1. Interprofessional Population Health Session: Fall Prevention in Older Populations
Kim Oosterhouse PhD, RN, CCRN-K, CNE
Kimi Suh MD, MPH, FAAFP
Jessica McIntyre MD, FAAFP
GNUR: 290 CONCEPTS IN OLDER ADULT HEALTH PATIENT CENTERED MEDICINE - 1

2. Learning Objectives
1) Describe the public health and individual significance of falls in older patients 2) Discuss risk factors for falls 3) Understand how fall risk is assessed, using evidence-based screening strategies (Stay Independent Brochure, Timed Up and Go, The 30 second chair stand, and the 4 Stage balance test) 4) Collaborate interprofessionally to identify strategies and create an evidence-based falls prevention plan

3. Why are we here together?
Population Health - The health outcomes of a group of individuals, including the distribution of such outcomes within the group". It is an approach to health that aims to improve the health of an entire human population.
Interprofessional Learning - When two or more professions learn with, from and about each other to improve collaboration and the quality of care of patients
PCM-1: Focus on USPSTF recommendations (health promotion), understanding screening and prevention of important public health topics, evidence-based tools
GNUR: Curriculum on falls, focus on evidence-based screening tools

4. Interprofessional Working Groups
Take minutes as a small group to discuss
1. Names and school – after everyone is introduced, someone from each school (nursing, medicine, dietetics) share what training is/will be like
 What are important qualities for an interprofessional health care team to have in order to provide the best patient care?
What may be barriers to effective interprofessional care?
Medical students – what is your understanding of the nursing/dietician role and value to the healthcare team?
Nursing students – what is your understanding of the dietician/physician role and value to the healthcare team?
Dietetic students – what is your understanding of the nursing/physician role and value to the healthcare team?
Clarification of roles?

5. Population Health
C. Kimi Suh, MD, MPH, FAAFP

6. Population Health
Population health can be defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” -multiple definitions -social determinants of health, health equity and multi-level interventions
Kindig D, Stoddart G (March 2003). "What is population health?" (PDF). American Journal of Public Health. 93 (3): 380–3.

7. Falls: A significant preventable public health concern
One of the most important geriatric syndromes and the leading cause of morbidity and mortality for people older than 65 years of age
Leading cause of both fatal and nonfatal injuries
Falls are a significant public health problem
In 2010, over 20,000 people 65 and older died from injuries related to unintentional falls

8. Falls are Costly
In 2015, total medical costs for falls totaled more than $50 billion.

9. U.S Census Bureau Adults >65:
Baby boomers are aging
U.S Census Bureau Adults >65:
2000: 34.8 million
2020: 54 million
2040: 77 million
Starting in 2011 baby boomers began turning 65 at a rate of 10,000 a day and will continue to do so until 2029.

10. Those who fall once are 2-3 times more likely to fall again

11. USPSTF Recommendation

12. The Elderly- A Critical and Vulnerable Population
Often overlooked population
Current elder-support services are not adequate
Hospital Systems driven towards value-based care of populations rather than fee-for-service care for individuals
Hospital acquired conditions (HACs) not covered under Medicare
Need for evidence- based tools and interventions for fall prevention

13. What can be done? Two-thirds of falls may be preventable
CDC’s STEADI: Stopping Elderly Accidental Deaths and Injuries
Screen patients for fall risk
Assess modifiable risk factors
Intervene using clinical and community strategies

14. Evidence Based Interventions
CDC Compendium, 2015
Multifaceted
Exercise
Tai Chi, balance/strengthening exercise programs
Home
Environmental evaluation for safety
Clinical
Polypharmacy, Neuropathy, Vision, Vitamin D

15. Kim Oosterhouse PhD, RN, CCRN-K, CNE
Determining Risk for Falls: Understanding Evidence-Based Fall Risk Assessments
Kim Oosterhouse PhD, RN, CCRN-K, CNE

16. Normal Changes with Aging
Musculoskeletal
Slower reflexes
Bone resorption > formation
Joint & ligament stiffness
Decreased muscle fibers
Cardiovascular
Decreased baroreceptor sensitivity
Auditory
Decline in vestibular function
Visual
Decreased accommodation
Changes in visual acuity
Decreased contrast sensitivity

17. Fall Risk Factors Environmental Disease Medications
Psychosocial (lifestyle)

18. High Risk Prior falls* Fear of falling
Number of chronic condition pain sites*
Parkinson’s disease*
Pain (any)*
Use of walking aid*
Gait deficit*
Vertigo
Anticonvulsants
Fall Risk Increasing Drugs (FRIDs)
*Risk more than doubled
Reuben, D. B., Herr, K. A., Pacala, J. T., Pollock, B. G., Potter, J. F., & Semla, T. P. (2018). Geriatrics at your fingertips. New York: American Geriatrics Society.

19. Assessment History of falls Medications Muscle strength
Gait, balance, mobility
Visual acuity
Neurologic impairment
Heart rate and rhythm
Orthostatic hypotension
Feet and footwear
Environmental hazards
Recommendations from 2011 American Geriatric Society and British Geriatric Society

20. Orthostatic & Postprandial Hypotension
Take BP and HR after 5 minutes in supine position
Move to sitting position; assess for dizziness. Take BP and HR after 1 minute
Move to standing; assess for dizziness. Take BP and HR after 1 and 3 minutes
Drop in SBP>=20 mmHg and or DBP>=10 mmHg is considered orthostatic hypotension
Take BP and HR prior to eating a meal
Take BP and HR in the same position every 10 minutes until 60 minutes after the meal
Drop in SBP>20 mmHg is considered postprandial hypotension

21. Consequences of Falls Hip Fractures Traumatic Brain Injury (TBI)
95% of hip fractures are caused by falls
Hip fractures are associated with considerable morbidity and mortality
Traumatic Brain Injury (TBI)
Persons over the age of 75 years have the highest rates of TBI-related hospitalization and death
Falls are the leading cause of TBI for older adults
Fallophobia
Fear of falling is an important predictor of general functional decline and risk factor for future falls
Disability
Functional decline

22. DEMONSTRATING FALL RISK ASSESSMENT TOOLS
Stay Independent Brochure
The 30-Second Chair Stand
4-Stage Balance Test
Timed Up and Go

23. Fall Risk Assessment Tools in the EHR
Morse Fall Scale
The Hendrich II Fall Risk Model
Others used as well
Identify the tool used and become familiar with it

24. SnapShot: Patient Overview

25. Ambulatory Setting, Fall Risk

26. Inpatient, Fall Risk

27. Fall Risk Score

28. Fall Risk Score

29. Communicate Risk, Decision Support

30. Post-Fall Assessment Purpose Components of a post-fall assessment
Determine underlying fall etiologies so that appropriate plans of care can be instituted
Identify the clinical status of the person, verify and treat injuries, identify underlying causes, and assist with risk reduction interventions
Components of a post-fall assessment
Fall-focused history, fall circumstances, medical problems, medication review, mobility assessment, vision and hearing assessment, neurological examination, and cardiovascular examination

31. Group Case Discussion Mrs. Parker Mr. Ying
What fall risk factors do you identify for this patient?
What are fall prevention strategies that you recommend? (medical and community based)
Based on your (future) professional role, what prevention strategies might you emphasize or take responsibility for? How might these recommendations overlap between professions?
What other members of the healthcare team may be involved in fall prevention? How?

32. Fall Prevention Programs
A Matter of Balance
CAPABLE
EnhanceFitness
FallsTalk / FallScape
Fit & Strong!
Healthy Steps in Motion
Healthy Steps for Older Adults
Otago Exercise Program
Stay Active and Independent for Life (SAIL)
Stepping On
Stay Safe, Stay Active
Tai Chi for Arthritis
Tai Ji Quan : Moving for Better Balance
YMCA Moving for Better Balance

33. Take home points (for the exam )