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

1. 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

2. An Evolving Model of Care Introduction

3. 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

4. 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

5. 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

6. Falls Clinic

7. Multidisciplinary Team Occupational therapy Nurse Case Conference Geriatrician Geriatrics Registrar Physiotherapy

8. 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

9. Referral process FALLS CLINIC Assessment Education and advice Recommendations to GP Referral for home assessment Referral for Falls and Balance program Referral to community services Review Emergency Department Hospitals: Acute admission Outpatient Triage GP Community service provider

10. Falls risk factors Cardiovascular Depression/Anxiety Fear of falling Vision Neurological Balance FALLS Musculoskeletal Environmental Nutrition Continence Polypharmacy

11. Cardiovascular

12. Neurological

13. Nutrition/Continence

14. Musculoskeletal

15. Vision assessment

16. Environmental Factors Assessment • Home hazard • Community services • Modified Barthel’s index • Home visit • Community transport

17. Gait, balance, footwear Assessment Examination Sensation Rhomberg’s Tandem Single leg stance Timed up and go 5x sit-stand Footwear Podiatry input

18. Medication Review

19. Multidisciplinary Team Occupational therapy Nurse Case Conference Geriatrician Geriatrics Registrar Physiotherapy

20. Recommendations REVIEW Telephone and/or clinic Falls History Compliance with recommendations Home safety assessment and modifications Falls and Balance program Community services GP/Specialist Community service provider Patient

21. An Evolving Model of Care 2011 and beyond

22. Falls Clinic Milestones Pre implementation July 2008 2009 2010 2011 TQEH Elizabeth DRC Modbury

23. Early Days Activate Referral Attend Clinic for assessment Make recommendations and communicate to GP Check recommendations in place

24. Later Days Activate Referral Triage and link with most appropriate service Attend Clinic for assessment Refine and value add to assessment Prioritise recommendations and provide more sophisticated service planning Make recommendations and communicate to GP Care Facilitation Check recommendations in place

25. Versatility Home Screening Option for individuals who are unable to tolerate a full clinic appointment Service Response: prioritisation around level of risk and urgency Versatility Hospital OPD, Community rehab, GP plus centres Booking takes into account suitable days/ dates and proximity to home

26. Clinic Locations

27. Relationships Host sites Networking and health promotion activities Geriatricians Local agencies and health professionals

29. Clinic Outcomes

30. 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

31. Referral Sources

32. Referral Numbers

33. Triage Outcomes

34. 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

35. Summary

36. 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.

37. 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.

38. Acknowledgements

39. 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 Staff