1. Champlain LHIN Fall Prevention Initiative

2. Champlain LHIN Fall Prevention Initiative
EMR Integration
Feedback from clinicians testing the Champlain Falls Prevention algorithm and Staying Independent Checklist told us that it was essential to make them a part of the EMR.
A great deal of work has been done with the Practice Solutions group to make this possible on the PS platform – with a go-live date in the near future – followed usage support with Nightingale on Demand.
Other clinicians wanted a method of communicating their assessment findings and interventions with other agencies to avoid duplication or gaps in the process.
A multifactorial draft work sheet based on the algorithm will be trialed with some community agencies in the fall of 2015 to gather their input.

3. BURDEN OF DISEASE
osteoporosis fractures are more common than MI, strokes and breast cancer combined
1 in every 3 women and 1 in every 5 men will sustain an osteoporosis related fracture in their lifetime
osteoporosis and its complications cost $2.1 billion in 2010 to the Canadian health care system

4. BURDEN OF DISEASE
there is 20,000-30,000 hip fractures in Canada every year
the cost of a hip fracture is estimated at more than $20,000 in the first year following the fracture and at more than $40,000 if the patient is institutionalized
following a fracture, less than 20 % of patients are evaluated for osteoporosis or receive appropriate treatment

5. BURDEN OF DISEASE 1/3 of patients age 65 and over fall once a year
1/4 of these falls will result in injuries
more than 90% of fractures in elderlies are due to falls
falls cost the province of Ontario $2.15 billion in 2004

6. BARRIERS
physicians are increasingly burdened with the complexity of patient care
time involvement in screening for risk of falls, assessment of risk factors for falls and modification/management of risk factors

7. REDUCING FALLS IN PRIMARY CARE
Screen for fall risks once per year in patients aged 65+
Conduct a comprehensive fall risk assessment to identify contributory causes and risk factors in those who have fallen
Implement multidisciplinary management strategies that target modifiable risk factors
Many of the risks identified are
REVERSIBLE!
Therefore, falls are often
PREDICTABLE and PREVENTABLE!

8. CHAMPLAIN LHIN FALL PREVENTION INITIATIVE Algorithm Development
Strategic regional approach to falls prevention across the Champlain LHIN geography, based on the 2011 provincial guidelines .
Review of literature → decision to use the American/British Geriatric Societies falls prevention algorithms with some augmentation .
Developed an algorithm and a detailed multi-factorial evaluation then piloted in primary/community care.
Evaluation of algorithm determined that the approach was effective in primary and community care practices with the recommendation to adapt to an EMR format.

9. CHAMPLAIN LHIN FALL PREVENTION INITIATIVE EMR Application
Opportunity: A regional collaboration initiated by a group of enthusiastic and action-oriented primary care representatives who use the same EMR already existed.
Engaged: with the LHIN on both the process and technology fronts.
Identified the algorithm as an opportunity worth pursuing and with support from the LHIN developed a proof of concept.
Approach chosen: “try it out” with an initial group of clinicians, obtain feedback, refine, and make more widely available to anyone who could benefit.

10. Presentation Highlights
Putting the Brakes on Breaks
The presentation will review several tools that were developed:
Fall Prevention, Champlain LHIN Fall Prevention Strategy
Fall screening algorithm
Multifactorial assessment
Incorporation of Osteoporosis Canada 2010 Guidelines
Bone Mineral Density screening
Use of reminders
Assessment of BMD result and fracture risk evaluation (CAROC, Frax)
Lifestyle modification
Adherence to therapy
Post fracture care management
Osteoporosis Foundation 13 Best Standards

13. See video

14. Screening for osteoporosis as per Osteoporosis Canada Guidelines
Appropriate screening with a BMD is an important step in identifying our patients that are at risk. By applying the Osteoporosis Canada 2010 guidelines, primary care providers can avoid unnecessary testing capturing patients that are at risk of fractures.
An often overlooked recommendation is to test not only women but also all men over age 65. While 1 in 10 men will suffer from osteoporosis compared to 1 in 4 women, men have double the rate of mortality at 1 year following a hip fracture (40% compared to 20% for women).
Reviewing Bone Density report and correcting fracture risk
The BMD report is non-patient specific and does not take into account other risk factors such as previous fragility fractures and use of corticosteroids. A correction based on the patient’s profile will provide a more accurate assessment of fracture risk. Several fracture risk tools have been developed, such as the FRAX and CARROC. One easy tool is the Osteoporosis Canada Fracture tool on fracture risk assessment.

15. Providing appropriate management for ALL patients
All patients should be counselled on dietary calcium recommendations, vitamin D supplementation and weight bearing exercises. Serum vitamin D levels are found to be low in the great majority of the Canadian population with some studies reporting 85% deficiency.
Below are links to Osteoporosis Canada recommendations for calcium intake.
There is also a fun tool patients can use to assess their dietary intake of calcium:
Calcium requirements
Calcium calculator
Exercise for healthy bones

16. Patients at moderate risk with additional risk factors and patients at high risk of fracture should be advised of pharmacotherapies to reduce risk of fracture
The choice of agent will depend on your patient’s profile and choices. A description of these with risk and benefits can be found at
Patients who sustained a fragility fracture should be advised of pharmacotherapies to reduce risk of fracture
Only 20% of patients who suffer from a fragility fracture are assessed for and have pharmacotherapy initiated. Again, the choice of agent will depend on the patient profile and patient’s choice.

17. Patients on pharmacotherapy should have appropriate review of adherence and success of the opted therapy
It is well known that adherence to osteoporosis medications is difficult for many patients. A quick call from your staff at 3 months and 12 months could enhance patients’ adherence and address difficulties encountered with the prescribed medication. This will allow for a discussion with your patient of other treatment options in a timely manner.
Repeat BMD testing should be done 1-2 years following initiation of treatment. Treatment success should be reviewed (0-3% gain in gm/cm2) and if further bone loss is identified other therapeutics options should be reviewed.

18. Leveraging the EMR can provide the necessary tools to achieve best practice results while being effective and efficient
Addition of reminders to screen all over 65 for risk of falls on a yearly basis
Addition of reminders when a fragility fracture or other risk factors are identified in the CPP
Addition of screening tools can improve the screening recommendations of patient under 65
Addition of an easy link to Osteoporosis Canada recommendations on calcium and Vitamin D to provide easy access to patient information resources
Addition of an easy link to tools that allows for improved analysis of the BMD and stratification of patients at risk
Addition of EMR tools that incorporates the algorithm from Osteoporosis Guidelines in the assessment of patients that may benefit from pharmacotherapy
Addition of delayed messages to assess adherence to therapy
Addition of delayed recall for repeat BMD testing to allow for the early capture of non-adherent patients
Addition of tools to easily identify patients who failed therapies

19. Falls Prevention Planning in Champlain
See articles published in Primary care Digest
Why it is important to have a falls prevention plan in Champlain
champlain/
Osteoporosis putting the brakes on breaks
A system change approach to falls prevention in Champlain
ttp://primarycaredigest.org/2015/04/13/a-system-change-approach-to-falls-prevention-in- champlain/
Supporting regional excellence in falls prevention a progress update
progress-update/
falls-prevention-planning-in-champlain-the-work-plan-for
work-plan-for /