Transcript SA Health PowerPoint Template

Falls Clinics –
An Evolving Model of Care
for High Risk Fallers
Dr Katherine Lucero
Geriatrician
Royal Adelaide Hospital
Diana Pignata OT,
Central and Northern Community Falls Prevention Team
An Evolving Model
of Care
Introduction
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
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
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
Falls Clinic
Multidisciplinary Team
Occupational therapy
Nurse
Case Conference
Geriatrician
Geriatrics Registrar
Physiotherapy
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
Referral process
FALLS CLINIC
Emergency
Department
Assessment
Education and advice
Hospitals:
Acute admission
Outpatient
Recommendations to GP
Triage
GP
Community service
provider
Referral for home
assessment
Referral for Falls and
Balance program
Referral to community
services
Review
Falls risk factors
Cardiovascular
Depression/Anxiety
Fear of falling
Neurological
Vision
Balance
FALLS
Musculoskeletal
Nutrition
Environmental
Continence
Polypharmacy
Cardiovascular
Falls Risk Factors
Clinic Assessment
Arrhythmia
History and examination
Valvular heart disease
Smoking history
Ischaemic heart disease
Postural blood pressure
Postural hypotension
ECG
Carotid sinus hypersensitivity
Endocrine disorders
Falls Clinic Recommendations
Investigations, specialist referrals
Medication review
Neurological
Falls Risk Factors
Clinic Assessment
Parkinson’s
History
Stroke
Examination
Dementia
Cognitive assessment
Anxiety/Depression
Geriatric Depression Scale
Fear of falling
Falls Efficacy Scale
Seizures
Falls Clinic Recommendations
Investigations
Referral to Neurologist, Memory Clinic, psychiatrist,
psychologist, community support
Nutrition/Continence
Falls Risk Factors
Clinic Assessment
Malnutrition, weight loss
History, examination
Constipation
Body mass index
Alcohol
Mini-nutritional assessment
Urinary incontinence
Continence assessment
Chronic GI, renal disease
Falls Clinic Recommendations
Investigations, specialist referrals
Dietitian review, RDNS for continence support
Musculoskeletal
Falls Risk Factors
Clinic Assessment
Osteoporosis
History
Vitamin D deficiency
Examination
Arthritis
Spinal conditions
Muscle weakness
Sensory abnormality
Falls Clinic Recommendations
Osteoporosis screen
Referral to Falls and Balance program
Vision assessment
Falls Risk Factors
Clinic Assessment
Bifocal lenses
History
Uncorrected refractive error
Examination
Cataracts
Visual fields
Glaucoma
Visual acuity
Macular degeneration
Contrast Sensitivity (MET)
Diabetic eye complications
Falls Clinic Recommendations
Advice on corrective lenses, referral to low vision centre
Optometry, ophthalmology referrals
Environmental Factors
Assessment
• Home hazard
• Community services
• Modified Barthel’s index
• Home visit
• Community transport
Falls Clinic Recommendations
Home safety assessment, modifications, information on
personal alarm
Referral to community services, ACAT
Gait, balance, footwear
Assessment
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•
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Examination
Sensation
Rhomberg’s
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
Medication Review
Falls Clinic Recommendations
Reducing polypharmacy
Educating patient, RDNS supervision, Webster Pack
Multidisciplinary Team
Occupational therapy
Nurse
Case Conference
Geriatrician
Geriatrics Registrar
Physiotherapy
Recommendations
REVIEW
GP/Specialist
Telephone and/or clinic
Falls History
Community service
provider
Patient
Compliance with
recommendations
Home safety assessment
and modifications
Falls and Balance program
Community services
An Evolving Model of
Care
2011 and beyond
Falls Clinic Milestones
Pre implementation
July 2008
2009
TQEH
2010
2011
Elizabeth
DRC
Modbury
Early Days
Activate Referral
Attend Clinic for
assessment
Make recommendations
and communicate to GP
Check recommendations
in place
Later Days
Activate Referral
Triage and link with most
appropriate service
Attend Clinic for
assessment
Refine and value add to
assessment
Make recommendations
and communicate to GP
Prioritise recommendations
and provide more
sophisticated service planning
Check recommendations
in place
Care Facilitation
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
Versatility
takes into
account
suitable
days/ dates
and
proximity to
home
Hospital
OPD,
Community
rehab, GP
plus centres
Clinic
Locations
Relationships
Local
agencies and
health
professionals
Host sites
Networking
and health
promotion
activities
Geriatricians
Clinic
Outcomes
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 KPI’s at regular
intervals
Referral Sources
Acute
SAAS
Community
GP
Unknown
0%
2%
15%
28%
18%
2009
N = 220
2010
N = 381
55%
65%
12%
0%
5%
Referral Numbers
60
2009
2010
2011
50
40
30
20
10
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug Sept Oct
Nov Dec
Triage Outcomes
clinic clients
declined service
alternate pathway
deceased
3%
2%
15%
25%
2010
N = 382
2009
16%
N = 220
67%
21%
51%
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
Summary
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.
Falls are multi-factorial and need a multidisciplinary 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.
Acknowledgements
Staff
Administration
• Janine Heading
Nurse
• Joachim Krack
Physiotherapy
• Gill Bartley, Program Manager
• Marina Vuckov
• Margaret Sullivan
• Marlena Esposito 2009-2011
• Yi Fabris 2009-2010
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