Falls Clinics - Falls Prevention in SA
Falls Clinics - Falls Prevention in SA
Falls Clinics - Falls Prevention in SA
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<strong>Falls</strong> <strong>Cl<strong>in</strong>ics</strong> –<br />
An Evolv<strong>in</strong>g Model of Care<br />
for High Risk Fallers<br />
Dr Kather<strong>in</strong>e Lucero<br />
Geriatrician<br />
Royal Adelaide Hospital<br />
Diana Pignata OT,<br />
Central and Northern Community <strong>Falls</strong> <strong>Prevention</strong> Team
An Evolv<strong>in</strong>g Model<br />
of Care<br />
Introduction
<strong>Falls</strong><br />
• Most falls are multi-factorial<br />
• The terms ‘simple’ and ‘mechanical’ falls<br />
are misnomers and do not reflect the<br />
complexity of falls<br />
• Multi-factorial <strong>in</strong>terventions <strong>in</strong> falls cl<strong>in</strong>ics<br />
have been shown to reduce falls and falls<br />
related <strong>in</strong>juries <strong>in</strong> older people*<br />
*Hill K et al. Effectiveness of <strong>Falls</strong> Cl<strong>in</strong>ic: an evaluation of outcomes and<br />
client adherence to recommended <strong>in</strong>terrventions. JAGS 2008
Background<br />
• In 2008, a regional falls prevention program was<br />
established <strong>in</strong> Central Northern Adelaide Health<br />
Service (CNAHS)<br />
• Early objectives <strong>in</strong>cluded:<br />
• Establish<strong>in</strong>g a new multi-discipl<strong>in</strong>ary <strong>Falls</strong><br />
Cl<strong>in</strong>ic at Day Rehabilitation Centre (DRC),<br />
Hampstead Rehabilitation Centre<br />
• Provid<strong>in</strong>g a multi-discipl<strong>in</strong>ary team to exist<strong>in</strong>g<br />
<strong>Falls</strong> Cl<strong>in</strong>ic at TQEH
Pre-Implementation<br />
• When plann<strong>in</strong>g the design of our <strong>Falls</strong> <strong>Cl<strong>in</strong>ics</strong>, we<br />
were guided by:<br />
• Experience by Geriatricians at RAH and TQEH,<br />
staff at <strong>Falls</strong> <strong>Prevention</strong> team<br />
• Review<strong>in</strong>g <strong>Falls</strong> <strong>Cl<strong>in</strong>ics</strong><br />
• Repatriation General Hospital<br />
• Bundoora, Melbourne<br />
• ANZFP Conference Melbourne 2008<br />
• Information gathered by the Victorian <strong>Falls</strong> Cl<strong>in</strong>ic<br />
Coalition<br />
• Research articles and publications
<strong>Falls</strong> Cl<strong>in</strong>ic
Multidiscipl<strong>in</strong>ary Team<br />
Occupational therapy<br />
Nurse<br />
Case Conference<br />
Geriatrician<br />
Geriatrics Registrar<br />
Physiotherapy
Referral Criteria<br />
• Age 65 years or older<br />
• <strong>Falls</strong><br />
• >45 years for Aborig<strong>in</strong>al/Torrens Strait Islander<br />
• 2 or more falls <strong>in</strong> the past 12 months or<br />
• 1 fall with a serious <strong>in</strong>jury<br />
• Liv<strong>in</strong>g <strong>in</strong> the CNAHS region<br />
• Multiple co-morbidities<br />
• Not currently <strong>in</strong> a multidiscipl<strong>in</strong>ary program<br />
• Medically stable
Referral process<br />
Emergency<br />
Department<br />
Hospitals:<br />
Acute admission<br />
Outpatient<br />
GP<br />
Community service<br />
provider<br />
Triage<br />
FALLS CLINIC<br />
Assessment<br />
Education and advice<br />
Recommendations to GP<br />
Referral for home<br />
assessment<br />
Referral for <strong>Falls</strong> and<br />
Balance program<br />
Referral to community<br />
services<br />
Review
<strong>Falls</strong> risk factors<br />
Cardiovascular<br />
Depression/Anxiety<br />
Fear of fall<strong>in</strong>g<br />
Vision<br />
Neurological<br />
Balance<br />
FALLS<br />
Musculoskeletal<br />
Environmental<br />
Nutrition<br />
Cont<strong>in</strong>ence<br />
Polypharmacy
Cardiovascular<br />
<strong>Falls</strong> Risk Factors<br />
Arrhythmia<br />
Valvular heart disease<br />
Ischaemic heart disease<br />
Postural hypotension<br />
Cl<strong>in</strong>ic Assessment<br />
History and exam<strong>in</strong>ation<br />
Smok<strong>in</strong>g history<br />
Postural blood pressure<br />
ECG<br />
Carotid s<strong>in</strong>us hypersensitivity<br />
Endocr<strong>in</strong>e disorders<br />
<strong>Falls</strong> Cl<strong>in</strong>ic Recommendations<br />
Investigations, specialist referrals<br />
Medication review
Neurological<br />
<strong>Falls</strong> Risk Factors<br />
Park<strong>in</strong>son’s<br />
Stroke<br />
Dementia<br />
Anxiety/Depression<br />
Fear of fall<strong>in</strong>g<br />
Cl<strong>in</strong>ic Assessment<br />
History<br />
Exam<strong>in</strong>ation<br />
Cognitive assessment<br />
Geriatric Depression Scale<br />
<strong>Falls</strong> Efficacy Scale<br />
Seizures<br />
<strong>Falls</strong> Cl<strong>in</strong>ic Recommendations<br />
Investigations<br />
Referral to Neurologist, Memory Cl<strong>in</strong>ic, psychiatrist,<br />
psychologist, community support
Nutrition/Cont<strong>in</strong>ence<br />
<strong>Falls</strong> Risk Factors<br />
Malnutrition, weight loss<br />
Constipation<br />
Alcohol<br />
Ur<strong>in</strong>ary <strong>in</strong>cont<strong>in</strong>ence<br />
Cl<strong>in</strong>ic Assessment<br />
History, exam<strong>in</strong>ation<br />
Body mass <strong>in</strong>dex<br />
M<strong>in</strong>i-nutritional assessment<br />
Cont<strong>in</strong>ence assessment<br />
Chronic GI, renal disease<br />
<strong>Falls</strong> Cl<strong>in</strong>ic Recommendations<br />
Investigations, specialist referrals<br />
Dietitian review, RDNS for cont<strong>in</strong>ence support
Musculoskeletal<br />
<strong>Falls</strong> Risk Factors<br />
Osteoporosis<br />
Vitam<strong>in</strong> D deficiency<br />
Arthritis<br />
Sp<strong>in</strong>al conditions<br />
Muscle weakness<br />
Sensory abnormality<br />
Cl<strong>in</strong>ic Assessment<br />
History<br />
Exam<strong>in</strong>ation<br />
<strong>Falls</strong> Cl<strong>in</strong>ic Recommendations<br />
Osteoporosis screen<br />
Referral to <strong>Falls</strong> and Balance program
Vision assessment<br />
<strong>Falls</strong> Risk Factors<br />
Bifocal lenses<br />
Uncorrected refractive error<br />
Cataracts<br />
Glaucoma<br />
Macular degeneration<br />
Diabetic eye complications<br />
Cl<strong>in</strong>ic Assessment<br />
History<br />
Exam<strong>in</strong>ation<br />
Visual fields<br />
Visual acuity<br />
Contrast Sensitivity (MET)<br />
<strong>Falls</strong> Cl<strong>in</strong>ic Recommendations<br />
Advice on corrective lenses, referral to low vision centre<br />
Optometry, ophthalmology referrals
Environmental Factors<br />
Assessment<br />
• Home hazard<br />
• Community services<br />
• Modified Barthel’s <strong>in</strong>dex<br />
• Home visit<br />
• Community transport<br />
<strong>Falls</strong> Cl<strong>in</strong>ic Recommendations<br />
Home safety assessment, modifications, <strong>in</strong>formation on<br />
personal alarm<br />
Referral to community services, ACAT
Gait, balance, footwear<br />
Assessment<br />
• Exam<strong>in</strong>ation<br />
• Sensation<br />
• Rhomberg’s<br />
• Tandem<br />
• S<strong>in</strong>gle leg stance<br />
• Timed up and go<br />
• 5x sit-stand<br />
• Footwear<br />
• Podiatry <strong>in</strong>put<br />
<strong>Falls</strong> Cl<strong>in</strong>ic Recommendations<br />
Advice on gait aid, footwear, hip protectors<br />
Podiatry, orthotics<br />
Referral to <strong>Falls</strong> and Balance program
Medication Review<br />
<strong>Falls</strong> Cl<strong>in</strong>ic Recommendations<br />
Reduc<strong>in</strong>g polypharmacy<br />
Educat<strong>in</strong>g patient, RDNS supervision, Webster Pack
Multidiscipl<strong>in</strong>ary Team<br />
Occupational therapy<br />
Nurse<br />
Case Conference<br />
Geriatrician<br />
Geriatrics Registrar<br />
Physiotherapy
Recommendations<br />
GP/Specialist<br />
Community service<br />
provider<br />
Patient<br />
REVIEW<br />
Telephone and/or cl<strong>in</strong>ic<br />
<strong>Falls</strong> History<br />
Compliance with<br />
recommendations<br />
Home safety assessment<br />
and modifications<br />
<strong>Falls</strong> and Balance program<br />
Community services
An Evolv<strong>in</strong>g Model of<br />
Care<br />
2011 and beyond
<strong>Falls</strong> Cl<strong>in</strong>ic Milestones<br />
Pre implementation<br />
July 2008 2009 2010 2011<br />
TQEH<br />
DRC<br />
Elizabeth<br />
Modbury
Early Days<br />
Activate Referral<br />
Attend Cl<strong>in</strong>ic for<br />
assessment<br />
Make recommendations<br />
and communicate to GP<br />
Check recommendations<br />
<strong>in</strong> place
Later Days<br />
Activate Referral<br />
Triage and l<strong>in</strong>k with most<br />
appropriate service<br />
Attend Cl<strong>in</strong>ic for<br />
assessment<br />
Ref<strong>in</strong>e and value add to<br />
assessment<br />
Make recommendations<br />
and communicate to GP<br />
Prioritise recommendations<br />
and provide more<br />
sophisticated service plann<strong>in</strong>g<br />
Check recommendations<br />
<strong>in</strong> place<br />
Care Facilitation
Versatility<br />
Home<br />
Screen<strong>in</strong>g<br />
Option<br />
Service<br />
Response:<br />
Book<strong>in</strong>g<br />
Versatility<br />
for<br />
<strong>in</strong>dividuals<br />
who are<br />
unable to<br />
tolerate a<br />
full cl<strong>in</strong>ic<br />
appo<strong>in</strong>tment<br />
prioritisation<br />
around level<br />
of risk and<br />
urgency<br />
takes <strong>in</strong>to<br />
account<br />
suitable<br />
days/ dates<br />
and<br />
proximity to<br />
home<br />
Hospital<br />
OPD,<br />
Community<br />
rehab, GP<br />
plus centres
Cl<strong>in</strong>ic<br />
Locations
Relationships<br />
Local<br />
agencies and<br />
health<br />
professionals<br />
Host sites<br />
Network<strong>in</strong>g<br />
and health<br />
promotion<br />
activities<br />
Geriatricians
Cl<strong>in</strong>ic<br />
Outcomes
Service ref<strong>in</strong>ement and benchmark<strong>in</strong>g can<br />
take place due to:<br />
•The larger relative numbers<br />
•Common triage process, MOC, staff<strong>in</strong>g,<br />
assessment measures and care plann<strong>in</strong>g<br />
•Measure of outcomes and KPI’s at regular<br />
<strong>in</strong>tervals
Referral Sources<br />
Acute <strong>SA</strong>AS Community GP Unknown<br />
2%<br />
0%<br />
15%<br />
28%<br />
18%<br />
2009<br />
N = 220<br />
2010<br />
N = 381<br />
55%<br />
65%<br />
12%<br />
0%<br />
5%
Referral Numbers<br />
60<br />
50<br />
2009<br />
2010<br />
2011<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
Triage Outcomes<br />
cl<strong>in</strong>ic clients decl<strong>in</strong>ed service alternate pathway deceased<br />
2%<br />
3%<br />
15%<br />
25%<br />
16%<br />
2009<br />
N = 220<br />
2010<br />
N = 382<br />
51%<br />
67%<br />
21%
Data was collected on ED presentations, hospital admission<br />
rates and length of stay from an electronic public health<br />
system. Qualitative data <strong>in</strong>clud<strong>in</strong>g client reports of falls and<br />
<strong>in</strong>terventions was also collected at follow up reviews
Summary
How <strong>Falls</strong> <strong>Cl<strong>in</strong>ics</strong> Fit<br />
<strong>Falls</strong> cl<strong>in</strong>ics form one component of a vast<br />
array of services and systems to support<br />
clients at risk of falls and fall <strong>in</strong>jury. They are<br />
suited to older people who present with a<br />
high number of falls risk factors and co<br />
morbidities.<br />
The cl<strong>in</strong>ics are supported by and are<br />
dependent on the services which operate to<br />
address falls and falls <strong>in</strong>jury risk factors.
<strong>Falls</strong> are multi-factorial and need a multidiscipl<strong>in</strong>ary<br />
approach.<br />
<strong>Falls</strong> <strong>Cl<strong>in</strong>ics</strong> have evolved from a f<strong>in</strong>ite care<br />
episode to a care cont<strong>in</strong>uum method.<br />
Triage, support, assessment, service plann<strong>in</strong>g,<br />
service l<strong>in</strong>kage, communication with care<br />
providers and care facilitation have become part<br />
of our cl<strong>in</strong>ic model.<br />
The service is flexible. Ongo<strong>in</strong>g ref<strong>in</strong>ement and<br />
evolution is <strong>in</strong>evitable as a result of evaluation<br />
and the health reform process.
Acknowledgements
Staff<br />
Adm<strong>in</strong>istration<br />
• Jan<strong>in</strong>e Head<strong>in</strong>g<br />
Nurse<br />
• Joachim Krack<br />
Physiotherapy<br />
• Gill Bartley, Program Manager<br />
• Mar<strong>in</strong>a Vuckov<br />
• Margaret Sullivan<br />
• Marlena Esposito 2009-2011<br />
• Yi Fabris 2009-2010<br />
Geriatricians (TQEH)<br />
• Renuka Visvanathan<br />
• Solomon Yu<br />
• Kandiah Parasivam<br />
Occupational therapy<br />
• Diana Pignata<br />
• Lauren Woodford<br />
• Alison Ryan<br />
• Ashleigh Scoll<strong>in</strong><br />
Geriatricians (RAH)<br />
• Kather<strong>in</strong>e Lucero<br />
• Alice Bourke<br />
• Ashlesha Vaidya<br />
Geriatrics Registrars (RAH)<br />
• Miranda Lam<br />
• Clare Haylock 2010<br />
• Sally Johns 2010
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