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Dr Katherine Lucero Geriatrician Royal Adelaide Hospital Diana Pignata OT, Central and Northern Community Falls Prevention Team Falls Clinics – An Evolving.

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Presentation on theme: "Dr Katherine Lucero Geriatrician Royal Adelaide Hospital Diana Pignata OT, Central and Northern Community Falls Prevention Team Falls Clinics – An Evolving."— Presentation transcript:

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

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 NurseOccupational therapy Physiotherapy Geriatrician Geriatrics Registrar Case Conference

8 Referral Criteria Age 65 years or older >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 Referral process Emergency Department Hospitals: Acute admission Outpatient GP Community service provider Triage FALLS CLINIC Assessment Education and advice Recommendations to GP Referral for home assessment Referral for Falls and Balance program Referral to community services Review

10 Falls risk factors VisionCardiovascular Balance Musculoskeletal FALLS Neurological Environmental NutritionPolypharmacyContinence Depression/Anxiety Fear of falling

11 Cardiovascular Falls Risk FactorsClinic Assessment ArrhythmiaHistory and examination Valvular heart diseaseSmoking history Ischaemic heart diseasePostural blood pressure Postural hypotensionECG Carotid sinus hypersensitivity Endocrine disorders Falls Clinic Recommendations Investigations, specialist referrals Medication review

12 Neurological Falls Risk FactorsClinic Assessment ParkinsonsHistory StrokeExamination DementiaCognitive assessment Anxiety/DepressionGeriatric Depression Scale Fear of fallingFalls Efficacy Scale Seizures Falls Clinic Recommendations Investigations Referral to Neurologist, Memory Clinic, psychiatrist, psychologist, community support

13 Nutrition/Continence Falls Clinic Recommendations Investigations, specialist referrals Dietitian review, RDNS for continence support Falls Risk FactorsClinic Assessment Malnutrition, weight lossHistory, examination ConstipationBody mass index AlcoholMini-nutritional assessment Urinary incontinenceContinence assessment Chronic GI, renal disease

14 Musculoskeletal Falls Risk FactorsClinic Assessment OsteoporosisHistory Vitamin D deficiencyExamination Arthritis Spinal conditions Muscle weakness Sensory abnormality Falls Clinic Recommendations Osteoporosis screen Referral to Falls and Balance program

15 Vision assessment Falls Risk FactorsClinic Assessment Bifocal lensesHistory Uncorrected refractive errorExamination CataractsVisual fields GlaucomaVisual acuity Macular degenerationContrast 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 Barthels 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 Rhombergs 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 NurseOccupational therapy Physiotherapy Geriatrician Geriatrics Registrar Case Conference

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

21 An Evolving Model of Care 2011 and beyond

22 Falls Clinic Milestones July TQEH Elizabeth DRC Modbury Pre implementation

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

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

25 Versatility Home Screening Option 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

27 Relationships Local agencies and health professionals Host sites Networking and health promotion activities Geriatricians

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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 KPIs at regular intervals

31 Referral Sources

32 Referral Numbers

33 Triage Outcomes

34 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 Janine Heading 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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