Dr Katherine Lucero Geriatrician Royal Adelaide Hospital Diana Pignata OT, Central and Northern Community Falls Prevention Team Falls Clinics – An Evolving.

Dr Katherine LuceroGeriatricianRoyal Adelaide Hospital

Diana Pignata OT,Central and Northern Community Falls Prevention Team

Falls Clinics – An Evolving Model of Care for High Risk Fallers

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

NurseOccupational therapy

PhysiotherapyGeriatricianGeriatrics Registrar

Case Conference

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

Emergency Department

Hospitals:Acute admission

Outpatient

GP

Community service provider

Triage

FALLS CLINIC

Assessment

Education and advice

Recommendations to GP

Referral for home assessment

Referral for Falls and Balance program

Referral to community services

Review

Falls risk factors

VisionCardiovascular

Balance

Musculoskeletal

FALLS

Neurological

Environmental

Nutrition PolypharmacyContinence

Depression/AnxietyFear of falling

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 referralsMedication review

NeurologicalFalls Risk Factors Clinic AssessmentParkinson’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 Clinic Recommendations Investigations, specialist referrals

Dietitian review, RDNS for continence support

Falls Risk Factors Clinic AssessmentMalnutrition, weight loss History, examination

Constipation Body mass index

Alcohol Mini-nutritional assessment

Urinary incontinence Continence assessment

Chronic GI, renal disease

Musculoskeletal

Falls Risk Factors Clinic AssessmentOsteoporosis History Vitamin D deficiency ExaminationArthritisSpinal conditionsMuscle weaknessSensory abnormality

Falls Clinic Recommendations Osteoporosis screenReferral 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 centreOptometry, 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 alarmReferral to community services, ACAT

Gait, balance, footwear

Assessment• 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, orthoticsReferral to Falls and Balance program

Medication Review

Falls Clinic Recommendations

Reducing polypharmacy

Educating patient, RDNS supervision, Webster Pack

Multidisciplinary Team

NurseOccupational therapy

PhysiotherapyGeriatricianGeriatrics Registrar

Case Conference

Recommendations

GP/Specialist

Community service provider

Patient

REVIEW

Telephone and/or clinic

Falls History

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

July 2008 2009 2010 2011

TQEH Elizabeth

DRC Modbury

Pre implementation

Early Days

Activate Referral

Attend Clinic for assessment

Make recommendations and communicate to GP

Check recommendations in place

Later Days

Activate Referral

Attend Clinic for assessment

Make recommendations and communicate to GP

Check recommendations in place

Triage and link with most appropriate service

Refine and value add to assessment

Prioritise recommendations and provide more

sophisticated service planning

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

takes into account suitable

days/ dates and

proximity to home

Versatility

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

65%

18%

15%

2%

2009N = 220

Acute SAAS Community GP Unknown

55%

6%

12%

28%

0%

2010N = 381

Referral Numbers

0

10

20

30

40

50

60

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

2009

2010

2011

Triage Outcomes

2010N = 382

51%

21%

25%

3%

67%

17%

15%

2%

2009

N = 220

clinic clients declined service alternate pathway deceased

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 multi-disciplinary 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

StaffAdministration• 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