Physical activity participation declines with advancing age. Lack of facility access, lack of transportation, and psychological barriers are key reasons why many older adults don’t exercise regularly. Home exercise programs may work to improve older adult involvement in exercise programs. Jette et al. (1999) reported that the Strong-for-Life Program used a home-based approach particularly suited to people with disabilities. As they noted, “if regular exercise is to be widely adopted and maintained by large numbers of older persons, it must be enjoyable, inexpensive, and achievable with minimal levels of supervision.”
In 1996, in response to the growing demand for exercise programs that address common barriers to exercise for many older adults, the Canadian Centre for Activity and Aging (CCAA) developed the Home Support Exercise Program (HSEP), an evidence-based physical activity intervention delivered through the home-care system. Later, in 2003, the Alberta Centre for Active Living partnered with the CCAA to disseminate the program across Alberta. Funding from the Alberta government also allowed healthy eating content to be added and the program to be offered to the health regions in a subsidized way.
Keeping elders functioning well in their own homes is considered the optimal course of action for individual life quality. Designed for home-care clients (older adults who already receive home-care services), HSEP is offered through community-health services and accessed by the regional health authorities. HSEP clients are frail, face declining mobility, and lead sedentary lifestyles. These older adults are often considered at risk for institutionalization—a traumatic and costly event. The HSEP has been found effective in improving functional abilities and can be delivered in a cost-effective manner.
Home Support Exercise Program
The Home Support Exercise Program (HSEP) consists of 10 simple yet progressive exercises designed to enhance and maintain functional fitness, mobility, balance, and independence of homebound older adults. These exercises require no specialized equipment and can be performed in the comfort of one’s home. The program includes:
- Walking from room to room
- Wall push-ups
- Rising up on toes
- Toe taps
- Seat walk
- Getting up from a chair
- Leg lifts: front, back and side
- Reach up, front, to the side
- Standing stretch (lower leg stretch)
- Seated stretch (back of leg stretch)
Participants of the program receive a manual that includes pictures and instructions for each of the exercises and a calendar, typically placed on the refrigerator, to track compliance and progress. Personal support workers, volunteers, or caregivers are trained to instruct, encourage, and monitor the home-based exercise programs. To date, the CCAA has trained more than 1,780 leaders and 85 Home Support Exercise Program facilitators.
The HSEP was piloted in collaboration with Lambton Elderly Outreach, a home-support service agency in Lambton County, Ontario. Responding to significant demand, the CCAA initiated the project in Middlesex-London, Huron and Perth counties, as well as in two First Nations’ communities: Onyota’a:Ka and Walpole Island First Nations Settlements. The program was introduced between July and December of 1996. Participants receiving home-support care completed the four-month exercise intervention. Significant improvements in functional mobility scores and individual improvements in balance, functional fitness, and vitality were seen in those who elected to participate regularly.
An evaluation of the process and implementation strategies was made in order to make recommendations for future training and development of the HSEP. The evaluation used a case study approach, employing interviews and focus groups to obtain reactions to all facets of the program – training, delivery, exercise adherence, and assessment – in each community. All key stakeholders, including case managers, personal support workers, and clients, participated in the evaluation. From this evaluation, it appeared that the HSEP was a suitable intervention for frail home-bound elderly and could be delivered through the existing infrastructure of home support.
In the late 1990s the CCAA began a controlled research project to further investigate the effectiveness of the exercise program in improving client functional mobility as compared to a nonexercising control group, and to further evaluate the feasibility of delivery through the home-care network. Clients were assessed in their homes before and after the 16-week intervention. Results suggest that the HSEP is beneficial in improving the physical and psychosocial well-being of this frail elderly population. Clients showed significant improvements in functional mobility, endurance, lower extremity strength, and confidence in performing daily activities without losing their balance or falling. Many clients reported that they felt better, had an improved outlook on life and could do things around their home more easily. Personal support workers reported increases in client energy levels and endurance. Thus, the HSEP has been demonstrated to be effective and can be successfully implemented through the home-care network.
In 2001, the Ontario Trillium Foundation awarded the CCAA a three-year grant to fund the dissemination of the HSEP in at least three areas of the province. The grant enabled the delivery of the HSEP to be carried out effectively through formal support service providers (Community Care Access Centres and home-care agencies).
Implementation and Dissemination
In 2003, the Alberta Centre for Active Living partnered with the CCAA to disseminate the program across Alberta. Funding from the Alberta government also allowed healthy eating content to be added and the program to be offered to the health regions in a subsidized way.
Keeping elders functioning well in their own homes is considered the optimal course of action for individual life quality. Designed for home-care clients (older adults who already receive home-care services), HSEP is offered through community-health services and accessed by the regional health authorities. HSEP clients are frail, face declining mobility, and lead sedentary lifestyles. These older adults are often considered at risk for institutionalization—a traumatic and costly event.
To begin implementing the program, home-care staff first participate in HSEP training and orientation. A trained community-care coordinator/home-care nurse introduces the client to the program, assesses their interest and ability, and authorizes the health-care aide to start the client on the program. Using one-on-one coaching, an HSEP trained health-care aide and client begin working through the ten exercises and seven healthy eating tips with the client, along with the HSEP resources and a progress chart (Jacob Johnson, Myers, Scholey, Cyarto, & Ecclestone, 2003).
Originally, this one-time orientation took approximately 60 minutes (Jacob Johnson et al., 2003). With the healthy eating addition, the HSEP now encourages allowing 60 to 90 minutes and spreading the information over three half-hour visits. This is proving to be more manageable and effective for staff and clients. Once the client is familiar with the program, ongoing encouragement and spot-checks, but not supervision, on regular visits are usually required.
Costs of this program are higher at the initial point of personal instruction and then decrease over time to be a nontime-consuming intervention for the home-care staff. On their regular visits with the client, maintenance and support (helping client establish a daily routine, praise, reviewing the exercises as needed, help in filling out the progress chart, and encouraging progression) become the home-care staff’s main role and should take no longer than five minutes during their regularly scheduled visit.
Does HSEP Work?
HSEP differs from prior interventions in several important respects:
- physician referral is not required;
- no equipment or client transport is needed;
- specialized activity trainers are not used;
- there is ongoing support and monitoring through regularly scheduled home-care visits (Jacob Johnson et al., 2003).
A nonrandom intervention study by Tudor-Locke, Myers, Jacob, Lazowski, & Ecclestone (2000) followed 60 elderly clients and 38 older adults in the control group.