Clinical-community linkages as a strategy for increasing evidence-based program reach: Results of the PT-REFER randomized controlled trial with older adults and YMCA associations

Background: Most older adults do not meet recommended guidelines for physical activity. Referrals from physical therapists (PTs) to community- and evidence-based physical-activity programs like Enhance (R) Fitness have potential to address this gap. We tested an intervention intended to increase referrals of older adults to Enhance (R) Fitness programs offered at YMCAs. Materials and methods: We developed a capacity-building intervention that included a structured toolkit and technical-assistance calls. From April 2016 to September 2018, using stratified randomization, we conducted a trial with 20 YMCA Associations randomized into intervention and control arms. The primary outcome was the number of new Enhance (R) Fitness enrollees during the trial period. Using both quantitative and qualitative methods, we also conducted process and intermediate-outcome evaluations to assess intervention implementation and Association outreach activities, barriers, and facilitators. Results: The intervention was implemented as intended, but PT outreach was similar for both intervention and control YMCA Associations. The intervention arm had similar enrollment (1695 new enrollees) to the control arm (1326 new enrollees; 95% confidence interval, -47%-199%, P = 0.61). Interviews revealed that barriers, including lack of staff and time for outreach, limited capacity for Enhance (R) Fitness program growth, and competing priorities, outweighed facilitators, including existing partnerships, presence of an outreach team, senior leadership support, and infrastructure for referrals. Conclusions: YMCA Associations in the intervention arm were unable to increase their outreach to PTs and enrollment in Enhance (R) Fitness. Our evaluation findings indicate that community organizations that prioritize program growth, have support at all organizational levels, and allocate staff and time for outreach and partnership development may be more successful in creating sustainable linkages with clinical partners and increasing evidence-based-program reach.