3 FaME Delivery

After all that planning it is time to deliver the programme! Referral pathways will look different in different areas. In some areas FaME participation will be following a GP, public health nurse, primary care physiotherapist, ICPOP referral or self-referral. In the FaME Ireland study, the main referral route used across the early adopter sites was through HSE primary care physiotherapists.  You might want to consider developing or adapting existing promotional materials, referral templates and clinical letters.  There is a suite of templates and proformas available on the FaME Implementation Toolkit website in the UK which can help if you are designing your own, and within the Resource Library on this website you will find a number of locally produced templates and examples developed by clinicians and service providers in the HSE.

3.1  Promotional Materials

To raise awareness for your programme, promotional materials such as posters in pharmacies, GP surgeries, parish halls and leisure centres can used to advertise FaME classes. You could use a sample promotional poster and adapt locally. Consider the local population that you are targeting with this material - is the format clear? Asking service users for their feedback can help refine this material based on the needs of your local populations.

3.2  Clinical Letters / Briefing for Referrers

Once people are screened and enrolled in classes, a letter can be sent to the GP in case medical clearance is necessary.  If clinical referral is the selected route locally, you can develop and use a briefing pack or letter that can be used to give to GPs to explain the FaME programme.  The UK FaME Implementation Toolkit contains some examples, and these could be adapted to work in an Irish setting.

Referral forms and templates from AGILE, the UK Physiotherapy Special Interest Group in Older People, working in collaboration with later Life Training are accessible on their website and include vital information to/from physiotherapists and exercise professionals (those who lead FaME and Otago exercise programmes) and support decision making in relation to:

• Suitability of programmes (i.e. when to offer/refer to FaME versus Otago exercise programmes) 

• Initial exercise prescription 

• Ongoing progression and tailoring of exercises for individuals and scope of practice 

Sharing this information helps patients smoothly move from hospital/health care to local exercise programmes and betters the communication and link from physiotherapy to effective exercise initiatives for people who are concerned about falling. This information will help clients progress from service to service smoothly, to the right strength and balance programme, helping them maintain and improve the progress they made in the shorter physiotherapy-led exercise sessions. 

3.3 Client Information / Briefing for Participants

The use of a participant information leaflet to outline what to expect, what to wear and so on could be developed or adapted for use locally.  

Use of a register and progression record are advised to ensure that all data are collected following each class. It is important to track progression through the resistance bands (they change in colour with increased resistance) as the progressive nature of FaME is a crucial ingredient in its effectiveness. Collecting this data over time will provide the proof of FaME’s impact on people’s independence.  

3.4 'Home Is Where The Dose Is: Getting the most of out of home exercises

Home exercises and behaviour change are key to making FaME effective by meeting the effective exercise dose. From the FaME Ireland study, many programme participants found adhering to home exercise prescription challenging – mainly due to motivation of exercising alone (rather than in the group setting). To help encourage motivation and adherence, we suggest handouts and using a guide to ‘Getting the most out of home exercises’ that PSIs may find useful. 

‘Topping up’ the dose of exercise with home exercise is vital to meet an effective prescription. We know from research that 1 hour per week is insufficient and doesn’t fully support behaviour change and develop new habits and routines to undertake sufficient strength and balance across a week. 

We also know from both research and practice that simply handing out a large booklet of exercises is not appealing, people rarely do the amount you ask them to do, and that ‘asking’ them to do it isn’t a successful approach. 

Supporting home exercise practice really starts at the point of pre-exercise assessment with conversations about motivations (to attend your session), preferences and goals.  

Alongside the exercise sheets provided to PSIs by Later Life Training, here are 10 approaches to keep home exercise on your radar every week/at every interaction with your participants: 

Introduce the home exercises gradually.  This will help people get used to doing a bit extra and then you can build them up (in terms of both number of exercises and number of repetitions) over the course of the programme. It is best in the first few weeks to start with one or two exercises that have been covered in the group session so that people know what they look and feel like. 

Explain to individuals that for optimum benefits they want to be aiming for at least 1 hour (preferably more) a week, in addition to your once-a-week class.  This does though need to be built up over time, so they understand and feel the benefit of these additional exercises and can see them helping them be better in the group sessions. If an individual prefers doing the exercises in one go, then ask them to do them 2-3 times a week in between classes for 10-20 minutes at a time, building up to 30-40 minutes. If they prefer embedding exercises into daily life they need to ensure that they still build up to more repetitions and more exercises, not get entrenched in a few that they do regularly. 

Add home exercises as a point of discussion to your register. Have a section on the register to note discussions that you have had; this can help you to progress discussions. People will respond to your level of interest i.e. that you remember what they told you last week. Ask about how they did (not whether they did) their home exercise and praise them if they managed to do what was asked. If they weren’t able to, explore reasons why and offer some suggestions to help embed them into everyday life. 

Build home strength and balance exercises and success stories from the week into your pre‑session checks.  Before asking if everyone is well/any adverse events this week, start with “is there any good news to report?” “what was your win this week?” or “has anyone progressed strength and balance exercises at home” or “ would anyone tell us how they got some strength and balance into their week?” 

Start with exercises that they will quickly feel get easier the more they do - for example sit to stands and heel raises.  These can either be done every day, 10 times in one go, or give a suggestion that a few can be done in every advert break (if they watch TV) or waiting for the kettle to boil - so that they associate an exercise with an everyday task. This is all about making it a habit. In the first few weeks it helps if everyone is doing the same home exercises so you can ask the group how they got on doing them, how they felt, how best to remember to do them and are they making a difference. 

Avoid handing out equipment early.  Get them into the habit of doing some exercises first before having to remember where the equipment is or how to use it. 

Use your sessions to highlight/master the exercises that will feature in their home exercise programmes.  Relate the exercise to home exercise, continue to refer to frequency being important for results. This approach should really be implicit in all of your sessions. 

Target the homework for individuals. If they are finding something in your session difficult, offer them a way to improve, this may be just one exercise to rehearse several times per day. 

Remember that we can support clarity of home exercise programmes by using consistent language in your sessions  Repeating specific teaching points during the session will help them ‘hear your voice’ in their heads whilst performing them at home. 

Progress, progress, progress.  As time goes on and we add more exercises, remember to offer exercise sheets (to remember technique). As the weeks progress you can add exercises that work on any asymmetry they may have (e.g. hamstring stretches on the leg with poor flexibility) or swap with other strength or balance exercises as you progress their ability over time within the group. 

3.5 More than a ‘Tea and Chat’ 

The strong evidence that FaME reduces falls, boosts physical activity, and builds confidence is compelling. Despite this, uptake and completion remain a challenge. Over 50% of attendees complete only a quarter of the programme. Many don’t effectively engage with the essential home exercise programme to meet effective dose. It is easy to understand how many FaME clients will have trouble keeping physically active and exercising, with long-term conditions, when living with frailty and concerned about falling.  Support with education and peer support can help.  

Making FaME available is not enough - time for social support to ensure behaviour change happens during and after the programme is essential. Facilitating social support was part of the evidence base for the two original FaME Randomised Controlled Trials. Findings from the UK real-world FaME Implementation studies make clear that behaviour change is not a ‘nice to have’, it is fundamental to how participants engage with, persist in, and benefit from FaME. Heightening the awareness of this valuable component of FaME to service funders and service managers is recommended, explaining how their exercise behaviour is sustained through planned peer support for those who choose to exercise in groups.  

Evidence shows that social cohesion, peer encouragement, and positive instructor–participant relationships are powerful enablers of sustained engagement, particularly in the crucial first six months of behaviour change. Importantly, the behaviours and social connections developed in FaME often continue beyond the programme itself, supporting the integration of exercise into everyday routines, maintaining home exercise, and reinforcing the importance of staying active for life.  

3.6  Continuing professional development using Communities of Practice

Finally, we have provided information about continuous improvement through ‘Communities of Practice’. We found that PSIs often feel isolated in their practice and newly qualified instructors are often uncertain about things, but they have nobody to ask for support. At some sites in the FaME Ireland site, Communities of Practice were greatly appreciated, and perceived as a great forum for information sharing, problem solving and networking. We highly recommend them.

What is a Community of Practice? 

The term Community of Practice (CoP) was first used by Lave and Wenger in 1991, who gave examples of apprenticeships including midwives, naval quartermasters, and tailors, to demonstrate that learning occurs through the social interactions between individuals. They were referred to as “groups of people who share a concern, set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis. 

How are they organised?  

Communities of Practice are commonly present as part of the normal infrastructure in large organisations such as the HSE. There is currently an online community of practice for Irish PSIs in the North Northwest Region. In some settings, where there is no existing infrastructure, informal networks that are self-organised, and not purposefully set up, may emerge. Alternatively, local Communities of Practice may be newly initiated and developed by organisations and used as a tool to consciously manage knowledge in order to improve outcomes. This latter description probably best fits the Communities of Practice observed during previous FaME research. 

To establish these Communities of Practice, formal invites were sent out to the Postural Stability Instructors, their managers and the service managers to attend sessions of approximately 2 hours in duration. For one Community of Practice event, FaME participants were also invited, attended and contributed to the discussion. The agenda was varied but essentially addressed local successes and areas for improvement/trouble shooting. 

What benefit did they have? 

Analysis of the Community of Practice events revealed several useful functions and benefits.   

Communities of Practice: 

• Enabled shared learning regarding set up of the programme and how implementation problems had been overcome and supported the consistent implementation across multiple providers. 
• Provided a forum for problem solving, where the group members could ask each other questions and co-produce solutions, including with service users. 
• Provided an opportunity for the members to make suggestions of programme improvement, testing the feasibility of new ideas with each other and testing the acceptability of variations with service managers. 
• Provided peer support and so helped to reduce the feeling of isolation, of ‘going it alone’, that instructors working independently and remotely often can have. They helped to boost instructor confidence by aiding knowledge consolidation, particularly about any components of the sessions they were less confident about and identified opportunities for ongoing learning. 
• Provided a forum for service user engagement and feedback. 
• Fostered better communication and shared working across different localities. 

Over time, the Communities of Practice evolved from being commissioner-initiated to being instructor-led, and the content changed from being a forum to supporting programme set up to a forum for improving quality and sustainability. When asked if the Communities of Practice events were useful, participants were overwhelmingly positive with comments such as:  

“I certainly find them useful from my point of view, I think because I am probably that one step removed in a way from the delivery, and I think it has been really interesting to hear what has been going on in the localities”  

“They were useful because I think it was interesting to understand what is happening within other districts and some of the challenges that there are… and I suppose more than anything is that you’re not on your own, we’re all experiencing some of those challenges”