Falls Strategy June

Transcription

1 Falls Strategy June

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3 Worcestershire Falls Strategy Contents (Forward: by Dr R Davies) 1.0 Vision for falls prevention and management 1.1 Strategic context 1.2 Building on success 2.0 Why is falls prevention and management important 2.1 Falls are a major cause of morbidity and mortality 3.0 Key components of the strategy 3.1 Early interventions to maintain independence and reduce the risk of falling 3.2 Preventing and managing falls amongst people who are at high risk of falling 3.3 Admissions prevention 3.4 Fractured neck of femur 3.5 Community hospitals 3.6 Improved bone health and reduced fragility fracture 3.7 Our most vulnerable populations at risk of falling: care homes (nursing and residential) 4.0 Performance management and delivery of the strategy 5.0 Commissioning for success 6.0 Contacts and useful links

4 Worcestershire Falls Strategy A plan to reduce falls and the impact of falls in Worcestershire Foreword Preventing and effectively managing falls when they occur has to remain a high priority for deliverers and commissioners at every level of health and social care. By working together more effectively across the health and social care systems (including patients, carers, councils, housing, private, voluntary and charitable organisations), we can intervene earlier to prevent people from falling and we can improve the care of those people who regrettably do fall. By striving for excellence for each person, we improve the quality of life for individuals, whilst reducing demand on high cost health and social care services. Over the last four years we have made significant progress in setting up and refining the pathways of care, but more needs to be done. This summary document sets out how, over the next three years, we will build on our successes and address the weaknesses in the systems of care. We will continue to do this by working with our partners under the leadership of a countywide Falls Strategy Group. The measure of success of the strategy will be a year on year reduction in people admitted with fractured neck of femur, a challenging ambition for an ageing population. It will also be demonstrated by the improved outcomes for people who do fall and the increased levels of participation of partners in effective preventative measures which can realise benefits across the health and social care systems. Dr R Davies Chair of Countywide Falls Strategy Group Clinical Lead for Falls and Bone Health

5 1.0 Vision for falls prevention and management The Worcestershire Falls Strategy aims to add life to years, improve independence, reduce the fear of falling, reduce disability and deaths related to falls and reduce emergency admissions. 1.1 Strategic context The strategy is being refreshed in a context of massive change and challenge across the health and social care sectors. The NHS White Paper and Public Health White Paper present opportunities to strengthen the working relationship between agencies and identify more effective early intervention approaches, that are tailored to meet needs at the local level. The Worcestershire ageing well strategy, dementia and health improvement strategies are just some examples of local strategies that will support the implementation of this document. However, as well as the opportunities, we face challenges of funding constraints and an ageing population. It is now more important than ever to intervene earlier to reduce demand on health and social care services and deliver effective and efficient health care. 1.2 Building on success The success to date in developing and implementing the falls strategy has been dependent on the effectiveness of the partnership working across Worcestershire Health & Social Care services, infrastructure providers and voluntary organisations. Whilst the Health and Care Trust host the majority of the specialist services, all the health and social care services have a role to play in preventing falls. The next steps in taking forward the implementation of the falls strategy are set out in this document. As a result of the strategy there will be: A population who know how to reduce their risk and take the required action Early and effective identification of people at risk and clear actions to reduce risk of falls A clear, effective and fully embedded pathway of health and social care services that treat people who have fallen and reduce future risk of falls and fracture A trained health and social care workforce who take actions to reduce risks of falls Effective technologies to reduce risk of falls and early detection of falls...and as a consequence there will be fewer fractured neck of femurs.

6 2.0 Why is falls prevention and management important? Falls have a dramatic effect on individuals, families and the public sector purse; they matter to us all. Worcestershire has an above average mortality from accident related injuries among the population aged 65 and over (average rate for ). Accidents put significant pressure on emergency services and the number of emergency hospital admissions in Worcestershire has increased steadily since January 2004 with falls accounting for at least three-quarters of accident related admissions. Falls have risen in particular between 2007/08 and 2010/11 in Redditch and Bromsgrove (See fig 1). However, this increase may at least be partly due to improvements in coding. Most falls are trips or slips on the same level and are most likely to occur at home, both indoors and outdoors. There appears to be generally more falls in winter, but the seasonal variation is hidden by the effect of increasing admissions. Figure1 - Falls admissions by district of residence 2005/ /11

7 Falls also put significant pressure on acute services with a long average length of stay. There are, on average, 630 admissions for fractured neck of femur each year, and a further 50 fractures of other parts of the femur. Fractured neck of femur admission rates is higher in the most deprived areas of Worcestershire. According to national data, the annual incidence of falls in people with dementia is twice the rate of older people without dementia and a quarter of those who fall and sustain a fracture. Lack of recording of diagnosis and coding issues mean that this group are not reflected in the data. Worcestershire has an ageing population. Currently the number of people over 65 and 80 years of age is estimated to be 70,900 and 27,500 respectively. By 2026 this number is set to increase to 103,300 and 52,600 respectively. Utilising the figures from the RoSPA we can therefore predict that annual incidence of falls should increase by 23,600 to 51,650 in patients over 65 and 9100 to 26,300 in those over 80 years of age during this time period. Figure 2 displays the current and predicted populations older than 65 years for each of the local authorities in Worcestershire and their predicted annual incidence of falls. Local authority Current population aged 65+ (2010) Estimated number of falls (2010) Predicted population (2025) Bromsgrove 18,500 6,200 26,000 8,700 Malvern 17,800 5,900 25,300 8,400 Redditch 11,500 3,800 17,900 6,000 Worcester 14,400 4,800 18,800 6,300 Wyre Forest 20,400 6,800 29,300 9,800 Wychavon 24,400 8,100 35,600 11,900 Predicted number of falls (2025) Figure 2 - Current estimated and predicted populations (> 65 years of age) in each of the Worcestershire local authorities and calculated incidence of falls 2.1 Falls are a major cause of morbidity and mortality which represents a significant financial burden for the NHS and social care. Falls are the most important type of accident and many occur in and around the home. Around 30% of over 65 s living in the community will fall per year. Over 60% of people in nursing homes fall each year.

8 The rate of falls injury hospitalisation increases exponentially for over 65 s with rates being higher in women than men. 75% of falls-related deaths occur in the home. Applying the current epidemiological data to those aged 50 and over in a typical Primary Care Organisation (pop ): 420 people are admitted to hospital due to a fall per year. 140 are admitted to hospital with a hip fracture per year. The annual number with a hip fracture is predicted to rise to 400 by Figures from Worcestershire PCT reveal that between January and December 2008 a total of 2266 individuals over 64 years of age were admitted to hospital following a fall. The most common diagnoses necessitating admission included fractured neck of femur (22%), head injuries (18%), senility, other fractures and soft tissue injuries. A graphical representation of this data is shown in Figure Fractured Neck of Femur Head Injury Senility Other fracture Fracture of Shoulder/Upper Arm Fracture of forearm Other urinary disorders Superficial injury of hip/thigh Fracture of lumbar spine/pelvis Pneumonia Fracture of lower leg Other Case Study 1 Mrs W attended a PSI class in Bromsgrove. Before the classes started she was taking part in no physical activity and her balance was getting worse and worse. After my lower back surgery, I had minimal feeling in my feet. After attending the classes the feeling has returned and I will be attending further classes with some of the other people I met in the class. Hayley, the PSI instructor said as the classes progressed I saw her gain mobility in her legs and shoulders and her confidence grew enormously. Mrs W has already started attending my local mobility class with a number of friends from the PSI programme. PSI instructor Figure 3 - Emergency admissions following falls in Worcestershire patients > 64 years of age (2010/11)

9 3.0 Key components of the strategy 3.1 Early interventions to maintain independence and reduce the risk of falling Preventing falls through earlier and more effective coordinated interventions will both improve the quality of life of individuals and families and reduce demand on health and social care services. We will therefore: Educate the public on what they can do to maintain good bone health and to reduce their risk of falling through awareness raising, social marketing campaigns, website for the public and taking a holistic approach. Equip service providers with the knowledge and skills to both reduce risk and manage patients through the falls pathways by implementing a comprehensive training and education programme. Build on the success of the Postural Stability Instruction (PSI) classes based within communities. People who attend classes, derive significant benefits, however, we must increase the number of people participating in these programmes. We will prototype a new model of delivery, linked closely to primary care, in which practices identify patients at risk of falling. They will refer patients onto their local courses, which will also offer other healthy living advice to improve the quality of life of patients. An ongoing programme of activities following the 33 week PSI course will be tested as a social model to reduce admissions in older people. Wyre Forest will be the pilot area for this approach. Establish systems and processes for voluntary and community sectors to identify people at risk of falling and effectively refer them into the falls pathway, as necessary, including appropriate use of the Level 1 Case Finding Tool. Embed falls prevention within other key plans and services such as the Cold Weather Plan. Engage Clinical Commissioning Groups, Housing Associations, voluntary and community sector organisations and public representatives in the development and implementation of local community based approaches to early intervention programmes. Reduce the risk of environmental factors that can cause falls, by making partners aware of the implications of poor infrastructure design and maintenance such as roads and pavements. Ensure staff and service users and their carers are aware of assistive technology solutions which can support people at home or in care homes. This area of work is the responsibility of the Falls Prevention Action Group, which will develop detailed action plans and report progress against targets to the Countywide Falls Strategy Group.

10 3.2 Preventing and managing falls amongst people who are at high risk of falling. The falls pathway, shown below, clearly sets out how services will maximize case finding of people at high risk of falling, manage their care effectively and reduce further risk of falling. This includes ambulance, A&E, inpatient care and community services. Figure 4 - Falls Pathway Falls pathway will: Operate a robust pathway to ensure that older people who are at high risk of falls, or have sustained a fracture, receive the appropriate interventions, in a timely manner, to reduce risk.

11 Use Electronic Discharge Summary systems (EDS) to notify Nurse Advisors for Older People of patients who have been discharged following a fall or fracture. Ensure that patients who are at high risk of falls receive a multi-factorial assessment and interventions, including lifestyle risks, review of medication, access to falls specific exercise programmes, environmental assessment to reduce unnecessary hazards (with possible onward referral to specialist falls clinic as required) and assessment and provision of appropriate aids including assistive technology (telecare/telehealthcare). Involve multi factorial risk assessments being undertaken by community matrons and locality teams for patients in their care, thereby reducing delay and avoiding duplication. Develop processes to ensure that all patients at risk of falls or who have sustained fragility are screened for osteoporosis and risk of falls. Review the implementation of the falls pathway to make modifications as required based on the experiences of the implementation phases to improve quality and productivity (and value for money). Commission training and education programmes to raise awareness of falls strategy and policies to embed preventative approaches into health, social care, voluntary and independent sector services. Further develop the specialist role of the Nurse Advisor for Older People Service to ensure consistency and effectiveness across the county. Develop well-check and risk assessment procedure of patient s homes on discharge following a fall to prevent a reoccurrence and to help educate on potential hazards. Implement the West Midlands ambulance service alternative pathways for falls. Develop and implement the map of medicine for falls to support appropriate interventions in primary care. The Group that has developed the detailed targets and action plan and is accountable for delivering this area of work is the Falls Pathways Group. This group will report progress to the Countywide Falls Strategy Group. 3.3 Admissions prevention Some population groups, particularly people with dementia, care home residents and the very frail in their own homes, are at a higher risk of falling. Admission prevention interventions pay particular attention to the needs of these groups and will include: Ensuring rapid access to appropriate services via Worcestershire health and social care access service, this thereby reduces the need for admission (to hospital or residential setting). A coordinated approach to assistive technology solutions, that can prevent falls, and enable people to live more independently. Effective inpatient falls policies, procedures and training for staff, in all patient settings and other nursing and care settings. This will ensure falls risk assessments are carried out and evidenced based strategies and interventions are developed so as to avoid falls occurring amongst vulnerable patients and reduce admissions to hospital.

12 Making best use of community alarms and the provision of a rapid response service as an alternative to the ambulance service, a commissioning priority. Working with clinical commissioning groups to implement risk stratification of high risk patient groups. 3.4 Fractured neck of femur By improving care for patients who have suffered fractured neck of femur care we will improve the outcomes for patients and reduce demand on health and social care services, including reducing the bed days spent in acute hospital beds. To do this we will: Operate a fractured neck of femur integrated care pathway across both acute hospital sites. Redesign hospital services received by patients who sustain a fractured hip to improve quality and speed of services by implementing the standards required by the best practice tariff for fractured neck of femur. This will ensure that patients are operated on within 36 hours of admission and are managed under the joint care of an Orthogeriatrician and Consultant Orthopaedic surgeon. These measures will reduce the number of bed days spent in acute hospitals as a result of a fracture. Embed good practice within primary care, supported by effective GP education programmes to ensure effective secondary prevention of fragility fractures and involve an in reach model to facilitate discharge to appropriate community resources therefore, reducing the number of bed days. Implement best practice, supported by effective policies, systems and training, to ensure effective integrated models of nursing and care in hospitals, ensuring timely supported discharge with community services support, where indicated. This work will be the responsibility of the Falls Pathway Group which has specific action plans that are monitored and reported to the Countywide Falls Strategy Group. 3.5 Community hospitals To ensure effective care and timely discharge we will: Implement the Falls High Impact Actions in the Community Hospitals. Establish an inpatient falls prevention working group to implement and monitor the prevention and reduction of falls within inpatient areas. Explore and examine falls data to establish a baseline figure for falls occurring within inpatient areas via the Quality Review Tool. Implement the Fallsafe Care Bundle within community hospitals. Support and enable staff to analyse and identify trends within their own clinical area and action accordingly. Implement the Fallsafe Care Bundle within community hospitals.

13 Ensure policies and guidelines are in line with national guidance. Ensure a programme of awareness raising and education. Identify and monitor the impact on the quality of patients experience and cost reduction. 3.6 Improved bone health and reduced fragility fracture By improving bone health we can reduce the risk of fracture and further falls. This will be achieved by: Responding to the first fracture and preventing any further fractures through the implementation of the hospital fracture liaison service. Following up people presenting with fragility fracture and proactively identify people at risk of fragility fracture. Implementing the NICE guidance for primary and secondary prevention of fragility fracture, including osteoporosis screening and management. Ensuring strong clinical leadership for dexa scans to improve management of bone health. Developing and implementing a map of medicine for osteoporosis to support appropriate management in primary care. This area of work will be the responsibility of the Osteoporosis Subgroup, which has detailed action plans and targets in place. 3.7 Our most vulnerable populations at risk of falling: Care homes (nursing and residential) A targeted approach for care homes is essential because of the vulnerable population residing within these institutions and the high proportion of residents falling. We need to be clear why so many people need admission to hospital following a fall and work with the care homes to reduce falls. It is clear that people with more complex needs are remaining in residential care homes and further work is needed to understand the most effective approaches to reducing risk of falls. To establish best practice we will: Use the data, including ambulance, GP and/or Community Nurse call outs for falls to target homes with the greatest number of falls and potential for reduction. It will incorporate detailed analysis and work with care homes to understand the stories behind the data and put in place effective systems to manage and reduce risk of falls. Develop a sustainable approach to ensure that all staff in care homes have a fundamental understanding of falls awareness and an effective training and education programme to support the implementation of best practice. Work with WCC to develop falls standards within the care home contract that supports the appropriate management of patients at high risk of falls with care homes.

14 Work with primary care to implement a Locally Enhanced Service (LES) for care homes that includes reducing the risk of falls and fractures. Explore the inclusion of a programme of postural stability instruction classes in care homes. Raise awareness of assistive technology products that support service user and homes in managing falls more effectively. Case Study 2 Mrs H, a 70 year old bariatric lady with osteoporosis, was completely independent prior to sustaining a fracture of her left femur after a fall before Christmas in She was referred to the Falls Team via the Falls Pathway. On assessment Mrs H reported that her independence and quality of life had been taken away with the fall. She was overwhelmingly anxious of falling and was reluctant to use a frame due to the stigma attached. The combination of these two factors meant she was becoming increasingly bedbound and dependent upon others, which she found devastating especially given her previous independent lifestyle. Mrs H would not stand without assistance and would not let go of her frame, despite having the ability to stand unsupported. Due to her new sedentary nature her strength and balance were deteriorating along with her confidence and mood, leading her into a downward spiral. We therefore introduced OTAGO exercises gradually and provided equipment to practice transfers and mobility to reform Mrs H s confidence and therefore independence. After 4 months she is delighted that she has returned to her pre-morbid level of independence allowing her to ditch her frame, shower independently and access her daughter s property; goals which were invaluable to her. Mrs H s strength and balance have significantly improved with exercise and although rare, if she trips up now, she has the co-ordination and reaction speed to prevent a full blown fall. The real keystone to Mrs H s success has been the influence the service has had upon her mood and confidence which is why I have referred her on to PSI to embrace the opportunity to further prevent falls while she is in the right mindset. It is vital that this lady avoids falls given her diagnosis of Osteoporosis and how far she has come from the former patient I assessed. Falls Physiotherapist The group charged with responsibility for this area of work and developing detailed action plans is the Care Homes Forum, reporting to the Countywide Falls Strategy Group. Case Study 3 Mrs P is an 85 year old lady who lives in Bromsgrove. Before the PSI classes started she was taking part in a little exercise but her balance was poor and deteriorating. Since attending the classes she says these classes have given me my confidence back. I am less afraid of falling and find daily tasks like getting things in and out of cupboards a lot easier. The instructor has been great and gave me information about other classes I could go to once I had finished and I am now going to a tai chi class Instructor, Hayley Gwilliam, said I have seen a definite improvement in Mrs P. She is much more confident, has a larger stride and looks up a lot more when she is walking rather than watching her feet. PSI Instructor

15 4.0 Performance management and delivery of the strategy A robust Falls Performance Framework is in place covering the strategic objectives, QIPP, CQUINs, Joint Commissioning targets, Ambulance Data, High Impact Actions, SHA and Local priorities. Performance has in the main been improving constantly over the past 12 months and is achieving targets, thus reducing the rate of falls, achieving improvements in quality of services and cost savings. Performance management mechanisms will remain in place, with data being reported quarterly to the Countywide Falls Strategy Group The Countywide Falls Strategy Group is accountable for the delivery of the strategy, reporting to the Joint Commissioning Executive. The group will monitor progress against measures identified below. New reporting arrangements from this group are required to the Health and Wellbeing Board and clinical senate. These need to be agreed with the CCGs. Sub groups will report progress against each strand of the strategy on a quarterly basis against their own actions plans, not sited in this strategy, but these will be available on the falls website: Over time reporting mechanisms will change with the development of Clinical Commissioning Groups. Specific structures are also in place to report progress to regional organisations. The outcome measures and performance indicators against which the strategy will be assessed are the KPI for QIPP: Reduce number of FNOF - over 65s Reduce the number of patients admitted with fragility fractures, excluding FNOF Reduce the number of admissions for falls over 65 years Reduce excess bed days for patients admitted with FNOF The targets and predicted savings for the NHS deriving from the improved performance at the time of writing the strategy is shown below. These will change over time, and it should be recognised that implementation of the pathway and associated training, should improve the accuracy of data recorded and this will increase the number of falls recorded. Case Study 4 Mrs O attended the PSI class in Wythall. Prior to the PSI class she did not take part in any physical activity and her balance was not good. Since coming to the classes her confidence has rocketed. I now have the confidence to go out on my own and don t need my walking stick. I am now dancing every week which I couldn t manage before so will continue that and also other exercise classes to increase my mobility. Her instructor said Progress has been excellent. She walks much better, is stronger and has the confidence to walk without her stick. PSI Instructor

16 QIPP Plan Target 10/11 Target 11/12 Target 12/13 Target 13/14 Number of admissions with # NOF for over 65yrs (Average cost of FNOF : 5,954.22) 0% Reduction of 1.7%. Reduction of 12 from Reduction of 4.7%. Reduction of 33 from Reduction of 7.3%. Reduction of 55 from Number of admissions with falls, over 65yrs, excluding # NOF and all other fractures. (Average cost of falls admissions: 2,141.38) 0 Reduction of 1.7%. Reduction of 22 from 1,256-1,234. Reduction of 4.7%. Reduction of 61 from 1,300-1,239. Reduction of 7.3%. Reduction of 98 from 1,347-1,249. Number of excess bed days for patients admitted with #NOF Number of 'other' fractures, excluding FNOF(Average cost of admissions for other fractures: 3,127.72) Baseline /10 (90.7% D/C within the trim). Target - 92% d/c within the trim. 0%. 93% d/c within the trim. 95% d/c within the trim. 98% d/c within the trim. Reduction of 1.7%. Reduction of 12 from Reduction of 4.7%. Reduction of 34 from Reduction of 7.3%. Reduction of 55 from Figure 5 - Economic Return on Investment

17 Based on this modelling of Falls Intervention Flow Chart in figure 6, the savings which can be derived from early interventions and across the pathway are significant for health and social care. Illustrations of these savings are shown below: Health Taking the costs of acute hospital care alone, an intervention of a postural stability course can derive a minimum of 240 cost saving for an investment of 120. This assumes the average cost of a fall to be This does not account for the social care costs and the additional costs of NHS services outside acute hospital care. Social Care Over the next 5 years it is estimated that 360 hip fractures will be prevented by implementing the new falls pathway. This is under the QIPP programme. Using the DOH economic evaluation of fractures prevention services, and applying local social care and home care costs an estimated savings of 900K will be realised over next 5 years. As we are already overachieving targets in the first year, we estimate the savings will over 1million. Figure 5 - Falls Intervention Flow Chart

18 5.0 Commissioning for success The key to commissioning for success includes understanding demand and reviewing existing commissioning practices to ensure that they remain fit for purpose. The pathways set out in the strategy will be kept under review, involving commissioners, customers and service deliverers in order that we can learn what works and where changes needed to be made. Partners involved in delivery of the strategy remain committed to sharing good practice and will modify systems of working to deliver the best services we can. The scope of commissioning ranges from prevention and early intervention, such as foot care and postural stability instruction, through to high intensity treatment and training care home staff who are charged with caring for our most vulnerable people, in particular those with dementia, who are at greater risk of falling. We need to commission services across the county where appropriate, but we will also prototype new models of working to deliver the strategy and reduce the demand on high cost services. The falls service is funded recurrently from the NHS, with the exception of PSI, which will need additional funding as demand for this cost effective programme increases. The 300k per annum from the NHS funds the specialist falls physio service, technical instructors, Falls Prevention Coordinator, fracture liaison nurse, administrative support and additional dexa scan capacity. Postural stability instruction classes are currently funded through the NHS with a budget of 100K which will cover a basic level of service across the county. As demand for the classes increase additional funding will be required. Wyre Forest Clinical Commissioning Group are investing an additional 50K into their area to prototype a new model of delivering PSI, linked more closely to primary care services. Case Study 5 Mrs X is 78, lives alone and had a fall half way down the stairs. There was a gradual onset of lower back/hip pain after the fall. Initially, she was admitted into a nursing home for respite care but later returned home, sleeping downstairs. Following a referral from the nurse advisor, assessments were carried out on her environment, equipment and health by the Falls Physiotherapist. As a consequence, referrals were made to: GP to address back pain, decreased appetite, swollen ankles, increased frequency of urine and low mood. Age UK for benefit assessment Podiatry for decreased sensation in feet Physiotherapy for unsteadiness on feet and decreased confidence/fear of falls Physiotherapy support worker for difficulty with transfers and steps. As a result, home adaptations were made, core stability and lower limb strengthening exercises were practiced, gait re-education and practice with stairs/steps with supervision was undertaken. Mrs X can now independently and safely manage a full flight of stairs, mobilise unaided in doors and use one walking stick for outdoor mobility. Pain has decreased, strength in lower limb has increased and she can get up from the floor independently. Mrs X is now attending PSI classes and is reported to be really enjoying them. Falls Physiotherapist

19 6.0 Contacts and useful links Falls Prevention Coordinator: Jackie Threshie: / Coordination of falls Prevention Services Health and Care trust Public Health: Karen Wright Tel: Prevention and Public Awareness Postural Stability Instruction Emma Gardner Tel: Co-ordinator: Clinical Development: Ruth Davoll Tel: Urgent Care Strategic Need Age UK / Herefordshire and Worcestershire: Osteoporosis Society: Department of Health:

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