A Pragmatic Application of the RE-AIM Framework for Evaluating the Implementation of Physical Activity as a Standard of Care in Health Systems

Abstract

Introduction: Exercise is Medicine (EIM) is an initiative that seeks to integrate physical activity assessment, prescription, and patient referral as a standard in patient care. Methods to assess this integration have lagged behind its implementation.

Purpose and objectives: The purpose of this work is to provide a pragmatic framework to guide health care systems in assessing the implementation and impact of EIM.

Evaluation methods: A working group of experts from health care, public health, and implementation science convened to develop an evaluation model based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. The working group aimed to provide pragmatic guidance on operationalizing EIM across the different RE-AIM dimensions based on data typically available in health care settings.

Results: The Reach of EIM can be determined by the number and proportion of patients that were screened for physical inactivity, received brief counseling and/or a physical activity prescription, and were referred to physical activity resources. Effectiveness can be assessed through self-reported changes in physical activity, cardiometabolic biometric factors, incidence/burden of chronic disease, as well as health care utilization and costs. Adoption includes assessing the number and representativeness of health care settings that adopt any component of EIM, and Implementation involves assessing the extent to which health care teams implement EIM in their clinic. Finally, Maintenance involves assessing the long-term effectiveness (patient level) and sustained implementation (clinic level) of EIM in a given health care setting.

Implications for public health: The availability of a standardized, pragmatic, evaluation framework is critical in determining the impact of implementing EIM as a standard of care across health care systems.

Figure 1

The clinical phase of the EIM Solution. Steps 1 through 3 of the EIM Solution take place primarily in the clinic setting and involve patients having their physical activity levels assessed, receiving brief counseling from a member of the health care team and/or receiving a semi-customized physical activity prescription, and receiving a referral to EIM network of physical activity resources. In some health systems, patients may also interact with, or be referred to, an intervention advisor. The role of the intervention advisor could include behavior change counseling and connecting the patient to the EIM network of physical activity resources. Dashed lines indicate an indirect or alternative pathway. The gray box indicates the community phase of the EIM Solution. Abbreviation: EIM, Exercise is Medicine.

Figure 2

The “community” phase of the EIM Solution. The fourth step of the EIM Solution involves the linkage of patients from health care systems to a supportive network of physical activity programs, places, and professionals. These EIM networks may be developed by using existing programs and professionals internally within a health system or externally in the community setting or connecting patients to resources for self-directed management. The dashed lines indicate alternative pathways. Abbreviation: EIM, Exercise is Medicine. [A text version of this figure is also available.]