outcome to the HEP introduced will be beneficial

during the dissemination of findings to stakeholders to facilitate acceptance and a smooth

transition to a practice change policy.

Measures

This project used measures to examine how healthcare is delivered in home health. These

actions include researcher’s observation and experience, published articles, and review of home

health agency policies at Humana at Home Agency. The rationale for choosing these steps

include validity, reliability with less possibility of bias since researcher is directly involved in the

process, obtained information from reputable journals, and a current review of home health

agency operational policy and procedures. Also, these measures are cost-effective, feasible,

dependable, and evidence-based to substantiate and strengthen the phenomenon of interest and

project findings.

Ethical Considerations

Ethical consideration in this project includes burden to employees concerning added

workload, an additional cost to home health regarding more staff to implement the program, staff

distress associated with the revelation of a lower standard of patient care before the research

proposal. The opportunity cost identified in this project includes the alternate use of funds and

employees for other projects such as the expansion of agency size or providing additional

incentives for staff. However, the long-term gain of this proposal includes financial benefits

from better HTN management not requiring acute care intervention, which attracts more funds to

33


the agency and increased agency patient census. This project went through IRB review and

received full approval. There are no conflicts of interest to report on this project.

CHAPTER FOUR: LIMITATIONS, RESULTS, AND DISCUSSIONS

Limitations of Study

The sample size is essential especially for data analysis, and many researchers prefer to

use large sample sizes to increase the reliability, validity, and generalizability of a study (Delice,

2010). The organization for this DNP project is a relatively small home health agency with a

small number of participants that match the research criteria. Thus, a small sample size of

twenty is used which constitute a limitation. Another limitation of the study is the ability of

participants to recall Pre-HEP activity level accurately. Although the research was conducted

with participants within one month of HEP and cognitive tests including the clock draw test are

used to ensure intact memory, there is a possibility that participants may not have accurately

recalled their Pre-HEP activity level. This is because there is reliable evidence of age-related

declines in cognitive functioning including memory (Nittrouer, Lowenstein, Wucinich &

Moberly, 2016). Participants’ trustworthiness to answering questionnaire truthfully is also a

limitation since researcher and clinicians who provided the HEP work at the facility those

subjects receive healthcare. Despite the fact that data collection is de-identified, there is a

tendency that participants may not have honestly completed the questionnaires due to concerns

about creating a negative provider impression. Further research is needed in other home health

agencies by a researcher who is not involved in the organization, with a higher sample size,

different assessment tool, and with subjects who received HEP from different clinicians to

compare the outcome to improve the generalizability of findings. This will also improve the

reliability of the study findings and recommendations for a HEP for the older population.

34


Results and Analysis

This study explicitly shows that a HEP increases activity level in older adults. Statistical

data analysis supports that HEP had a positive influence on raising activity level of individuals

who received the HEP. The paired sample t-test and Pearson’s coefficient r were used because

the paired sample t-test is the most powerful for symmetrical distributions (normal and uniform)

datasets (Poncet, Courvoisier, Combescure, & Perneger, 2016) (see figures 1a & 1b below).

The Pearson’s correlation r, on the other hand, shows an association that exists between paired

variables on x and y-axis (Triola, 2011). From the statistical analysis, the paired t-test shows a

strong correlation between Pre-and Post HEP activity levels with a high correlation of - 0.546

and 0.013 significance (see tables 2a-2d below). Also, the t-statistic is very significant as it is

less than 0.001 (see table 4 below).

Figure 1a- Histogram

Dataset is a normal (symmetrical) distribution as indicated by the curve.

35


Figure 1b - Histogram

Dataset is a normal (symmetrical) distribution as indicated by the curve.

Table 2a - Paired Samples Statistics

Mean N Std. Deviation Std. Error MeanPair 1 PRE_HEP .7500 20 1.83174 .40959

POST_HEP 4.7500 20 1.11803 .25000

The mean for Pre-HEP activity level is 0.75 indicating inactivity while the Post-HEP mean is

4.75 showing an increase in activity level.

Table 2b - Paired Samples CorrelationsN Correlation Sig.

Pair 1 PRE_HEP & POST_HEP 20 -.546 .013

High correlation indicated at -0.546 with a 0.013 significance

36


Table 2c - Paired Samples Test

Paired Differences

tMean Std. DeviationStd. Error

Mean

95% Confidence Interval of the Difference

Lower UpperPair 1 PRE_HEP -

POST_HEP-4.00000 2.61574 .58490 -5.22420 -2.77580 -6.839

Table 2d - Paired Samples Test

df Sig. (2-tailed)Pair 1 PRE_HEP - POST_HEP 19

Negative Pre-and Post-HEP mean indicates a difference in activity levels.

From table 4 above, the t-statistic is very significant as it is less than 0.001, so we can reject the

null hypothesis that HEP does not increase activity level in older adults since p-value is

technically less than or equal to 0.05.

Furthermore, the Pearson’s correlation r is significant at the 0.01 level (2-tailed) for

activity level change Post HEP and 0.05 for Pre-and Post-HEP activity level comparisons (See

tables 3a & 3b below).

Table 3a) Pre-and Post HEP - Pearson’s r Correlation

PRE_HEP POST_HEPPRE_HEP Pearson Correlation 1 -.546*

Sig. (2-tailed) .013N 20 20

POST_HEP Pearson Correlation -.546* 1Sig. (2-tailed) .013N 20 20

*. Correlation is significant at the 0.05 level (2-tailed).

37


Table 3b) Activity Level Change Post HEP - Pearson’s r Correlation

Activity Level Change POST_HEP

Activity_Level_Change Pearson Correlation 1 .810**

Sig. (2-tailed) .000N 20 20

POST_HEP Pearson Correlation .810** 1Sig. (2-tailed) .000N 20 20

**. Correlation is significant at the 0.01 level (2-tailed).

Descriptive statistics presented below show results of higher activity level Post HEP

compared to Pre-HEP in a clustered and simple bar means (see figures 2a & 2b below).

Figure 2a) Clustered Bar Mean – Descriptive Statistics

38


Figure 2b) Simple Bar Mean – Descriptive Statistics

.00 = NO HEP 1:00 = HEP

A measure of central tendency shows a higher level of change 4.75 with Post-HEP

activity level compared to Pre-HEP activity level change of 0.75 (see table 4a below). A data set

distribution also shows maximum activity level Post-HEP and maximum inactivity level for Pre-

HEP (see table 4b below).

Table 4a) Central Tendency – Descriptive Statistics

PRE_HEP POST_HEPActivity Level

ChangeN Valid 20 20 20

Missing 0 0 0Mean .7500 4.7500 4.0000Median .0000 5.0000 5.0000Mode .00 5.00 5.00

39


Table 4b) Data Set Distribution Summary - Descriptive Statistics

N Minimum Maximum Mean Std. DeviationPre-HEP 2 3.00 17.00 10.0000 9.89949Post-HEP 2 1.00 19.00 10.0000 12.72792Valid N (listwise) 2

Pre-HEP response = Maximum inactivity level reported

Post-HEP response = Maximum active level reported

Discussion

A shift towards a proactive approach rather than a reactive approach towards healthcare

management of older adults is remarkable. This implies that evidence-based modalities be put in

place to focus on disease prevention and control rather than treatment following disease

exacerbation. Thus, this study supports that home health clinicians need to add a HEP to the

plan of care of patients with hypertension (HTN) to help manage their HTN better through the

increase in activity levels. It is documented that engaging in exercise as little as one day per

week is as efficient or more effective than pharmacotherapy for reducing all-cause mortality with

HTN (Pescatello, MacDonald, Lamberti, & Johnson, 2015). An introduction to a home exercise

modality will incorporate a routine for home health patients, which will boost their physiological

and health status.

Strengths of the Study

The strengths of the study include:

1. RAPA tool is an objective measurement of activity level in older adults.

2. Statistical analysis – Paired sample t-test and Pearson’s correlation r are reliable test

statistic.

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3. Cognitive test – clock draw test and pre-test ensured participant’s understand and able to

complete the RAPA questionnaires appropriately.

CHAPTER FIVE: CONCLUSION

Home health agencies and healthcare in general must consider implementing evidence-

based benefit of increased activity level for elderly patients in home health. Tying theory to

practice by introducing a policy change that involves instituting increased activity in older adults

through coaching and training in a HEP for patients suffering from HTN will be a valuable

intervention. Increasing the activity level in older adults is an intervention that has been

examined by many researchers as evidenced in the literature. A better approach to manage HTN

using a HEP as a lifestyle modification will boost home health patient outcomes. It is evident

that dependency on skilled nurse teaching and pharmacotherapy is not sufficient in promoting

the health of older adults as evidenced by poor management of diseases. Although there is

evidence-based knowledge on the tremendous benefits of exercise, most home health agencies

do not have a standard of practice to incorporate a HEP for patients with HTN. However, home

health agencies are strategically positioned to carry out a structured intervention to support the

elderly population who has a higher tendency of sedentary lifestyle as compared to the younger

people. The therapeutic effects of exercise on high blood pressure control are achievable

through a HEP designed for the aged population by home health agencies, which is the focus of

this DNP scholarly project. Thus, this project challenges clinicians in home health to

strategically and professionally design and introduce an individualized HEP tailored at

increasing the activity level of older patients. This approach will encourage them to overcome

the barriers associated with compliance and continued adherence. Although there is evidence-

based knowledge on the tremendous benefits of exercise, most home health agencies do not have

41


a standard of practice to incorporate a HEP for patients with HTN. Consequently, clinicians in

home health, act as agents of change for the elderly population by educating and motivating them

towards a more active lifestyle. This research supports the fact that it is apparently impossible to

overemphasize the benefit of a HEP and its resultant increase in the activity level of older adults

in home health because sedentary lifestyle and diseases such as HTN are not mutually exclusive.

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