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Notes on Person-Centred Care in Exercise Physiology (EXSS 3075)

Overview

  • The material presents person-centred care (PCC) within Exercise Physiology (EXSS 3075) at the University of Sydney, framed by evidence-based practice (EBP) and contextualised care. It integrates PCC with clinical exercise prescription for cardiometabolic and chronic age-related diseases.
  • Central aim: combine evidence, patient goals, and practice setting to design feasible and effective exercise programs; deliver high-quality, patient-centred care.
  • Key contrasts:
    • Evidence-based establishment of causality, rigorous designs (randomised controlled trials, longitudinal studies) versus client-centred, context-sensitive judgments that adapt to individual goals and settings.
    • “It is shown that …” (robust designs) vs “It is likely that … / There are signs that …” (less robust or context-bound evidence).

Learning objectives

  • Understand the meaning and rationale for person-centred care.
  • Define the elements of AEP (aerobic exercise physiology) practice contributing to high-quality patient-centred care.
  • Learn how to combine evidence-based practice, person-centred care, and contextualisation of the evidence base, client goals, and practice setting to design and implement feasible and effective exercise programs.
  • Apply these concepts of optimal care to patients with cardiometabolic and other chronic diseases of ageing.

What is person-centred care?

  • Definition: PCC is health care that respects the person, their family and carers, and responds to the person’s preferences, needs and values.
  • PCC offers: respect, emotional support, physical comfort, information, communication, continuity and transition of care.
  • Recognises that a person is usually a patient for limited times and does not define themselves by that role.

Principles and core values of PCC

  • Principles:
    • Consumer involvement
    • Support for healthcare rights
    • Shared information
    • Shared decision making
  • Core values (what PCC seeks to achieve):
    • Respect the person
    • Information gathered from the person to develop the plan
    • Establish and maintain care to enable collaboration with the person
    • The person is the expert

What PCC looks like in practice

  • The “new mental model” places the person at the center; professionals serve the patient’s goals, and the system serves professionals.
  • Involving consumers, carers and families in planning, decision-making, monitoring and reviewing policies and care.
  • Guiding Principles: PCC is collaborative, respectful, tailored, involving and empowering the person, advocating for their needs, and recognizing the person’s experiences and knowledge.
  • Patient experience indicators include being heard, informed, known, treated with dignity, receiving timely and appropriate care, coordinated care, and a welcoming environment.

Rationale and evidence for PCC

  • PCC is foundational for safe, high-quality health care.
  • Evidence suggests PCC contributes to better communication, empathy, understanding patient concerns, and perceived attentiveness; shorter training (<10 hours) can be as effective as longer training for certain outcomes.
  • Evidence base includes Cochrane reviews on training practitioners to share control with patients, with mixed effects on satisfaction and health status, but generally positive in empathy and patient concerns alignment.

Is there evidence practitioners can be trained to deliver PCC?

  • Cochrane Review (2012) shows benefits in:
    • Clarifying patients’ concerns and beliefs
    • Communicating about treatment options
    • Increases in empathy and perceived attentiveness
  • Short training (<10 hours) can be as effective as longer training for some PCC-related outcomes.
  • Mixed results on patient satisfaction, behaviour, and health status.

How can you as an AEP practice PCC?

  • Develop an identity as a health care professional (HCP) and as a certified exercise physiologist (CEP).
  • Embed PCC in professional behaviours, culturally-safe practice, interprofessional collaboration, assessment, EBP-based planning, delivery, and social responsibility.
  • PCC should be core to all health care practice, including exercise physiology.

Context: social determinants and equity

  • PCC must start before the client-practitioner interaction; social determinants of health influence health behaviours and service delivery.
  • Health-seeking behaviours depend on health literacy and expectations; optimal health service planning must consider cultural factors, economic resources, health needs, and family beliefs.
  • Equity considerations: avoid biases when assessing risk factors and health behaviours; avoid assumptions about lifestyle.

Cultural sensitivity and Indigenous health examples

  • Indigenous Australians face unique barriers to physical activity participation (cultural, financial, availability of facilities).
  • PA programs should align with Indigenous holistic views of health and life to improve participation.
  • Diabetes and other chronic disease management examples show the need for culturally sensitive messaging.

Role of the Exercise Physiologist (AEP) in PCC

  • Initiate a therapeutic relationship and understand the person’s goals relevant to your scope.
  • Take a thorough, empathic history focusing on strengths and limitations.
  • Co-design a feasible and safe exercise management plan aligned with goals.
  • Identify barriers and facilitators; involve family and caregivers.
  • Promote continuous review and revision as goals/capabilities evolve.
  • Measure and document person-centred outcomes.

Communication skills for PCC in AEP

  • Key building blocks include:
    • Empathy
    • Active listening
    • Shared goal setting and decision making
    • Involvement of family and friends
    • Understanding individual preferences and needs
    • Dialogue based on open-ended, reflective questions
  • Practical cues:
    • Listen carefully, observe closely
    • Shift conversations from “What’s the matter with you?” to “What matters to you?”

Patient-facing questions and initial consultation strategies

  • Begin with broad, open questions to elicit what matters to the patient.
  • Use the question: “What’s important to you in all parts of your life?”
  • Then identify goals related to health and life priorities; align with three-to-six month targets and longer-term plans.
  • Example inquiry sequence includes asking about current activity, barriers, enablers, and desired outcomes.

Thorough medical screening for exercise and pre-exercise history

  • Key to PCC: thorough screening to identify risks and tailor evidence-based prescriptions.
  • Steps include:
    • Take a good history and confirm referral goals
    • Identify diseases requiring exercise and contraindications
    • Identify conditions requiring modified guidelines for adults
    • Identify barriers/facilitators to physical activity
    • Assess current/past exercise habits, preferences, injuries
    • Assess symptoms at rest and with exercise
    • Perform targeted physical exam and review other practitioners’ assessments
    • Conduct pre-exercise functional and exercise capacity assessments

Pre-exercise medical history components

  • Chief complaint/reason for referral (rephrase: how can I help you?)
  • Person-centred goals
  • Social history
  • Functional status
  • History of present illness
  • Past medical history
  • Family history
  • Medications/allergies
  • Review of systems
  • Exercise/injury history

What is most important to your patient? planning and goal prioritization

  • Use a “What’s important to me?” support plan to capture priorities and track progress.
  • Tools include action plans and “What do I want to change?” prompts, to tailor the plan and keep the patient in control.
  • A visual plan can include timelines (now, 3 months, 6-12 months) and the patient’s desired life outcomes.

Person-centred goal setting

  • Identify goals with the older person, family and caregivers.
  • Questions to identify life and health goals; determine specific three- to six-month targets and longer-term targets.
  • Prioritize goals through agreement between patient and provider; aims to improve outcomes.
  • Use SMART criteria for goals: Specific, Measurable, Attainable, Relevant, Time-bound.
  • Include short-term goals (3 months) to maintain motivation.

Agreeing on interventions and care plans

  • Interventions must have: patient concurrence, alignment with goals/preferences, and accommodation of physical and social environments.
  • Discuss and agree on each intervention with the older person.
  • Finalize and share the care plan; use digital tools (e.g., ICOPE app) to summarize and share with involved parties.

Monitoring progress and re-assessment

  • Monitor progress; judge success; identify barriers; recognize changes in goals; anticipate needs for new plans.
  • Re-assess in response to changing health status or function.
  • Regular follow-up is essential for achieving goals.

Integrating medical and non-medical care (ICOPE framework)

  • WHO framework for integrated, people-centred health services for older people.
  • ICOPE emphasizes: assessment of individual needs/preferences/goals; personalized care plan; coordinated services to maintain intrinsic capacity and functional ability; delivered via primary and community-based care.
  • Domains of intrinsic capacity include locomotor, psychological, vitality, visual, hearing, cognitive capacities.

Intrinsic capacity and locomotor focus

  • Locomotor capacity: mobility as a determinant of healthy ageing; programs tailored to improve/maintain mobility; environment adaptation and assistive devices support mobility.
  • Screening for mobility losses can be done with simple tests (e.g., chair rise test; SPPB is a composite of walking speed, chair rise, balance).
  • If there is limited mobility, multimodal exercise (core muscle groups, back, thigh, abdomen, lower body) with supervision; Vivifrail project provides guides to tailoring programs.
  • If mobility is normal, provide standard activity prescriptions; if limited mobility, escalate to specialized care or rehabilitation when needed.

Multimodal exercise and protein considerations

  • A multimodal program combines aerobic and resistance training with balance training to address falls risk and sarcopenia.
  • In cases like obesity or diabetes, combine aerobic and resistance training for optimal effects; high-intensity training may be beneficial where appropriate; ensure supervision during high-intensity initiation.
  • Protein intake considerations: for sarcopenia and obesity, consider higher protein intake to preserve lean mass during weight loss; tailor to tolerances and renal function.

Environmental and assistive considerations

  • Assess and modify physical environment to reduce fall risk; provide assistive devices as needed; ensure safe spaces for walking; consider home adaptations.
  • Social care needs: assess caregiver support, finances, housing, and access to services; connect with community resources and social support networks.

Care pathways and regional programs (Cardio-metabolic focus)

  • Telehealth and integrated care programs (e.g., iCCnet): tele-cardiology/wide team approach to manage high-risk cardiology patients locally; local GPs and nurses manage patients with specialist input via videoconference.
  • Outcomes include reductions in mortality for acute MI and positive acceptability by patients and GPs; Indigenous patients show strong uptake when care is local.
  • For chronic disease at home, telehealth programs like Virtual Clinical Care (VCC) provide home monitoring, case management, patient education, and equipment; improvements in patient satisfaction and reductions in readmissions are reported.

Co-morbidities and tailored PCC in diabetes and vascular risk

  • Chronic diseases often co-exist (macrovascular risk in diabetes, visceral/sarcopenic obesity, hypertension, dyslipidemia, pro-inflammatory milieu, autonomic neuropathy).
  • Exercise prescription should consider these interrelated risk factors and tailor to individual needs; integrate with medical therapy.

Dementia and PCC challenges and strategies

  • Dementia (e.g., Alzheimer’s) presents PCC challenges due to progressive cognitive decline.
  • PCC principles for dementia: dignity, understanding history and preferences, viewing situations from the person’s perspective, opportunities for conversation and social engagement, and involving family in care planning.
  • Mindful caregiving: stay present with the patient when the future is uncertain; focus on the present.
  • The CLEAR Dementia Care model emphasizes psychological well-being, emotional care, physical health, and social engagement.

PCC in chronic disease management at home

  • Boxed examples: telehealth programs like VCC and other home-based supports aim to empower self-management, with patient education and remote monitoring.
  • Focus on person-centred care pathways that consider home environment, caregiver support, and access to community resources.

Putting it all together: making PCC work in practice

  • Optimal management of chronic and cardio-metabolic diseases requires: empathic, patient-centred care; contextualized, evidence-based exercise prescriptions; multidisciplinary teams; and shared decision-making.
  • The PCC approach is not a one-off intervention but a continuous process of aligning goals, plans, and supports with the patient’s priorities.

Practical prescriptive guidance and tailoring to the evidence base

  • Tailoring to the clinical history and context: do not rely on an “off the rack” prescription; tailor to fit the individual’s needs and capacities.
  • Table 4 (prescriptive elements for older adults in cardiac rehabilitation): outlines targeted exercise types (aerobic, resistance, balance) and their relative benefits for various conditions (e.g., diabetes, obesity, osteoporosis, osteoarthritis, retinopathy, neuropathy, cognitive impairment). Use the evidence to select modalities that maximize benefit while remaining feasible and safe.
  • Table 2 (musculoskeletal conditions): provides condition-specific exercise prescriptions and modifications (e.g., Achilles tendonitis, ankle osteoarthritis, back pain, knee issues). Emphasizes avoiding pain, footwear considerations, posture, and modification strategies (seated vs standing, supervision, etc.).
  • The “off the rack” metaphor reinforces the need for customization and cost considerations in care planning.

How to communicate and document PCC plans

  • Use shared documentation (care plans, one-page profiles) that capture goals, preferences, risks, and supports; share with patient, family, and care team with consent.
  • The ICOPE app can help summarize and distribute plan components to all involved.

Summary points: evidence to plan PCC

  • EBP should inform PCC through consideration of patient goals, clinical context, and strength of evidence.
  • Seek robust RCTs or high-quality systematic reviews to justify plans;
  • Ensure internal validity and generalizability; feasibility in the local setting is crucial.
  • Communicate how client goals relate to proven benefits of chosen modalities; present sequencing and progressive dosing to support adherence; address barriers such as low self-efficacy, fear, finances, caregiver demands, and transportation.

Key takeaways for practice

  • PCC is holistic and tailored, rooted in collaboration with the patient and their support network.
  • Multidisciplinary teams can help set goals that are meaningful and achievable.
  • Interventions should be agreed with the patient and aligned to prioritized needs and goals.
  • Sustained, regular follow-up is essential for achieving long-term outcomes.
  • We should integrate PCC with WHO’s ICOPE framework to maintain intrinsic capacity and functional ability in older adults.
  • Use patient-centred communication to elicit what matters to the patient, and build plans that support autonomy, safety, and quality of life.

Appendix: key program elements and references mentioned in the slides

  • iCCnet: Telehealth program that supports local management by GPs and nurses with specialist input via videoconference; aims to reduce transfers and improve regional care; positive outcomes in mortality and satisfaction.
  • ICOPE: Integrated Care for Older People; WHO framework for person-centred assessment and pathways in primary care; emphasizes intrinsic capacity, functional ability, and coordinated services.
  • Vivifrail: Practical guide for developing exercise programs tailored to capacities in older adults; used to design multimodal programs.
  • Dementia PCC model: Emphasizes dignity, life history, and involvement of family; mindful care in the present.
  • WHO mobility care: Screening for mobility loss using SPPB; recommendations to implement multimodal exercise with supervision; home adaptations and assistive devices.
  • Data references: ABS 2007-08 National Health Survey data on health risks by SES disadvantaged areas; Indigenous activity data and diabetes-related considerations.

Closing note

  • The PCC approach in Exercise Physiology integrates empathic patient engagement, personalised exercise prescriptions grounded in evidence, and collaborative teamwork to manage chronic diseases of ageing effectively. This requires ongoing communication, flexibility, and a commitment to addressing social determinants and equity in care delivery.