1. Webinar 2:Falls prevention and primary care partnerships Hosted by: Sandy Blake – Clinical Lead for the reducing harm from falls programme and Director of Nursing

2. Outline of webinar AgendaPresented by: Atlas of Healthcare Variation – Falls domain ₋Catherine Gerard, Evaluation Manager, HQSC Counties Manukau Community falls prevention in older people ₋Dr Shankar Sankaran, Chair of the Reducing Harm from Falls Expert Advisory Group, and Consultant Geriatrician/ Clinical Leader, Whole of Systems Health of Older People at Counties Manukau District Health Board ₋Melinda Gardner, Project Manager, Community Falls prevention in Older People, Counties Manukau Health Whanganui falls prevention and osteoporosis collaborative clinical pathway Whanganui Regional Health Network: ₋Julie Nitschke, Clinical Director Primary Care ₋Sharon Duff, Community Developer ₋Dr Rick Nicholson, General Practitioner

3. Atlas of healthcare variation Falls in people aged 50 and over Atlas looks at whether there is variation by DHB and opportunities for quality improvement: – People with one or more ACC claim for fall- related injury – Admissions following a fall – Hip fracture rates following a fall – Management: time to operation and medications for bone health

4. Atlases

5. Unwarranted variation Jack Wennberg: ‘Variation in the utilization of health care services that cannot be explained by variation in patient illness or patient preferences.’

6. Taxonomy of variation 1 Effective care Preference-sensitive care Supply-sensitive care Appleby, Raleigh, Frosini et al. Variations in health care: the good, the bad and the inexplicable. Kings Fund (2011).

7. This is not a league table High is not necessarily better Low may not be worse The middle might not be right Bisphosphonate on discharge following hip fracture

8. Indicators Rate/1,000 people who had one or more: – ACC claim for a fall-related injury – Hospital admission – Average bed days – Hip fracture – Time to surgery – Medications on discharge Sub-analyses by year (2011-2014), age, ethnicity and gender

9. View atlas and explain how to view and different ways of presenting the dataatlas

10. Key findings Age band ACC claims, rate per 1000 (count) Hospital admissions, rate per 1000 (count) Hip fracture, rate per 1,000 (count) 50–64 119 (99,900)6 (5,200)0.2 (178) 65–74 128 (48,000)11 (4,600)1.2 (460) 75–84 180 (35,000)38 (7,400)6.1 (1205) 85+ 283 (22,000)106 (8,100)23.3 (1800) Total 138 (205,000)17 (25,000)2.4 (3,600)

11. Key findings Of people aged 85+: 28% had an ACC claim in 2014 for a fall-related injury 11% were admitted to hospital Average LOS was 15.5 days Hip fracture: 50% were in those aged 85+ Women had twice the rate

12. Key findings – variation Average bed days (falls) Two-fold variation: NZ mean 11.2 days, range 7.3 – 14.7 days) Medications for bone health in 6 months following hip fracture: 21% dispensed bisphosphonate – Varied from 0% – 38% – Significant reduction since 2012 (mean 33%) 68% dispensed vitamin D – No significant variation

13. Key findings – update Rate of falls and hip fracture continue to increase in 85 and over age group Average length of stay continues to vary 2-fold The use of bisphosphonates varies more than 3-fold and has significantly decreased since 2012

14. These data raise questions Why do some DHBs have consistently higher rates? What impact might orthogeriatric services have on these data? What about Fracture Liaison Services?

15. Suggested actions In your DHB area: know your data – what’s your plan? Topic 10: 10 priorities in an integrated approach to falls in older people Falls Workbook: From Atlas to Action

16. Community falls prevention in older people An ACC and CMH Alliance collaborative April 2016

17. Falls and fracture care and prevention A road map for a systematic approach Hip fracture patients Objective 1: Improve outcomes and improve efficiency of care after hip fractures Non-hip fragility fracture patients Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care Individuals at high risk of 1 st fragility fracture or other injurious falls Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention Older people Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards Stepwise implementation - based on size of impact 1. DH Prevention Package for Older People

18. Context   ACC strategic direction “population systems based approach”   Health Quality & Safety Commission work 1. 1. In home strength and balance 2. 2. Group based community strength and balance 3. 3. Hip fracture registry 4. 4. Fracture Liaison Service 5. 5. Supported hospital discharge 6. 6. Service integration across primary and secondary care.

19. Funding   $408,202 per annum for 3 years   Critical components 1 and 2   Contribution.

20. Community programmes   Technical Advisory Group criteria   Separate ACC funding for a lead provider to support community programmes.

21. Background   Establishment of ACC and CMH falls prevention steering group: Primary care Secondary care ACC Management Consumer.

22. Our business case   Demonstrate readiness of CMH to support implementation   Confirm model of care and approach   Give confidence benefits and cost savings can be achieved   Recommend best utilisation of ACC funding.

23. Target groups 1. 1. Maori and Pacific Island people age 65-74 years of age and older enrolled with general practice, with a fall related ACC claim in the previous 12 months 2. 2. Age 75 years and older enrolled with general practice, with a previous fall related ACC claim in the previous 12 months 3. 3. Age 75 years and older and enrolled with general practice with no ACC claim guidelines 4. 4. Age 75 years and older enrolled on At Risk Individual programme.

24. Ask, Assess, Act

25. Programme reach EasternFranklinMangere/ Otara Manukau In-home strength and balance 169-22574-9883-111167-222 Community strength and balance 506-1,517221-663249-747501-1,503

26. Required programme capacity EasternFranklinMangere/ Otara Manukau Classes required per day for community programmes Minimum 3 Maximum 8 Minimum 2 Maximum 4 Minimum 2 Maximum 4 Minimum 3 Maximum 8

27. Implementation

28. Phased approach   Phase I indicative time-frame 01 July 2016-30 June 2017 - all referrals for in home and community strength and balance programmes will be through CMH general practices   Phase II indicative time-frame 01 July 2017 – referrals for in home and community strength and balance programmes will be through CMH general practices as well as secondary, EC, ED and St John services – ‘any door is the right door.’

29. Funding 1. 1. Population approach for general practice to undertake telephone screening of at risk groups 2. 2. In-home strength and balance programmes delivered by community locality physiotherapists and 3. 3. That a review of the funding allocation is undertaken at 1 year.

30. Stakeholder engagement   Integrated Clinical Care Governance Group   Primary Care Leadership Team   Locality General Managers   Alliance Leadership Team   ACC.

31. Webinar April 26 th

32. SOME WHANGANUI FACTS-2014 11 (10.9) new ACC falls claims a day from people aged over 50 years $2,157,749 paid in 2014 for active claims 70 fractured hips from those domiciled in Whanganui (more than one a week) Average length of stay in hospital for hip # is 11.3 days 86% # hips operated on same or next day In the 50-59 year age group, those that fell and sustained a # or dislocation – 8.34% (national 8.78%)

33. WHANGANUI 20 POINT WORK PLAN 2015-16 Within the 20 point work plan fracture liaison and falls prevention pathways were developed using co-design with consumers and A multidisciplinary team

34. COLLABORATIVE CLINICAL PATHWAY TEAM Consumers – Whanganui Regional Health Network HQSC - Clinical Lead Falls Prevention Program ACC - Community Injury Prevention Consultant GP - Clinical Lead Primary Health - Clinical lead Consultant - Orthogeriatrician Community Organisation – AgeConcern St John Ambulance – Regional Aged Care – Clinical Staff Occupational Therapist - DHB Physiotherapist – DHB Fragility Fracture Nurse – WDHB / WRHN

35. FALLS PREVENTION PATHWAY

36. OSTEOPOROSIS & FRAGILITY FRACTURE PATHWAY

37. ELECTRONIC INFORMATION TO GP PRACTICES An Electronic Patient Report Form (ePRF) – will be sent to GP’s after a health incident and will go live in April to GP’s Enable practices nurses to follow up falls risks St John will also be referring straight to Falls Team

38. DASHBOARD RED FLAG FOR FALLS RISK Patient Dashboard will identify at risk patients and give us a red flag when: – Patient aged 65+ – Patient must also have at least one of the following: An ACC45 submitted in the last year where one of the read codes recorded suggests a fracture 4 or more long term medications or classified with: Alcohol dependence, Problem Drinker, Stroke, Dementia, Motor Neurone Disease, Multiple Sclerosis, Osteo Arthritis, Osteoporosis, Parkinson's Disease

39. FALLS RISK ASSESSMENT

40. REFERRAL FORM

42. OUR SPECIALITY FALLS PREVENTION TEAM Falls Prevention Team based at WDHB Primary Health Occupational Therapist Primary Health Physiotherapist Physiotherapy assistant Falls Prevention Nurse Fragility and Fracture Service based at WDHB Fragility Fracture Nurse Ortho-geriatrician

43. OUR FALLS PREVENTION TEAM IN THE COMMUNITY Consumers - utilising services and being proactive Whanau /Family – supporting, promoting and referring GP Practices – identifying need, responding and referring Community Organisation – e.g. Age Concern providing Steady As You Go Programmes and Car Fit St John Ambulance – informing GP of risk Aged Care – identifying risk and referring to GP Equipment and alarms - home safety companies providing equipment and personal alarms Healthy homes – insulation and assistance for over 65 years Community pharmacists - providing medication reviews

44. EMPOWERING OUR OLDER PEOPLE Taking Responsibility Personal factors e.g. balance, strength, Environmental factors e.g. mats, cold rooms, poor lighting Exercises to improve leg strength, balance and body awareness Regular check-ups with GP - Vitamin D and review of medications Eye-sight checks each year Non slip, well-fitting shoes and slippers Check their home and garden for trip hazards – install handrails Work towards a warm and dry home

45. WHAT CAN PRACTICES CONTRIBUTE Opportunistic screening - DEXA scans if meet criteria Using the advanced form to refer patients to the fragility fracture nurse Medication reviews Providing information to enable patient to self manage such as green prescription or self help groups Referral to specialist

46. WHAT DOES THIS MEAN FOR OUR PEOPLE More healthcare professionals on their team Information that is easy to read and helpful Encouragement towards personal goals Knowledge of community support Partnership to reduce harm.

47. Thank you Questions? Please use the public chat feature