1. Community Pharmacy Falls Prevention Service Claire Thomas MSc

2. Agenda  Update on the recommissioning of the service – key changes  Team Based Learning approach to improve knowledge of falls risk & prevention  Update from Age UK Doncaster  Advice on service delivery  Training for Level 2 pilot service (8 pharmacists only)

3. Aim  Enable you to provide high quality falls prevention consultations

4. By the end of this session you will be able to:  Understand key changes to the service  Define a fall  Describe the risk factors for falling  Discuss how medication can lead to falls  List ‘culprit/high risk’ medicines  Provide advice to people to reduce their risk of falls  Provide a falls prevention service

5. Falls What is a fall?

6. A fall is defined as:  ‘an event whereby an individual comes to rest on the ground or another lower level with or without loss of consciousness’ 2

7. Falls What are the consequences of falling?

8. Consequences of falling:  Serious injury: head injury/fracture  ‘Long-lie’  Death  Psychological  Loss of mobility  Increased dependency & disability  Impact on family/carers

9. Why provide this service? Nationally:  Cost to NHS >£2.3 billion annually 1  86,000 hip fractures annually 2 In Doncaster between Sept 2014 & Aug 2015 there were:  2,597 falls  1,935 admissions for fractures  £4,168,646 total cost of fractures

10. Key Changes to the Service  New Fee structure (tiered service)  Level 1 Basic Falls Risk Assessment  Level 2 (Pilot) Meds Optimisation  Electronic data recording  Prepopulation of referral forms  Option for domiciliary consultations

11. Patient aged 65+ on 3+meds/high risk meds agrees to Falls Prevention consultation (Level 1 service) Patient aged 65+ on 3+meds/high risk meds agrees to Falls Prevention consultation (Level 1 service) Leaflet and advice Complex patient (4+ meds) invited for & agrees to Medication Optimisation Review Level 2 (Pilot Scheme) See next slide for detail Complex patient (4+ meds) invited for & agrees to Medication Optimisation Review Level 2 (Pilot Scheme) See next slide for detail Fall in last 12 months? Referral to SFS + GP notified + advice & leaflet Non-complex patient. Other risk factors (e.g. continence/vision/balanc e problem) Non-complex patient. Other risk factors (e.g. continence/vision/balanc e problem) Community Pharmacy Falls Prevention Service Does patient meet SFS referral criteria? Signpost/refer to appropriate services or referred to GP + advice & leaflet Patient agrees to SFS referral Advice & leaflet Notify GP Advice & leaflet Notify GP No Yes No Yes No

12. TBL: Falls Risk & Prevention  3 questions to discuss in groups  5 mins to agree group answer  5 mins for debate

13. Falls Risk Factors  Falls history  Gait/balance deficit  Mobility impairment e.g. arthritis, PD.  Fear  Visual impairment  Cognitive impairment  Urinary incontinence  Home hazards  Medication  Certain medical conditions

14. Medication and Falls - Evidence  Use of multiple medicines  Anti-arrhythmics e.g. digoxin, amiodarone, beta- blockers, flecainide  Psychotropics i.e. antipsychotics, sedatives, benzodiazepines & antidepressants.

15. Medicine Use in Older People Ageing process - pharmacokinetic, pharmacodynamic & homeostatic changes:  Drug distribution  Altered receptor sensitivity  Reflex tachycardia  Balance  Thirst & hydration

16. Advice for Patients  Adequate calcium & vitamin D intake  Bone-protective medication adherence  Stop smoking  Avoid alcohol  Regular exercise  Minimize home hazards  Well fitting footwear & clothing  Regular eye tests  Use of hand rails/walking aids  What to do in the event of a fall

17. Falls Prevention Service Level 1  Basic Falls Risk Assessment  Identify patients at risk & provide interventions to prevent their first fall/fracture (primary prevention)  Identify patients who have already fallen & refer to SFS

18. Falls Prevention Service  Patient recruitment  Inclusion criteria  Falls risk assessment  Referral to Specialist Falls Service  GP notification form  Payment  Monitoring/evaluation

19. Patient Recruitment  Self referral  Presenting in pharmacy following a fall  Identified by dispensing staff  Identified by counter staff

20. Inclusion Criteria  ≥ 65yrs on 3 or more medicines  ≥ 65yrs & have fallen/been frightened of falling in the past 12 months  ≥ 65yrs & prescribed a ‘culprit/high risk’ medicine  Patients referred to the pharmacy by another healthcare professional

21. Falls Prevention Consultation  Register patient on PharmOutcomes  Complete Falls Risk Assessment checklist on PharmOutcomes  Provide lifestyle advice & leaflet  Print SFS referral form or GP notifcation where appropriate

22. Specialist Falls Service Referral Refer patients who:  Have had a fall in the past year  That is not a one off accidental slip/trip Fax referral form with copy of checklist

23. GP Notification Form Types of issues appropriate to include:  Frequent side effects  Sign posted to optician  Continence problems  Balance/gait problems  Previous fragility fracture but no bone protection  Compliance issues with bone protection medication

24. Pharmacist Interventions  Advice on managing side effects  Patients who have fallen referred  Patients with vision problems sign posted  Identification of & support with compliance issues to bone protection therapy  Falls and fracture prevention advice

25. Payment & Monitoring  £17.50 per consultation  Additional £56 if domiciliary service  Paid monthly for number of consultations undertaken  Claims generated through PharmOutcomes  Activity/performance monitored by commissioners using PharmOutcomes

26. Tips for providing the service  Engage your pharmacy team  Engage with local GP practices  Use the checklist  Remember to ask about OTC medicines  Provide prevention advice & leaflet  Encourage patients to inform family, carers & HPs if they do fall

27. Summary Falls & fall-related injuries are a common, serious, costly & often preventable problem. By providing this service you can help improve the primary prevention of falls in Doncaster and help your patients live independently for longer.

28. References 1. National Institute for Health & Care Excellence. Clinical Practice Guideline 161 Falls: assessment & preventtion of falls in older people. London: 2013 2. National Institute for Clinical Excellence. Clinical Practice Guideline for the assessment and prevention of falls in older people. Clinical Practice Guidelines. London: Royal College of Nursing 2004.

29. Additional Resources  Falls: assessment and prevention in older people. NICE guideline 161 available at: http://www.nice.org.uk/guidance/cg161 http://www.nice.org.uk/guidance/cg161  Age UK www.ageuk.org.ukwww.ageuk.org.uk  Doncaster LPC: http://psnc.org.uk/doncaster-lpc/http://psnc.org.uk/doncaster-lpc/