Dublin North CityPrimary Care Teams

Falls Prevention and Bone Health Initiative

Phase 2 ResultsMillmount PCT and Network 1

Laura Binions30th September 2015

National Background

• Estimated one in every three people over 65 yrs and one in every two over 80 yrs fall every year.

• In 2008 the “Strategy to Prevent Falls and Fractures in Ireland’s Ageing Population” was published to ensure development of integrated falls and fractures programme to meet the need of the growing older population.

• Under the Care of the Elderly in Primary Care programme a working group was set up and a draft document was published “A Guide to Falls Screening and Multi-factorial Falls Risk Assessment in Primary Care” updated January 2013

The Stats

• 30% of the older population or 130,000 of 65 and over fall annually in Ireland.

• Estimated 300,000 people over 50 yrs may have osteoporosis.

• Yearly cost of falls and fractures €404 million.• Hip fractures account for 2,800 approx hospital

admissions per year.

• By 2031 approx 1 million people will be over 65 living in Ireland.

Local Background• Ballymun Primary Care Team ran a pilot project: “Falls

and Fractures Prevention in Primary Care setting” in 2007.

• Several Exercise groups (FaME) have been run in the area by Physiotherapist Services.

• Information days have been held in local areas.

• Occupational Therapy, Physiotherapy and Nursing have implemented falls screen tools to their initial assessments.

• Falls Prevention and Bone Health Management Group set up in DNC to promote more efficient and effective protocols along with integrated pathways between hospital and community services.

• Falls Prevention on Bone Health Coordinator started in September 2014 on 6 month pilot project.

Objective

• Experience and findings

• Documentation revision

• Feedback

• Next steps

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Role of Coordinator

• Development and adaptation of Screens and Assessments.

• Linking with all stakeholders involved.

• Training and support for PCT members in role out of new Screen and Assessment process.

• Data collection of all clients who have been through pathway and onward referrals.

• Analysis of data gathered in relation to numbers referred, screened, referrals both PCT and others.

• Use data to highlight those most at risk and where education programmes would be most beneficial.

• Use data to confirm need for specialist service in falls prevention and bone health.

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What we were doing

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Client over 65 years

PCT Referral

Level 1 Screen Completed

No further Intervention requiredRecorded on data base

Require further AxLevel 2 Multi-Factorial Screen Completed

Onward Referrals

PCT referrals GP referral

Specialist service as appropriate,St Marys, DEXA etc

All onward referrals recorded on database

Coordinator reviews all referrals as appropriate at PCT meeting

Pilot Aim

Millmount PCCT

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Pilot began 28/10/2014- 7 months

Millmount PCTby age group

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Impact of fall on the older Person

12Injurious or falls requiring intervention were more common in women and those who were 80+.

The Irish Longitudinal Study on Ageing (TILDA)

Falls Injurious falls

52-64 yo 18.4% 7.3%

75+ 29.8% 9.9%

Self reported injuries46 fallers

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1:4 reporting injuries or further intervention sustained a fracture following a fall

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37 (42%) had Onward Referrals

Bone Health – DXALevel 2 only

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Of those at risk, 1:6 were not asked about bone health.Of those at risk, 17 (34%) were not referred for DXA.

Screening and Intervention

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Network 1

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Screened 16/3-31/5/2015

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Findings

Male Results• 17% of 70-79 had a fall and 100% fallers required further intervention

/injury.• 30% of 80-89 had a fall and 67% fallers required further intervention /injury.• 1 person under 65 had multiple falls

Female Results• 52% of 70-79 had a fall and 33% fallers required further

intervention/injury.• 39% of 80-89 had a fall and 60% fallers required further intervention/ injury• 33% of 90+ had a fall 100% fallers required further intervention/injury.

Falls rate vary between 17% to 39%; injuries/intervention from 1:3 to 100% across the age groups.

DXA – Network 1

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14 (54%) of those with falls risk WERE NOT referred for DXA.

THE EXPERIENCE & LEARNING

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Summary and Findings• Age profile similar in Millmount and Network 1 for 70-89 women 80-

89 men• 40-58% of older persons require more assessment (Level 2)

• Our experience showed that between 40-60% of those screened were at risk of falls and more than half of them require further intervention.

• The referrals to DXA , falls clinic and some profession (nursing) remain low. More information sessions required.

• Referral rates to GPs for bone health has increased following education sessions on bone health and St Marys services. Staff reported knowing more about services available after attending education day.

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Success & Challenges

GP involvement• Coordinator continuing to link with GPs regarding the Initiative and

their role in same.• 1 Practice now requests all screens and level 2 Assessment

completed on their clients at 2-monthly client review.

Administration and Organisational Analysis• Very limited computer base forms completed by Network 1 staff,

using post therefore some delay on input of client data on database.• Millmount almost 100% are computer completed and utilise email

and new scanner facility.• Excellent compliance with using CRO

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Modification to practice

Revised Documentation

• Addition of not applicable criteria to Screen receiving excellent feedback

• Combined Level 2 with Referral form reducing completion time and streamlining the process

• Staff still report increased time in completing Level 2 form

• CRO working well for distribution of all documentation

• A focus group would be beneficial to identify clearly with staff what to change in the documentation and to further streamline the process.

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Documentation Evaluation

• All documentation is reported as being clear and largely easy to complete. Some issue with Level 2.

• Most Staff felt it was MDT appropriate and relevant to practice.

• Staff’s main concern was time taken to complete in particular Level 2 with 64% recording 5-20 minutes and 29% reporting 20-30 minutes.

• Staff still remain concerned with time taken to complete level 2 and own initial assessments.

• Found combination of Referral and Level 2 very useful and time efficient, however some felt required more info on Level 2, to effectively prioritise referrals.

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“ very detailed and time consuming to complete”

“I feel this could be reviewed to make it more relevant to practice”

“ Duplication of OT assessment takes a lot of time”

“Needs to be shorter and less questions for client when is being done along with an assessment for ones own discipline”

“Time efficient as OTs were doing similar assessment”

Further education around MDT aspect of forms not profession specific required

Overall Results of Phase 2 Survey

• Overall positive feedback about the initiative and its concept.

• Training and support vital • Excellent feedback regarding practical education

sessions• Need for continued support and buy in from all

professions in PCT team.• Essential that the process is as time efficient as

possible

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Where to Next?• Continue to link with management to reinforce importance of Initiate

with all staff.• Set up focus group to further review documentation and increase

compliance

• Continue to audit client data and staff feedback of process.

• Organise further information sessions on topics relating to healthy aging.

• Continue links with Affinity project.

• Link with older persons services re mapping of area services and current falls prevention programmes running in day centres

References

• Strategy to Prevent Falls and Fractures in Irelands Ageing Population. June 2008

• A guide to Falls Screening and Multi-Factorial Falls Risk assessment in Primary Care 2011-2013

• Gannon B, O’Shea E, Hudson E, 2008. ‘Economic Consequences of Falls and Fractures Among Older People’. Irish Medical Journal. 101(6): 170-3.

Acknowledgements

• DNC Falls prevention and bone health management group

• Donal Cassidy DNC Primary Care development officer

• Daragh Rodger ANP St Marys Hospital• Dr. Chei Wei Fan St Marys Hospital• Management and Staff Dublin North City Pilot

Sites

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Thank you for listening

Any questions?