PROGRAM PROFILE

Providing Rural Veterans With Access to Exercise Through Gerofit

Clinical video telehealth can be used to deliver functional circuit exercise training to older veterans in remote locations.

Fed Pract. 2018 November;35(11):16-23

Author(s):

Brandon C. Briggs, MS

Chani Jain, MPH

Miriam C. Morey, PhD

Erin H. Blanchard, MS

Cathy C. Lee, MD

Willy M. Valencia, MD

Krisann K. Oursler, MD, ScM

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References

1. American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510-1530.

2. Centers for Disease Control and Prevention. Adult participation in aerobic and muscle-strengthening physical activities—United States, 2011. MMWR Morb Mortal Wkly Rep. 2013;62(17):326-330.

3. Littman AJ, Forsberg CW, Koepsell TD. Physical activity in a national sample of veterans. Med Sci Sports Exerc. 2009;41(5):1006-1013.

4. US Department of Veterans Affairs, Office of Rural Health. Annual Report: Thrive 2015. https://www.ruralhealth.va.gov/docs/ORH_Annual_Report_2015_FINAL.pdf. Published 2015. Accessed July 16, 2018.

5. Rawstorn JC, Gant N, Direito A, Beckmann C, Maddison R. Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis. Heart. 2016;102(15):1183-1192.

6. Morey MC. Celebrating 20 years of excellence in exercise for the older veteran. Fed Pract. 2007;24(10):49-65.

7. Cowper PA, Morey MC, Bearon LB, et al. The impact of supervised exercise on the psychological well-being and health status of older veterans. J Appl Gerontol. 1991;10(4):469-485.

8. Morey MC, Cowper PA, Feussner JR, et al. Evaluation of a supervised exercise program in a geriatric population. J Am Geriatr Soc. 1989;37(4):348-354.

9. Morey MC, Pieper CF, Crowley GM, Sullivan RJ, Puglisi CM. Exercise adherence and 10-year mortality in chronically ill older adults. J Am Geriatr Soc. 2002;50(12):1929-1933.

10. Morey MC, Pieper CF, Sullivan RJ Jr, Crowley GM, Cowper PA, Robbins MS. Five-year performance trends for older exercisers: a hierarchical model of endurance, strength, and flexibility. J Am Geriatr Soc. 1996;44(10):1226-1231.

11. Valencia WM, Botros D, Pendlebury D, et al. Proactive reach and telehealth monitoring (Gerofit) enhance resistance exercise at rural setting. Innovat Aging. 2017;1(suppl 1):225.12. Pendlebury D, Botros D VW. Proactive Reach: an innovative access approach to identify & deliver GEROFIT exercise telehealth counseling to rural veterans & enhance CBOC services. J Am Geriatr Soc. 2017(suppl 1):S208. Poster presented at: Annual Scientific Meeting of the American Geriatrics Society; May 18, 2017; San Antonio, TX.

13. Morey MC, Crowley GM, Robbins MS, Cowper PA, Sullivan RJ Jr. The Gerofit program: a VA innovation. South Med J. 1994;87(5):S83-S87.

14. Cooper R, Kuh D, Hardy R; Mortality Review Group; FALCon and HALCyon Study Teams. Objectively measured physical capability levels and mortality: systematic review and meta-analysis. BMJ. 2010;341:c4467.

15. Rikli RE, Jones CJ. Development and validation of a functional fitness test for community-residing older adults. J Aging Phys Act. 1999;7(2):129-161.

16. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49(2):M85-M94.

17. Morey MC, Cowper PA, Feussner JR, et al. Two-year trends in physical performance following supervised exercise among community-dwelling older veterans. J Am Geriatr Soc. 1991;39(10):986-992.

18. Morey MC, Lee CC, Castle S, et al. Should structured exercise be promoted as a model of care? Dissemination of the Department of Veterans Affairs Gerofit program. J Am Geriatr Soc. 2018;66(5):1009-1016.

19. Blanchard E, Castle S, Ines E, et al. Delivering a clinical exercise program to rural veterans via video telehealth. Poster C167 presented at: Annual Scientific Meeting of the American Geriatrics Society; May 19-21, 2016; Long Beach, CA.

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21. Peters DM, Fritz SL, Krotish DE. Assessing the reliability and validity of a shorter walk test compared with the 10-meter walk test for measurements of gait speed in healthy, older adults. J Geriatr Phys Ther. 2013;36(1):24-30.

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23. Romero-Arenas S, Blazevich AJ, Martinez-Pascual M, et al. Effects of high-resistance circuit training in an elderly population. Exp Gerontol. 2013;48(3):334-340.

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25. Romero-Arenas S, Martinez-Pascual M, Alcaraz PE. Impact of resistance circuit training on neuromuscular, cardiorespiratory and body composition adaptations in the elderly. Aging Dis. 2013;4(5):256-263.

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27. Takeshima N, Rogers ME, Islam MM, Yamauchi T, Watanabe E, Okada A. Effect of concurrent aerobic and resistance circuit exercise training on fitness in older adults. Eur J Appl Physiol. 2004;93(1-2):173-182.

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29. Biddle ED, Reynolds P, Kopp T, Cammarata H, Conway P. Implementation of functional training tools elicits improvements in aerobic fitness and lower body strength in older veterans. Poster C169 presented at: Annual Scientific Meeting of the American Geriatrics Society; May 19-21, 2016; Long Beach, CA.

Exercise increases endurance, muscle strength, and functional performance with corresponding gains in mobility, survival, and quality of life.¹ However, even with these benefits and improvements in clinical outcomes, only 15% of adults aged ≥ 65 years follow current guidelines for exercise.² Despite their prior military training, the majority of veterans do not meet physical activity recommendations.³ Time, travel, and support are common barriers to exercise participation and adherence—barriers that are further amplified among older adults.

The Veterans Health Administration (VHA) is recognized as a world leader in telehealth service development. Currently, 677,000 veterans have received telehealth services, which represents 12% of the 5.6 million veterans under VHA care.⁴ Clinical video telehealth (CVT) is widely used within the VHA system to deliver health care that otherwise would not be available to veterans. Veterans who have difficulty traveling to the nearest US Department of Veteran Affairs (VA) medical center (VAMC) can access CVT programs at a participating VHA community-based outpatient clinic (CBOC). The VA has more than 45 CVT programs, including programs for mental health, weight management, cardiology, and dermatology. Outside the VA, cardiac exercise rehabilitation provided by CVT has been shown to be as effective as center-based programs in improving cardiovascular risk factors and functional capacity.⁵ A VHA exercise program that leveraged CVT resources and was dedicated to older adults with a wide range of comorbid conditions would have a high impact on the health and well-being of older veterans.

Gerofit is a VHA clinical demonstration program of supervised center-based exercise for veterans aged ≥ 65 years. Developed at the Durham VAMC Geriatric Research, Education, and Clinical Center (GRECC) in North Carolina, it has demonstrated improved clinical outcomes, including physical function, mobility, quality of life, and survival.^6-10 The program offers veterans individualized exercise in a group setting that focuses on improving endurance, strength, and balance. The exercise prescription is based on the patient’s physical limitations as identified in a physical performance assessment.

With support from VHA Geriatric Extended Care (GEC) and the Office of Rural Health (ORH), Gerofit was implemented in 10 VAMCs across 8 VISNs. However, barriers such as travel time, distance, and transportation limit participation. Previously, we found that rural veterans lack access to exercise programs.^11,12 Although some do aerobic exercise (AEX), most do not do resistance training (RT), though they are willing to learn. Access to Gerofit for rural veterans is expanding with recent support from the ORH Enterprise Wide Initiative. Rural program expansion includes several different Gerofit initiatives, many involving CBOCs.

The Salem VAMC Gerofit program sought to adapt the facility-based assessment and exercise procedures into a self-reliant CVT class for its CBOCs. This article describes the development of the Salem VAMC Gerofit CVT program, hereafter referred to as Tele-Gerofit.

Program Design

Gerofit was established in 1986 at the Durham GRECC as an exercise and health promotion program for veterans aged ≥ 65 years.¹³ Its goal is to prevent or improve functional decline from physical inactivity and age-related conditions. Gerofit targets the geriatric patient population and thus extends beyond cardiac and pulmonary rehabilitation or weight loss programs. The primary exclusion criteria are based on safety issues in the context of a group exercise setting of older adults and include oxygen dependency, unstable cardiac disease, and moderate-to-severe cognitive impairment.