Transcript Falls prevention and primary care partnerships

Webinar 2:Falls prevention and
primary care partnerships
Hosted by:
Sandy Blake – Clinical Lead for the reducing harm from falls
programme and Director of Nursing
Outline of webinar
Agenda
Presented by:
Atlas of Healthcare Variation – Falls
domain
₋ Catherine Gerard, Evaluation Manager,
HQSC
Counties Manukau Community falls
prevention in older people
₋ Dr Shankar Sankaran, Chair of the
Reducing Harm from Falls Expert
Advisory Group, and Consultant
Geriatrician/ Clinical Leader, Whole of
Systems Health of Older People at
Counties Manukau District Health
Board
₋ Melinda Gardner, Project Manager,
Community Falls prevention in Older
People, Counties Manukau Health
Whanganui falls prevention and
osteoporosis collaborative clinical
pathway
Whanganui Regional Health Network:
₋ Julie Nitschke, Clinical Director Primary
Care
₋ Sharon Duff, Community Developer
₋ Dr Rick Nicholson, General Practitioner
Atlas of healthcare
variation
• Falls in people aged 50 and over
• Atlas looks at whether there is variation
by DHB and opportunities for quality
improvement:
– People with one or more ACC claim for fallrelated injury
– Admissions following a fall
– Hip fracture rates following a fall
– Management: time to operation and
medications for bone health
Atlases
Unwarranted variation
Jack Wennberg:
‘Variation in the utilization of health
care services that cannot be explained
by variation in patient illness or patient
preferences.’
Taxonomy of variation1
• Effective care
• Preference-sensitive care
• Supply-sensitive care
Appleby, Raleigh, Frosini et al. Variations in health care: the good, the bad
and the inexplicable. Kings Fund (2011).
This is not a league table
• High is not necessarily better
• Low may not be worse
• The middle might not be right
Bisphosphonate on discharge following hip fracture
Indicators
• Rate/1,000 people who had one or more:
–
–
–
–
–
–
ACC claim for a fall-related injury
Hospital admission
Average bed days
Hip fracture
Time to surgery
Medications on discharge
• Sub-analyses by year (2011-2014), age,
ethnicity and gender
• View atlas and explain how to
view and different ways of
presenting the data
Key findings
Age
band
50–64
ACC claims, rate
per 1000 (count)
Hospital admissions,
rate per 1000 (count)
Hip fracture, rate per
1,000 (count)
119 (99,900)
6 (5,200)
0.2 (178)
128 (48,000)
11 (4,600)
1.2 (460)
180 (35,000)
38 (7,400)
6.1 (1205)
85+
283 (22,000)
106 (8,100)
23.3 (1800)
Total
138 (205,000)
17 (25,000)
2.4 (3,600)
65–74
75–84
Key findings
Of people aged 85+:
• 28% had an ACC claim in 2014 for a
fall-related injury
• 11% were admitted to hospital
• Average LOS was 15.5 days
Hip fracture:
• 50% were in those aged 85+
• Women had twice the rate
Key findings – variation
Average bed days (falls)
• Two-fold variation: NZ mean 11.2 days, range 7.3 –
14.7 days)
Medications for bone health in 6 months following hip
fracture:
• 21% dispensed bisphosphonate
– Varied from 0% – 38%
– Significant reduction since 2012 (mean 33%)
• 68% dispensed vitamin D
– No significant variation
Key findings – update
• Rate of falls and hip fracture continue
to increase in 85 and over age group
• Average length of stay continues to
vary 2-fold
• The use of bisphosphonates varies
more than 3-fold and has significantly
decreased since 2012
These data raise questions
• Why do some DHBs have
consistently higher rates?
• What impact might orthogeriatric
services have on these data?
• What about Fracture Liaison
Services?
Suggested actions
In your DHB area: know your data –
what’s your plan?
• Topic 10: 10 priorities in an
integrated approach to falls in older
people
• Falls Workbook: From Atlas to
Action
Community falls prevention in older
people
An ACC and CMH Alliance
collaborative
April 2016
Falls and fracture care and prevention
A road map for a systematic approach
Stepwise
implementation based on size
of impact
Hip
fracture
patients
Non-hip fragility
fracture patients
Individuals at high risk of 1st
fragility fracture or other
injurious falls
Older people
Objective 1: Improve outcomes and improve
efficiency of care after hip fractures
Objective 2: Respond to the first fracture,
prevent the second – through Fracture
Liaison Services in acute and primary care
Objective 3: Early intervention to restore
independence – through falls care pathway
linking acute and urgent care services to
secondary falls prevention
Objective 4: Prevent frailty, preserve bone
health, reduce accidents – through
preserving physical activity, healthy lifestyles
and reducing environmental hazards
1. DH Prevention Package for Older People
Context
 ACC
strategic direction “population
systems based approach”
 Health Quality & Safety Commission work
1.
2.
3.
4.
5.
6.
In home strength and balance
Group based community strength and
balance
Hip fracture registry
Fracture Liaison Service
Supported hospital discharge
Service integration across primary and
secondary care.
Funding
 $408,202
per annum for 3 years
 Critical components 1 and 2
 Contribution.
Community programmes
 Technical
Advisory Group criteria
 Separate ACC funding for a lead provider
to support community programmes.
Background
 Establishment
of ACC and CMH falls
prevention steering group:

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Primary care
Secondary care
ACC
Management
Consumer.
Our business case
 Demonstrate
readiness of CMH to support
implementation
 Confirm model of care and approach
 Give confidence benefits and cost savings
can be achieved
 Recommend best utilisation of ACC
funding.
Target groups
Maori and Pacific Island people age 65-74 years
of age and older enrolled with general practice,
with a fall related ACC claim in the previous 12
months
2. Age 75 years and older enrolled with general
practice, with a previous fall related ACC claim in
the previous 12 months
3. Age 75 years and older and enrolled with general
practice with no ACC claim guidelines
4. Age 75 years and older enrolled on At Risk
Individual programme.
1.
Ask, Assess, Act
ASK
Enrolled patients age 75 years and
older and living in the community
Telephone screening
Any member general practice team
(administration)
ASSESS
ACT
Any patient responding yes to any of
the screening questions
Face to face in the practice
Practice Nurse led
1a Community strength and
balance training programme for those
meeting TUG and 4-SBT criteria AND
cognitively intact, not receiving a
personal care package, not utilising a
walker internal/external
1 Have you slipped, tripped or fallen
in the last year?
1 Timed Up and Go (TUG) Test
≥12 seconds
ACT
2 Can you get out of a chair without
using your hands?
3 Are there some activities you’ve
stopped doing because you are afraid
you might lose your balance? Do you
worry about falling?
And
Four Stage Balance Test (4-SBT)
Inability to hold tandem stand for 10
seconds
1b Referral to Community Central
for home based strength and balance
programme for those meeting TUG
and 4-SBT criteria AND cognitively
intact (or mild cognitive impairment),
receiving a personal care package,
utilising a walker internal/external (3 of
3 criteria)
Programme reach
Eastern
In-home
strength
and
balance
Community
strength
and
balance
Franklin
Mangere/
Otara
Manukau
169-225
74-98
83-111
167-222
506-1,517
221-663
249-747
501-1,503
Required programme capacity
Eastern
Classes
required per
day for
community
programmes
Franklin
Mangere/
Otara
Manukau
Minimum 3
Minimum 2
Minimum 2
Minimum 3
Maximum 8
Maximum 4
Maximum 4
Maximum 8
Implementation
Otara & Mangere Locality
Of the 100,000 plus people living in this locality in
2013, almost 59,000 are Pacific (our largest
Pacific community) and 17,500 Maaori. About
77% of people are living in areas of high
socioeconomic hardship. 21 primary care
practices are supported by Alliance Health+,
National Hauora Coalition, Procare and Total
Healthcare
Eastern Locality
Our second largest locality with over 146,000
residents in 2013. This includes more than
51,000 people of Asian ethnicities and over
18,000 people aged 65 years and over.
General practices in the Eastern Locality are
supported by East Health Trust PHO, ProCare
PHO and National Hauora Coalition PHO
Manukau Locality
Our largest locality of over 181,000 residents in
2013. This includes almost 40,000 Pacific people,
42,000 Maaori people and 41,000 Asian
ethnicities. About 50% of people are living in
areas of high socioeconomic hardship. 44 general
practices are supported by ProCare, National
Hauora Coalition and Total Healthcare
Franklin Locality
Our most rural locality with over 67,000 residents
in 2013. Approximately 13% of people are aged
65 years and over. There are 8 General Practices
all supported by ProCare and Alliance Health+
PHOs.
Phased approach

Phase I indicative time-frame 01 July 2016-30
June 2017 - all referrals for in home and
community strength and balance programmes
will be through CMH general practices
 Phase II indicative time-frame 01 July 2017 –
referrals for in home and community strength
and balance programmes will be through CMH
general practices as well as secondary, EC, ED
and St John services – ‘any door is the right
door.’
Funding
Population approach for general practice to
undertake telephone screening of at risk groups
2. In-home strength and balance programmes
delivered by community locality
physiotherapists and
3. That a review of the funding allocation is
undertaken at 1 year.
1.
Stakeholder engagement
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Integrated Clinical Care Governance Group
Primary Care Leadership Team
Locality General Managers
Alliance Leadership Team
ACC.
Webinar April 26th
SOME WHANGANUI FACTS-2014
• 11 (10.9) new ACC falls claims a day from people aged
over 50 years
• $2,157,749 paid in 2014 for active claims
• 70 fractured hips from those domiciled in Whanganui
(more than one a week)
• Average length of stay in hospital for hip # is 11.3 days
• 86% # hips operated on same or next day
• In the 50-59 year age group,
those that fell and sustained a
# or dislocation – 8.34%
(national 8.78%)
WHANGANUI 20 POINT WORK PLAN 2015-16
Within the 20 point work plan fracture liaison and
falls prevention
pathways were
developed using
co-design with
consumers and
A multidisciplinary
team
COLLABORATIVE CLINICAL PATHWAY TEAM
Consumers – Whanganui Regional Health Network
HQSC - Clinical Lead Falls Prevention Program
ACC - Community Injury Prevention Consultant
GP - Clinical Lead
Primary Health - Clinical lead
Consultant - Orthogeriatrician
Community Organisation – AgeConcern
St John Ambulance – Regional
Aged Care – Clinical Staff
Occupational Therapist - DHB
Physiotherapist – DHB
Fragility Fracture Nurse – WDHB / WRHN
FALLS PREVENTION PATHWAY
OSTEOPOROSIS & FRAGILITY FRACTURE
PATHWAY
ELECTRONIC INFORMATION TO GP
PRACTICES
• An Electronic Patient Report Form (ePRF) – will be sent to
GP’s after a health incident and will go live in April to GP’s
• Enable practices nurses to follow up falls risks
• St John will also be referring straight to Falls Team
DASHBOARD RED FLAG FOR FALLS RISK
• Patient Dashboard will identify at risk patients and
give us a red flag when:
– Patient aged 65+
– Patient must also have at least one of the following:
• An ACC45 submitted in the last year where one of the
read codes recorded suggests a fracture
• 4 or more long term medications
• or classified with: Alcohol dependence, Problem
Drinker, Stroke, Dementia, Motor Neurone Disease,
Multiple Sclerosis, Osteo Arthritis, Osteoporosis,
Parkinson's Disease
FALLS RISK ASSESSMENT
REFERRAL FORM
REFERRAL FORM
OUR SPECIALITY FALLS PREVENTION TEAM
Falls Prevention Team based at WDHB
Primary Health Occupational Therapist
Primary Health Physiotherapist
Physiotherapy assistant
Falls Prevention Nurse
Fragility and Fracture Service based at WDHB
Fragility Fracture Nurse
Ortho-geriatrician
OUR FALLS PREVENTION TEAM IN THE
COMMUNITY
Consumers - utilising services and being proactive
Whanau /Family – supporting, promoting and referring
GP Practices – identifying need, responding and referring
Community Organisation – e.g. Age Concern providing Steady As
You Go Programmes and Car Fit
St John Ambulance – informing GP of risk
Aged Care – identifying risk and referring to GP
Equipment and alarms - home safety companies providing
equipment and personal alarms
Healthy homes – insulation and assistance for over 65 years
Community pharmacists - providing medication reviews
EMPOWERING OUR OLDER PEOPLE
Taking Responsibility
Personal factors e.g. balance, strength,
Environmental factors e.g. mats, cold rooms, poor lighting
• Exercises to improve leg strength, balance and body awareness
• Regular check-ups with GP - Vitamin D and review of medications
• Eye-sight checks each year
• Non slip, well-fitting shoes
and slippers
• Check their home and garden
for trip hazards – install handrails
• Work towards a warm and dry home
WHAT CAN PRACTICES CONTRIBUTE
• Opportunistic screening - DEXA scans if meet
criteria
• Using the advanced form to refer
patients to the fragility fracture nurse
• Medication reviews
• Providing information to
enable patient to self manage
such as green prescription or self help groups
• Referral to specialist
WHAT DOES THIS MEAN FOR OUR PEOPLE
• More healthcare professionals on their team
• Information that is easy to read and helpful
• Encouragement towards personal goals
• Knowledge of community support
• Partnership to reduce harm.
Thank you
Questions?
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