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Falls Clinics – An Evolving Model of Care for High Risk Fallers

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Presentation on theme: "Falls Clinics – An Evolving Model of Care for High Risk Fallers"— Presentation transcript:

1 Falls Clinics – An Evolving Model of Care for High Risk Fallers
Dr Katherine Lucero Geriatrician Royal Adelaide Hospital Diana Pignata OT, Central and Northern Community Falls Prevention Team

2 An Evolving Model of Care
Introduction

3 Falls Most falls are multi-factorial
The terms ‘simple’ and ‘mechanical’ falls are misnomers and do not reflect the complexity of falls Multi-factorial interventions in falls clinics have been shown to reduce falls and falls related injuries in older people* *Hill K et al. Effectiveness of Falls Clinic: an evaluation of outcomes and client adherence to recommended interrventions. JAGS 2008

4 Background In 2008, a regional falls prevention program was established in Central Northern Adelaide Health Service (CNAHS) Early objectives included: Establishing a new multi-disciplinary Falls Clinic at Day Rehabilitation Centre (DRC), Hampstead Rehabilitation Centre Providing a multi-disciplinary team to existing Falls Clinic at TQEH

5 Pre-Implementation When planning the design of our Falls Clinics, we were guided by: Experience by Geriatricians at RAH and TQEH, staff at Falls Prevention team Reviewing Falls Clinics Repatriation General Hospital Bundoora, Melbourne ANZFP Conference Melbourne 2008 Information gathered by the Victorian Falls Clinic Coalition Research articles and publications

6 Falls Clinic

7 Multidisciplinary Team
Occupational therapy Nurse Case Conference Geriatrician Geriatrics Registrar Physiotherapy

8 Referral Criteria Age 65 years or older Falls
>45 years for Aboriginal/Torrens Strait Islander Falls 2 or more falls in the past 12 months or 1 fall with a serious injury Living in the CNAHS region Multiple co-morbidities Not currently in a multidisciplinary program Medically stable

9 Community service provider
Referral process FALLS CLINIC Assessment Education and advice Recommendations to GP Referral for home assessment Referral for Falls and Balance program Referral to community services Review Emergency Department Hospitals: Acute admission Outpatient Triage GP Community service provider

10 Falls risk factors Cardiovascular Depression/Anxiety Fear of falling
Vision Neurological Balance FALLS Musculoskeletal Environmental Nutrition Continence Polypharmacy

11 Cardiovascular Falls Risk Factors Clinic Assessment Arrhythmia
History and examination Valvular heart disease Smoking history Ischaemic heart disease Postural blood pressure Postural hypotension ECG Carotid sinus hypersensitivity Endocrine disorders Falls Clinic Recommendations Investigations, specialist referrals Medication review

12 Neurological Falls Risk Factors Clinic Assessment Parkinson’s History
Stroke Examination Dementia Cognitive assessment Anxiety/Depression Geriatric Depression Scale Fear of falling Falls Efficacy Scale Seizures Falls Clinic Recommendations Investigations Referral to Neurologist, Memory Clinic, psychiatrist, psychologist, community support

13 Nutrition/Continence
Falls Risk Factors Clinic Assessment Malnutrition, weight loss History, examination Constipation Body mass index Alcohol Mini-nutritional assessment Urinary incontinence Continence assessment Chronic GI, renal disease Falls Clinic Recommendations Investigations, specialist referrals Dietitian review, RDNS for continence support

14 Musculoskeletal Falls Risk Factors Clinic Assessment Osteoporosis
History Vitamin D deficiency Examination Arthritis Spinal conditions Muscle weakness Sensory abnormality Falls Clinic Recommendations Osteoporosis screen Referral to Falls and Balance program

15 Vision assessment Falls Risk Factors Clinic Assessment Bifocal lenses
History Uncorrected refractive error Examination Cataracts Visual fields Glaucoma Visual acuity Macular degeneration Contrast Sensitivity (MET) Diabetic eye complications Falls Clinic Recommendations Advice on corrective lenses, referral to low vision centre Optometry, ophthalmology referrals

16 Environmental Factors
Assessment Home hazard Community services Modified Barthel’s index Home visit Community transport Falls Clinic Recommendations Home safety assessment, modifications, information on personal alarm Referral to community services, ACAT

17 Gait, balance, footwear Assessment Examination Sensation Rhomberg’s
Tandem Single leg stance Timed up and go 5x sit-stand Footwear Podiatry input Falls Clinic Recommendations Advice on gait aid, footwear, hip protectors Podiatry, orthotics Referral to Falls and Balance program

18 Medication Review Falls Clinic Recommendations Reducing polypharmacy
Educating patient, RDNS supervision, Webster Pack

19 Multidisciplinary Team
Occupational therapy Nurse Case Conference Geriatrician Geriatrics Registrar Physiotherapy

20 Community service provider
Recommendations REVIEW Telephone and/or clinic Falls History Compliance with recommendations Home safety assessment and modifications Falls and Balance program Community services GP/Specialist Community service provider Patient

21 An Evolving Model of Care
2011 and beyond

22 Falls Clinic Milestones
July TQEH Elizabeth DRC Modbury Pre implementation Clinics were commenced as soon as possible at the end of 2008, with a very busy time of development, liaison and relationship building, educational falls network development, resource sharing and continual falls clinic processes refinement during 2009 and The Elizabeth clinic and Modbury Clinics opened in this year. 22

23 Early Days Activate Referral Attend Clinic for assessment
Make recommendations and communicate to GP Check recommendations in place

24 Later Days Activate Referral
Triage and link with most appropriate service Attend Clinic for assessment Refine and value add to assessment Prioritise recommendations and provide more sophisticated service planning Make recommendations and communicate to GP Check recommendations in place Care Facilitation

25 Versatility Home Screening Option Booking Versatility
for individuals who are unable to tolerate a full clinic appointment Service Response: prioritisation around level of risk and urgency Booking takes into account suitable days/ dates and proximity to home Versatility Hospital OPD, Community rehab, GP plus centres

26 Clinic Locations 26

27 Relationships Local agencies and health professionals Host sites
Networking and health promotion activities Geriatricians Building of relationships has been an integral component to the model that has developed in Falls Prevention

28 If we imagined the Falls Program Clinical Operations to look like this
If we imagined the Falls Program Clinical Operations to look like this. The clinics work in the green areas. Referrals currently coming in via the 3 bottom portals, all being triaged in the same way. An average of 56% of Falls Clinic referrals are actually seen at the clinics, 36% of those from SAAS and a mixed pattern from the 1300 no.

29 Clinic Outcomes

30 Service refinement and benchmarking can take place due to:
The larger relative numbers Common triage process, MOC, staffing, assessment measures and care planning Measure of outcomes and KPI’s at regular intervals With the significant number of referrals we are able to work on a continuous refinement of services, and further benchmarking is possible because…we maintain a common

31 Referral Sources The referrals from GPs and the community sector increased in 2010 as our relationships increased in the community with the falls network providing regular education and information, with regular liaison with different community services and closer liaison with GPs and their practices occurred Also in 2010 the emergence of referrals from SAAS begins.

32 Referral Numbers An increase of referral numbers each year can be noted. With spikes in referrals likely to be attributed to seasonal variation (wet conditions, less strength in reduced Vit D conditions in winter and so on) as well as possible service promotions eg falls service directory launch

33 Triage Outcomes In 2009 many clients found their way to the clinics as the simpler model of referral and triaging occurred. In 2010 a larger number of referrals were processed, however the percentage attending the clinics became fewer as we had developed more refined triaging skills. The use of alternate pathways to meet clients needs increased. The declined client group are those who decline to attend, information is sent to both the client and their GP wherever possible. The deceased number indicates the frailty , medical condition and age of the high risk fallers that make up this client group Which fits in with the continuum of care to link elderly patients into the services and linkages this is consistent with noted best practice and outcomes for older patients with complex needs. Clients who have recently seen a geriatricians are mostly likely to be linked to alternate pathway rather than been seen by our Geri again.. . This is an interesting group which we have not followed up. The Victorian Falls Clinic coalition are wanting too investigate this group, and our rates are not dissimilar too theirs. 67% x 220= 150 51% x 382 = 194

34 Acute Services Utilisation has been looked at.
Falls related data 6 months pre clinic and 6 months post clinic indicated a 74% reduction in falls related ED presentations. For hospital admissions there was a 65% reduction and for hospital bed stay a 44% reduction. Data was collected on ED presentations, hospital admission rates and length of stay from an electronic public health system. Qualitative data including client reports of falls and interventions was also collected at follow up reviews

35 Summary

36 How Falls Clinics Fit Falls clinics form one component of a vast array of services and systems to support clients at risk of falls and fall injury. They are suited to older people who present with a high number of falls risk factors and co morbidities. The clinics are supported by and are dependent on the services which operate to address falls and falls injury risk factors.

37 Falls are multi-factorial and need a multi-disciplinary approach.
Falls Clinics have evolved from a finite care episode to a care continuum method. Triage, support, assessment, service planning, service linkage, communication with care providers and care facilitation have become part of our clinic model. The service is flexible. Ongoing refinement and evolution is inevitable as a result of evaluation and the health reform process.

38 Acknowledgements

39 Staff Administration Occupational therapy Janine Heading Diana Pignata
Nurse Joachim Krack Physiotherapy Gill Bartley, Program Manager Marina Vuckov Margaret Sullivan Marlena Esposito Yi Fabris Geriatricians (TQEH) Renuka Visvanathan Solomon Yu Kandiah Parasivam Occupational therapy Diana Pignata Lauren Woodford Alison Ryan Ashleigh Scollin Geriatricians (RAH) Katherine Lucero Alice Bourke Ashlesha Vaidya Geriatrics Registrars (RAH) Miranda Lam Clare Haylock 2010 Sally Johns 2010

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