Improving Pathways for our Falling Community.

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Improving Pathways for our Falling Community.

• Southern Mallee Primary Care Partnership Strong
  Steps Initiative.

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Overview

• Strong Steps
• Issue of falls within the community
• Risk Factors to Falls
• Research
• Objective
• Improve referral pathways with the Emergency
  Department (ED) and Rural Ambulance Victoria
  (RAV)
• Continuum of care from rehabilitation to
  community.

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Southern Mallee Primary Care Partnerships

• Location Swan Hill, Buloke and Gannawarra
  LGAs.
• PCPs Aim to improve health and well being of
  Victorians, through a collaborative approach to
  service co-ordination, health promotion and
  planning.

• DHS funded, falls prevention, whole of community
  project.
• Swan Hill LGA only.
• Strong Steps project structure/ committee.

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Strong Steps

• Aim to ensure residents living in the Swan Hill
  region are using long-term protective factors to
  reduce the risk of falls.
• Objectives
• 1) To implement a sustainable preventative falls
  awareness strategy.
• 2) Increase general target groups participation
  in physical activity that enhances strength,
  balance and social participation.
• 3) Develop interventions to target special at
  risk groups.
• 4) Improve referral pathways.

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Background

• 1 in 3 people over the age of 65 fall each year,
  increasing to 1 in 2 for those over the age of
  80.
• Costs over 300 million to the Vic Government.
• 7 out of 10 people who fall will injure
  themselves.
• Significant morbidity / mortality rates.

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Risk Factors

• Age, gender, history of falls
• Lack of physical activity
• Changes in eyesight
• Hazards in and around the home
• Inappropriate medication use

• Health Conditions
• Hazards within the community
• Feet problems/ foot wear
• Balance / walking difficulties

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Research

• Individuals who have a history of falls are at
  greater risk of falling again.
• The best way to decrease falls is by assessing
  an individuals risk factors, developing a
  management plan and implementing strategies based
  on identified risks.
• Locally identified that many of those who fall
  generally will present to ED (225 cases from
  04-05 not admitted)or RAV.

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• Causes of injury hospital admissions.
• Victoria 2001 (n93,208) Graph

• In 2001 almost a third of the unintentional
  injury ED presentations (32) were falls.

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Strong Steps Working Group

• Progress the continuum of care and improve
  referral pathways, to reduce the number of
  recurrent falls.
• ED and RAV staff to regress from the medical
  model, and implement aspects of the social model
  of health.
• Aim To prevent those D/C home from having
  multiple falls and re-presenting to ED/RAV.
  Having follow-up referral strategies implemented
  to decrease there risk of falls.
• Allied health to also consider referral to
  exercise groups to maintain clients abilities
  post rehabilitation.

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Emergency Department Referrals

• ED staff previously did not complete falls
  screen/ assessment, management or referral.
• Agreed to trial the implementation of an easy to
  use referral process.
• Aim to make change/disruption to current work as
  minimal as possible, with no large change in
  administration duties.
• Referral to appropriate department will ensure
  assessment is completed, risks identified and
  issues managed.
• Written into hospital policy.

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Emergency Department Falls Prevention Pathway
Patient 55 presents to ED due to fall
YES
No referral Required. Follow current protocol.
NO
Triage nurse flags falls patient
Determine cause of accident. Patients account
Is patient to be admitted to a ward?
Determine appropriate referral to allied health
team
Consumer consent gained
Orange FRAS Sticker to be placed in patients
record. (Triage Assessment)
Mobility Issues
Home Hazards
Continence Issues
Refer to Occupational Therapist
Refer to Physiotherapist
Refer to Continence Services
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Evaluation Plan

• To trial for a three month period.
• Gather stats from VISU i.e. number of falls
  cases presented to ED from target group, within
  three month time frame allied health
  departments to keep record of the number of
  referrals received from ED.
• Comparison to same three month period from 12
  months earlier and 3 month period prior to
  pathway implementation.
• Surveying of ED and Allied health staff to
  determine the effectiveness and appropriateness
  of pathway.

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Trial

• From 1st Aug 31st of Oct 2006, this process was
  trailed to determine the impact
• Pre trial stats
• Aug-Oct 05 (38 cases, 30 D/C home no follow up,
  4 to acute ward, 3 transferred hospitals, 1 to
  Aged Care (2 re-presented to ED).
• April June 06 (55 cases, 40 D/C home no follow
  up, 13 to acute ward, 1 transferred hospitals, 1
  left at own risk (6 re-presented to ED).

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Trial Stats

• 51 cases, 39 D/C home, 11 unknown, 1 left on own.
  0 were admitted to the ward and 9 were referred
  to allied health (within the first month).
• Falls are costing hospitals more then road
  accidents, due to longer stay/ recovery time.

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Post Trial Audit

• Consultation with department heads.
• Time effective referral form.
• Consultation and education with ED staff.
• Plan
• Continue to monitor over a 6 month period with
  close supervision from project officer.
• Implement more education/ audits if required.
• Part of hospital KPI for ongoing evaluation.

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RAV Pathway

• Along with implementation of ED pathway it was
  determined that RAV officers often are called to
  cases that may not require transportation.
• Willingness to implement a similar referral
  pathway, to that of ED.

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Rural Ambulance Victoria
Falls Prevention Pathway
Determine cause of fall and appropriate
referral pathway
Attend call to person 55 years of age or over
as a result of a fall
NO
Gain consent for referral, for falls assessment
Does person require medical attention?
Medical Issues
Home Hazard
Mobility Issues
YES
Encourage transport. Enlist family to monitor
until GP appointment
Refer to Occupational Therapy
Refer to Physiotherapy
Transport and follow procedure as normal, ED
staff to do falls follow up and refer on
as required
Once referral completed fax to appropriate
person and provide client with a falls are
preventable brochure to read whilst awaiting
contact from allied health
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Education

• Regional education sessions held December 2006.
• Training developed by project officer, conducted
  by RAV training staff.
• Training covered
• Issues around falls
• Stats

• Risk factors to falls.
• Why they are a risk and how to decrease ones
  risk.
• Referral plan, referral / protocol
• Case Studies.

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Evaluation Plan

• Only started in January so no statistical
  results.
• PLAN
• Trial for three months.
• Evaluating stats of referrals received compared
  to number of calls (no transportation).
• Staff view of process.

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Continuum of Care

• Following rehabilitation program refer to
  community exercise group.
• Re-integrate into the community.
• New surroundings for many older adults.
• Physiotherapist or allied health assistant to
  attend initial session to assist with integration
  to new environment.

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Rehabilitation Clients referral process to the
Swan Hill Leisure Centre
Continue with hospital exercise group
Nearing completion of set rehabilitation program
No
Determine if client capable/ready to access
community groups.
YES
Yes
Determine if client needs to continue
supervised exercise program
Determine if client is happy to attend Swan Hill
LC
NO
Yes
No
D/C physiotherapy HEP
Gain consumer consent
Provide with HEP
Determine if client would like therapist to
accompany first session
Yes
Therapist to call LC arrange time for first
session. Accompany client to session.
No
Provide client with LC brochure. Client to
arrange first session through phone call.
Fax referral to SHLC.
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Evaluation Plan

• Only in early stages (started Jan. 07), no
  physiotherapy group classes until mid January.
• PLAN
• 6 month trial.
• Leisure centre staff to track the number of
  referrals received, and audit at 1, 3 and 6
  months to determine if client is continuing with
  exercise.
• Staff and client surveys to determine if all are
  happy with the pathway, if they find it
  beneficial etc.

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References

• Clapperton, A., Ashby, K. Cassell,E. Hazard.
• Injury profile, Victoria 2001 54 1-24.
  Victorian Injury Surveillance Applied Research
  System (VISAR) 2003.
• Close J, Ellis M, Hooper R, Glucksman E, Jackson
  S, Swift C. Prevention of falls in the elderly
  trial (PROFET) a randomised control trial.
  Lancet 353(9147) (1999) 93-97.
• Sutherland,M., Dean, P. Watson, M. Dont fall
  for it. Falls can be prevented! Australian
  Government. Department of Health and Ageing.
  (2004).

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References (cont)

• Exercise Physiology services Bendigo Health
  Care Group, 2003.
• Department of Human Services, Victoria. Aged Care
  in Victoria Falls Prevention. DHS, 2006.
  http//www.health.vic.gov.au/agedcare/maintaining/
  falls/index.htm (accessed 2006/2007).
• Paniagua MA, Malphurs JE, Phelan EA. Older
  patients presenting to a country hospital ED
  after a fall missed opportunities for
  prevention. American Journal of Emergency
  Medicine 24(4) (2006) 413-417.

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Research (cont)

• Yaxley J, Kulh M, Moore T, Budge M. Successfully
  locating high risk fallers The community
  outreach assessment program (COAP) ACT
  Ambulance Referral Service. Australia Falls
  Prevention Conference 2006.
• West Gippsland Healthcare Group (Central West
  Gippsland PCP). Falls Project Officer, 2006.

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Questions