Stand-Up for Senior Independence (SUSI)

1. Stand-Up for Senior Independence(SUSI) Lea Blackburn, LISW, ACSW Riverside Methodist Hospital John J. Gerlach Center for Senior Health 614-566-4225 blackbl@ohiohealth.com

2. SUSI Funded By: • Ohio Department of Public Safety • Division of EMS • HB 138 Special Projects • Columbus Foundation

3. Needs Evidence • According to Columbus Fire Department over 90% of the personal assist runs are related to patient falls. • During 6 month period EMS personnel have responded to 585 personal assist runs. • Annual cost of $438,750 • Takes EMS unit out of service

4. Needs Evidence • According to CDC • every hour an older adult dies as the result of a fall • in 1998, more than 9,600 persons 65 and older died from fall related injuries, making falls the leading cause of death among this age group • 60% of all deaths involve individuals over the age of 75 • 30-35% of people 65+ fall each year • 20% of falls cause serious injury

5. Frailty / Falls Relationship • Frailty is defined by a constellation of symptoms including weight loss, weakness, fatigue, inactivity due to food intake. An illness or trauma such as a fall can trigger the acceleration of frailty. • Leading to loss of independent function

6. GOAL • An older adult who has experienced a fall (not resulting in a fracture) will effectively implement environment modifications and individual behavior changes to prevent ongoing frequent falls and thus remain independent.

7. STUDY POPULATION • Community-dwelling elders aged 70 or greater, who have experienced 2 falls requiring an emergency squad response within a 30 day period of time. • Changed the age criteria to 60 • 119 initial home visits for assessment of eligibility. • 40 total subjects met the research criteria.

8. Exclusion Criteria • Fall was due to exacerbation of chronic medical condition including, but not limited to, a spontaneous fracture due to osteoporosis. • Prior diagnosis of dementia and under care of physician • Prior diagnosis of depression and under care of physician

9. Objectives • The referral program will reduce the likelihood of falling among community-dwelling elders who have previously have fallen at least twice within 30 days, as demonstrated by a fall rate which is significantly above the baseline rate among this group.

10. demographic characteristics home environment and living arrangements circumstances & location to the fall baseline and follow-up functional status co-morbidity’s Clinical assessment results depression dementia nutrition home environment Added the CAGE (Alcohol screening) Study Variables

11. follow-up after clinical recommendations 1 month by phone 3 months by phone 6 month home visit occurrence of falls during study period hospital admissions during the study period and reason for admission Study Variables

12. Collaborating Partners • Columbus Fire Department • Community Public Health Professionals

13. Study Design • This is a cohort study, which uses historical data to measure the level of success of the SUSI program. • A randomized trial would provide the best evidence for evaluating SUSI, it is not a practical design.

14. Study Begins with: • Referral for clinical assessment from CFD or Public Health Professional

15. Clinical Assessments • Depression screening - Geriatric Depression Scale (GDS) • Dementia Screening - Folstein 3MS Mental Status Exam • Nutrition Screening - 1991 Nutrition Screening Initiative Level 1 • Home Environment Screening • Alcohol screening (CAGE) • Health Status Questionnaire

16. Screened to Suggest Risk • Educated by the Project Coordinator • Coordinator will communicate with Primary Physician regarding the baseline information. • Coordinator with consent (and prescription if appropriate) from PCP will arrange PT, OT, Dietician or Home Medical Equipment

17. Baseline Location & Reason for FallSubject fell 2x within 30 days • Most Frequent Location of Fall • Living Room / Den • Kitchen • Qualitative reasons given: • Lost balance while reaching • Legs gave out • Turned around too quick

18. # of Falls at 180 days

19. Results n=40 • 12.8% screened positive for depression • 57% screened positive for dementia • 100% required home environment changes • 47.5% screened positive for nutrition deficit • 32.5% required a dietician referral • 80% required a Physical Therapy referral • 286 visits for 28 subjects • 25% required Occupational Therapy • 89 visits for 1 subjects

20. Qualitative Results • “I feel like there is hope” • Dentures were too loose, broken hearing aide, depressed and needs bathroom equipment • referred to OSU dental clinic for dentures • referred to Cols Speech & Hearing for new aide • referred to home modification company to install grab bars • Ordered PT & OT • I know why I fell • denying need for help

21. Qualitative Results • “I can simply ask my doctor for an OT / PT evaluation?” • “I’ll do anything to stay in my own home.” • “I’m just too old” • “Therapy will come to my home?” • “Medicare covers PT / OT evaluation and treatment?”

22. Case Example • 89 year old male has fallen 3x within 30 days. • Assessment result needs: • Depressed, • Dietary needs • Home Modifications • dx with macular degeneration

23. Outcomes PCP addressed overall health including depression dietician counselor Home modifications - grab bars, shower drain, removed carpets medic alert system meals on wheels homemaker and home health aid services for visually impaired came to home and provided ‘gadgets’ to allow to read again Physical Therapy 3x wk for 6 weeks improve gait and balance. No falls for 125 days Case Example

24. Conclusions • Falling is not a result of a single factor it is a combination of some or all of the following factors: • Dementia • Over the age of 80 • Reaching for items in kitchen or living room • Currently receiving some form of caregiver support.

25. Variables that Directly Correlate with a Decrease in Falls • Improvement in Depression • 71% improvement in GDS • Improvement in Nutritional Status • 55% improvement • Home Modifications • Carpets removed 45.9% • Grab bars added 40.5% • Home Medical Equipment 32%

26. Additional finding • There was no statistical significance between co-morbidities and falling.

27. Qualitative Information with Significance • Lack of communication about falls to their primary physician or family. • Subjects stated they ‘knew’ why they had fallen. • Subjects are afraid they will fall again. • A statistically significant number of physicians were unaware that Medicare part B will cover OT or PT in the home with a prescription regarding fall risk.

28. Recommendations • Education for EMS and health care providers. • Education for the older adult and their family. • Riverside Hospital Gerlach Center for Senior Health developed a placemat with fall prevention strategies for EMS to take to older adults home or health care providers to distribute.