3Falls Most falls are multi-factorial The terms ‘simple’ and ‘mechanical’ falls are misnomers and do not reflect the complexity of fallsMulti-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
4BackgroundIn 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 CentreProviding a multi-disciplinary team to existing Falls Clinic at TQEH
5Pre-ImplementationWhen planning the design of our Falls Clinics, we were guided by:Experience by Geriatricians at RAH and TQEH, staff at Falls Prevention teamReviewing Falls ClinicsRepatriation General HospitalBundoora, MelbourneANZFP Conference Melbourne 2008Information gathered by the Victorian Falls Clinic CoalitionResearch articles and publications
7Multidisciplinary Team Occupational therapyNurseCase ConferenceGeriatricianGeriatrics RegistrarPhysiotherapy
8Referral Criteria Age 65 years or older Falls >45 years for Aboriginal/Torrens Strait IslanderFalls2 or more falls in the past 12 months or1 fall with a serious injuryLiving in the CNAHS regionMultiple co-morbiditiesNot currently in a multidisciplinary programMedically stable
9Community service provider Referral processFALLS CLINICAssessmentEducation and adviceRecommendations to GPReferral for home assessmentReferral for Falls and Balance programReferral to community servicesReviewEmergency DepartmentHospitals:Acute admissionOutpatientTriageGPCommunity service provider
10Falls risk factors Cardiovascular Depression/Anxiety Fear of falling VisionNeurologicalBalanceFALLSMusculoskeletalEnvironmentalNutritionContinencePolypharmacy
16Environmental Factors AssessmentHome hazardCommunity servicesModified Barthel’s indexHome visitCommunity transportFalls Clinic RecommendationsHome safety assessment, modifications, information on personal alarmReferral to community services, ACAT
17Gait, balance, footwear Assessment Examination Sensation Rhomberg’s TandemSingle leg stanceTimed up and go5x sit-standFootwearPodiatry inputFalls Clinic RecommendationsAdvice on gait aid, footwear, hip protectorsPodiatry, orthoticsReferral to Falls and Balance program
19Multidisciplinary Team Occupational therapyNurseCase ConferenceGeriatricianGeriatrics RegistrarPhysiotherapy
20Community service provider RecommendationsREVIEWTelephone and/or clinicFalls HistoryCompliance with recommendationsHome safety assessment and modificationsFalls and Balance programCommunity servicesGP/SpecialistCommunity service providerPatient
22Falls Clinic Milestones JulyTQEH ElizabethDRC ModburyPre implementationClinics 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
23Early Days Activate Referral Attend Clinic for assessment Make recommendations and communicate to GPCheck recommendationsin place
24Later Days Activate Referral Triage and link with most appropriate serviceAttend Clinic for assessmentRefine and value add to assessmentPrioritise recommendations and provide more sophisticated service planningMake recommendations and communicate to GPCheck recommendationsin placeCare Facilitation
25Versatility Home Screening Option Booking Versatility for individuals who are unable to tolerate a full clinic appointmentService Response:prioritisation around level of risk and urgencyBookingtakes into account suitable days/ dates and proximity to homeVersatilityHospital OPD, Community rehab, GP plus centres
27Relationships Local agencies and health professionals Host sites Networking and health promotion activitiesGeriatriciansBuilding of relationships has been an integral component to the model that has developed in Falls Prevention
28If 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.
30Service refinement and benchmarking can take place due to: The larger relative numbersCommon triage process, MOC, staffing, assessment measures and care planningMeasure of outcomes and KPI’s at regular intervalsWith 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
31Referral SourcesThe 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 occurredAlso in 2010 the emergence of referrals from SAAS begins.
32Referral NumbersAn 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
33Triage OutcomesIn 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 groupWhich 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= 15051% x 382 = 194
34Acute 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
36How Falls Clinics FitFalls 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.
37Falls 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.