Bridging the gap between acute and community falls services Melissa Turner Falls Therapy Link Worker Westminster Rehabilitation Services Melissa.Turner@clch.nhs.uk Providing community healthcare in London and the Home Counties
Objective To discuss ways to: develop links between acute and community falls services improve patients access to specialist falls assessments case find in A&E and Fracture Clinics 2
Why develop links between acute and community? Falls and Osteoporosis are common Falls and their consequences are: expensive intensive on A&E resources preventable 3
Why develop links between acute and community? The acute sector short stay fast paced other priorities Identification of those at risk well suited to acute sector The community sector relies on referrals mainly secondary prevention Many falls go unmanaged until/even when injury occurs Multifactorial falls assessment and intervention is time intensive - 50 plus hours of exercise - environmental modification - may require co-ordination and follow up with MDT Better suited to community sector 4
NICE Falls guidelines recommend: 1. Falls risk screening (case identification) All people > 65 years routinely asked re: falls in past 12/12 If yes, further clarify: - Were falls recurrent ie 2 in past 12/12 A&E staff Fracture clinic staff - Was medical attention sought for these fall/s - Does observation show gait and/or balance disturbance If yes to any of above questions, refer to a service with appropriately skilled clinicians: - Community Falls Prevention Service - Consultant led Falls Clinic To make this decision, must question re: falls context/characteristics 2. Multifactorial falls risk assessment 3. Individualised multifactorial falls intervention Community Falls Prevention Falls Clinic 5
NICE Osteoporosis guidelines recommend: Targeting Risk Assessment Consider assessment of fracture risk for: - all women > 65 years and all men > 75 years - women < 65 years and men <75 years in the presence of risk factors: previous fragility fracture current use or frequent recent use of oral or systemic glucocorticoids history of falls family history of hip fracture other causes of secondary osteoporosis low body mass index (BMI) (less than 18.5 kg/m 2 ) smoking alcohol intake of more than 14 units per week for women and more than 21 units per week for men Do not routinely assess fracture risk in people < 50 years unless they have major risk factors Methods of Risk Assessment Estimate absolute risk when assessing risk of fracture (eg % 10 year risk major OP #) Use either FRAX (+/- BMD score) or Qfracture Do not routinely measure BMD to assess fracture risk without prior FRAX (without a BMD value) or QFracture Following FRAX (without a BMD value) or QFracture, consider measuring BMD with DXA if fracture risk is in intervention threshold for a proposed treatment; recalculate absolute risk using FRAX with the BMD value 6
NICE Osteoporosis guidelines recommend: Targeting Risk Assessment Consider assessment of fracture risk for: - all women > 65 years and all men > 75 years Too complex for opportunistic assessment in A&E - women < 65 years and men <75 years in the presence of risk factors: previous fragility fracture current use or frequent recent and use of oral or systemic glucocorticoids history of falls family history of hip fracture other causes of secondary osteoporosis low body mass index (BMI) (less than 18.5 kg/m 2 ) smoking alcohol intake of more than 14 units per week for women and more than 21 units per week for men Patients focus is more urgent needs eg injuries / fractures Appropriate to sit alongside fracture clinic appointment /opportunistic use of clinic waiting time BUT which staff members role Do not routinely assess fracture risk in people < 50 years unless they have major risk factors Methods of Risk Assessment Estimate absolute risk when assessing risk of fracture (eg % 10 year risk major OP #) Use either FRAX (+/- BMD score) or Qfracture Established component of many community falls prevention programs Do not routinely measure BMD to assess fracture risk without prior FRAX (without a BMD value) or QFracture Following FRAX (without a BMD value) or QFracture, consider measuring BMD with DXA if fracture risk is in intervention threshold for a proposed treatment; recalculate absolute risk using FRAX with the BMD value 7
Falls Therapy Link Worker CLCH model to bridge the gap partnership with: - St Mary s Hospital - Chelsea and Westminster Hospital aim to improve patients access to specialist falls assessment 1 WTE Band 7 PT or OT Responsibilities: Collection, triage and forwarding of referrals Case finding from A&E and Fracture Clinic Assessment role in the SMH Falls Clinic and feedback loop between the clinic and community therapy services Training at SMH, CWH, CLCH; doctors, nurses and therapists Regular promotion of falls as an important health issue 8
What does this model look like? Case finding in A&E Case finding in Fracture Clinic Role in Falls Clinic Training 9
A&E 10
Fracture Clinic CLCH Falls Therapy Link Worker and Health Promotion Worker attend Hospital Fracture Clinic Triage clinic list by: DOB prior to 1966 HOPC Screening for falls and fracture risk; >50 years conservative to capture both populations Looking for site of fracture and how it occurred; - fragility fracture vs major trauma - fall vs MVA vs skiing accident etc Note on clinic list and patients file to identify opportunity for ax Clinic nurses assist with logistics 11
Fracture Clinic Screening assessment occurs at the fracture clinic Explanation of role and reason for assessment opportunity Number, context and characteristics of fall/s Observation of gait FRAX Management Referral to relevant falls prevention services for multifactorial falls risk assessment Provision of lifestyle and exercise advise for bone health Referral for DEXA Documentation Consultant led Falls Clinic Community Falls Prevention Program Community exercise Tai Chi, gym class, Open Age, Age UK 1. **Refer directly to DEXA and OP clinic follow up 2. Refer to GP to order DEXA and follow up In acute and community records duplication=frustration 12
Falls Clinic Review of clinic list prior to clinic to determine: Patients borough Current/recent community therapy programs Collate relevant resources needed for clinic Assessment/referral forms Brochures eg falls services, NOS, footwear, eye care Attend pre-clinic MDT meeting Handover community therapy information Plan assessments; BERG, gait ax, vestibular ax, DHI, FES-I, homefast Make required onward therapy referrals Document encounter in community medical record and handover to community therapists 13
Training Doctors FY1/FY2 inductions A&E rotations Nurses Difficult to engage Therapists/Therapy students Hospital and community staff In-service calendar Band 5/6 rotations 14
What are the barriers to links? Time Information Technology Organisational governance Competing priorities Communication Patient engagement Staff engagement Environment /space Service related factors 15
How to overcome these barriers Keep things as simple as possible!! Be very clear on the role and its boundaries Be visible and available to be contacted Make the time for regular training and make sure that it is varied Form networks with key stakeholders and nurture these links Be prepared to utilise any available space Use mobile working strategies if able Be politically astute and patient 16
A last piece of advice One off meetings don t work! Maintaining links requires: Constant presence Constant promotion Constant training 17
References Alice C Scheffer, AC., van Hensbroek PB., vandijk N., Luitse JSK., Goslings JC., Luigies RH. and de Rooij SE. (2013) Risk factors associated with visiting or not visiting the accident & emergency department after a fall, BioMed Central The Open Access Publisher, published 26th July 2013, accessed 17th June 2016 http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-13-286 The Chartered Society of Physiotherapy. The cost of falls, accessed 17th June 2016 http://www.csp.org.uk/professional-union/practice/your-business/evidence-base/cost-falls The Chartered Society of Physiotherapy. Physiotherapy works falls and frailty, accessed 17th June 2016 http://www.csp.org.uk/professional-union/practice/evidencebase/physiotherapy-works/falls-and-frailty The World Health Organisation. (2007) WHO Global Report on Falls Prevention in Older Age, accessed 17th June 2016 http://www.who.int/ageing/publications/falls_prevention7march.pdf NICE. (2012) CG 146 Osteoporosis: assessing the risk of fragility fracture, accessed 17th June 2016 https://www.nice.org.uk/guidance/cg146 NICE. (2013) CG 161 Falls in older people: assessing risk and prevention, accessed 22nd June 2016 https://www.nice.org.uk/guidance/cg161 18