Development and Implementation of a Geriatric Walking Clinic

Follow-up

Veterans are followed closely between their clinic appointments via phone calls from a nurse who provides encouragement and helps set new goals. The nurse collects the step count data to determine progress and set new walking goals. Those unable to adhere to their walking prescription are reassessed for their barriers. The nurse also helps participants identify ways to overcome individual challenges. The PCP is consulted when barriers include medical problems, such as pain or poor blood sugar control.

At the 6-week follow-up visit, the health care provider reviews the pedometer log and repeats all outcome assessments, including the physical performance testing and the participant surveys. Veterans receive feedback from these outcome assessments. To assess participant satisfaction, CAVHS GRECC developed a satisfaction questionnaire, which was given to participants.

Results

A total of 249 older veterans participated in the GWC program. The mean age was 67 (±6) years; 92% were male, 60% were white, and 39% were African American. Most participants lived in a rural location (60%) and were obese (69%); consistent with national standards, obesity was defined as a body mass index (BMI) ≥ 30 kg/m². Several barriers to exercise were endorsed by the veterans. Most commonly endorsed barriers included bad weather, lack of motivation, feeling tired, and fear of pain. Most participants (93%) were actively engaged via regular phone follow-ups visits; 121 (49%) participants returned to the clinic for the 6-week reassessment. Repeat performance testing at the 6-week visit showed a clinically significant average 14% improvement in the 6MWT, 6% improvement in the Timed Up and Go test, and a 27% improvement in gait speed. Of those veterans who were obese, 64% lost weight. On entry into the program, 32 participants (13%) had poorly controlled diabetes mellitus (DM), defined as hemoglobin A_1c (HbA_1c) ≥ 8. Among this group, HbA_1c improved by an average of 1.5% by the 6-week visit. The GWC program may have contributed to the improved glycemic control as a generally accepted frequency of monitoring HbA_1c is at least 3 months.

At the 6-week clinic visit, 94% of those surveyed completed a program evaluation. The GWC scored high on satisfaction; over 80% strongly agreed that they were satisfied with the GWC program as a whole, 80% strongly agreed that the program increased their awareness about need for exercise, 82% strongly agreed that the clinician’s advice was applicable to them, and 77% strongly agreed that the program improved their motivation to walk regularly (Table 1).

Program Economics

An analysis of the clinic costs and benefits was performed to determine whether costs could potentially be offset by the savings realized from improved health outcomes of participating veterans. For this simplified analysis, costs of maintaining the GWC were set equal to the costs of the full-time equivalent employee hours, equipment, and educational materials. Based on the authors’ experience, they projected that for each 1,000 older veterans enrolled in the GWC, there is a requirement for 0.5 medical support assistant (GS-6 pay scale), 1.0 registered nurse grade 2 (RN), 1.0 health science specialist (GS-7), and 0.25 physician. At the host facility, the annual personnel costs are estimated at $205,149. The total annual cost of the GWC, including the equipment and educational materials, is estimated at $240,149.

Although full financial return on investment has yet to be determined, the authors estimated potential cost savings resulting if patients enrolled in a GWC achieved and maintained the types of improvements observed in the first cohort of patients. These estimates were based on identified improvements in 3 patient outcome measures cited in the medical literature that are associated with reductions in subsequent health care costs. These measures include gait speed, weight loss, and HbA_1c. It is estimated that the cost savings associated with improvement of gait speed by 0.1 m/s (a clinically relevant change) is $1,200 annually.¹⁵

On average, patients enrolled in the GWC program improved their gait speed by 0.22 m/s. Cost savings related to gait speed improvement for 1,000 participants could reach $1,200,000. Conservative estimates of cost savings per 1% reduction of HbA_1c is $950/year.¹⁶ Among those with poorly controlled DM (ie, HbA_1c of ≥ 8), average HbA_1c declined by 1.5%. Provided that 13% of the patients have poorly controlled DM, the total cost saving for 1,000 participants could be $209,950 annually.

It also is estimated that a 1% weight loss in obese patients is associated with a $256 decrease in subsequent total health care costs.¹⁷ In the GWC, the obese participants lost an average of 1.3% of their baseline weight. Assuming that about 60% of all older veterans participating in the clinic program are obese, annual cost savings per 1,000 participants related to weight loss is estimated to be $199,680. After accounting for the costs of operating the clinic, the total cost savings for a GWC with 1,000 enrolled older veterans is estimated to be as much as $1.4 million annually. Such a favorable cost assessment suggests that the program should be evaluated for widespread dissemination throughout the entire VHA system. Other potential benefits associated with GWC participation, such as improved quality of life and greater functional independence, may be of even greater importance to veterans.