Confident Steps – A Balance and Falls Prevention Program

Kendall Shearer and Danielle Spencer

Outline

• Program Development • Falls Prevention Research • Development stages • Outcome measures • Criteria

• Program Implementation • Program Evaluation

• Successes and Challenges

• Future Opportunities

Program Development

A fall is defined as, “ an event which results in a person coming to rest inadvertently on the ground or floor or

other lower level” (WHO Definition)

Program Development

Falls Prevention Research • Falls result in increased mortality, morbidity and decreased

function , amongst the elderly population

• Costs associated with falls in the health sector are high and continue to grow with increasing age of the population

• 30% of people over 65 living at home fall annually, 50% are over 80 and 50% of these are multiple fallers (WHO,

2004)

• Risk of falling increases dramatically as risk factors increase. With one risk factor 27 % likely , 78% more likely with four or

more risk factors. (Tinetti, 1994)

Program Development

• 2009: Consideration of developing a Falls Prevention program run on a day patient model

• A working party developed

• Review of falls literature/ research for prevalence and costs associated with falls, assessment, interventions and outcome measures used for falls prevention

• Review of other falls programs and assessment clinics

Program Development

• Convincing the Health Funds

• Initially only accepted by 1 health provider

• The proposal was reviewed again in 2011 to incorporate the Australian Guidelines for Preventing Falls and Harm from Falls in Older People (2009)

• Remodeling to fit within Day patient Guidelines • Commencement of Program February 2012

Program Development

Interventions Recommended

Multifactorial interventions – intrinsic and extrinsic risk factors • Exercise • Balance training, including vestibular training • Vision correction • Advice on footwear • Home hazard advice • Medication review • Optimise ADL function • Use of assistive devices • Control of postural hypotension

Program Development

Principals

Falls Prevention programs should be: • Multidisciplinary • Engaging the older person • Implementing falls prevention strategies that identify

risks and are individualised

Program Development

Referral Criteria

• 4 or more risk factors or 2 + falls in previous 12 months (indicating a high risk category)

• Adequate cognitive functioning (MMSE >24/30) • Ability to participate in a group with independent

mobility with or without aid

Program Development

Outcome Measures

• Timed Up and Go - TUG ( Mobility) • Alternate Step Test ( Balance) • Functional Reach Test ( Balance) • 6 min Walk Test ( endurance) • Sit to Stand ( leg strength) • Falls Efficacy Scale ( fear of falling) • Lawton’s ( IADL scale) • Goal Attainment scale ( Individual goals- behaviour

change)

Program Implementation

Referrals

Internal referrals from Calvary Rehabilitation Hospital External referrals from:

• GP’s • Other Calvary sites • Public Health services • Other medical specialists

Medical criteria and funding eligibility required for acceptance of referrals

Program Implementation

Assessment Geriatrician Assessment includes: •Full review of various medical conditions affecting the patient •Recommendations for GP/Patient to follow up to effectively manage medical conditions and falls risk factors OT/PT Assessment includes:

• Outcome measures • Review of ADL’s/supports in place • Gait/use of mobility aid • Review of Vision • Home environment/OT Home Assessment

Program Implementation

Content and Structure • Duration: 2 hours, twice a week, 6 weeks • Capacity: 8 patients for exercise, 16 patients for education • Exercise: Tai Chi, Resistance, Balance, Home program • Education and Goal setting

• Discharge • 8 week follow up

Program Implementation

Education

Education Topic Education Topic

Falls Information/Goal setting – OT Health and Medical Issues – Doctor

The Benefits of Exercise – PT Outdoor Hazards – OT

Sensory Issues and Balance – OT Community Options – OT/COTA

Falls Self Efficacy – Psychology Falls Emergency Plan – OT and PT

Nutrition- Dietetics Medications – Pharmacy

Continence – Physiotherapy Home Environment-OT

Program Evaluation

Successes and Challenges

Successes • Outcome Measures • Increasing referral rate • Collaborative working • Positive patient feedback

Challenges

• Referral Conversion • Cost effectiveness / Funding • Multiple medical issues / various functional levels

Program Evaluation

Outcome Measures

Outcome measures for 2012 and 2013 have proved to be mostly highly significant/significant. Table 1: 2013 Outcome Measures

Note the improvement as a percentage for each outcome measure

ASSESSMENT Average Pre Average Post Difference % Improvement t-test Significance

Timed Up Go 14.86 12.95 1.91 12.85 0.059 Inconclusive

6 Min Walk 282.58 332.12 49.54 17.53 0.000023 High

Berg Balance 45.87 48.73 2.87 6.25 0.00118 High

5x Sit to Stand 18.61 15.31 3.3 17.73 0.00344 Significant

Falls Self Efficacy 103.02 111.98 8.97 8.71 0.000033 High

Program Evaluation

Increasing Referral Rate

The referral rate is increasing from year to year as indicated in the graph 1 below: Graph 1: Referral rate

Marketing to GP’s and health professionals is an integral part of program co-ordination to maximise the referral rate

Program Evaluation

Successes

Collaborative Working: High multidisciplinary input – aided collaborative working

• various health fields within Calvary • externally with COTA and public health services

Positive patient feedback: Patient evaluation forms and general comments consistently report positive comments on program content and benefit.

Program Evaluation

Challenges

Referral Conversion Total referrals for 2013: 85

Graph 2: Referral conversion

Program Evaluation

Challenges

Cost Effectiveness/ Funding • Financial viability • Staffing with varied referral rate Multiple Medical Issues/ Various Functional Level • Attendance • Meeting all participants needs

Future Opportunities

National Standard10: Preventing Falls and Harm from Falls • Hospital discharge planning to refer to community services • Education to patient and families

Maximise group capacity • Ongoing marketing and continual program review

Evaluating rate of falls pre and post program participation Evaluating clinical significance of outcome measures

Participant Comments “I’m now doing my own shopping again” “I really appreciate your input making (the education) clear and helpful” “I was very reluctant to attend but am now so glad I did” “I have met all goals plus more” “I wouldn’t be where I am without the group” “I appreciated the ongoing goal-setting process”

References

Australian Commission on Safety and Quality in Health Care, 2009, ‘ Guidebook for Preventing Falls and Harm From Falls in Older People: Australian Community Care. Active Ageing Australia, 2012 www.fallssa.com.au/hospitals/successfully-engaging-patients-and-carers, Falls Prevention in SA Hill, K. Moore, K. Dorevitch, M. Day, L 2008, Effectiveness of Falls Clinics: An evaluation of outcomes and client adherance to recommended interventions, The Journal of American Geriatrics Society, vol. 56, no.4, pp 600-608. Kannus, P, Sievdnen, H, Palvanen, M, Jarvinen, T, Parkkari, J 2005, Prevention of falls and consequent injuries in elderly people, www.thelancet.com, vol. 366, pp 1885-1893 National Collaborating Centre for Nursing and Supportive Care, 2004, The assessment and prevention of falls in older people, National Institute for Clinical excellence (NICE), London.

References NSQHS Standards, Oct 2012, Standard 10 Preventing Falls and Harm from Falls Australian Commission on Safety and Quality in Healthcare. Clemson, L & Swann, M (2008), Stepping On- Building Confidence and Reducing Falls, Sydney University Press Stratford P, Gill C, Westaway M and Binkley J 1995, Assessing disability and change on individual’s patients: a report of a patient specific measure, Physiotherapy Canada 47: 258-262. Tinetti, M. 2003, Preventing falls in elderly persons, The New England Journal of Medicine, vol. 348, no.1, pp42-48. Todd, C, Skelton, D 2004, What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls? WHO Regional Office for Europe (Health Evidence Network report); Copenhagen Yardley, L., Kirby, S., Ben-Shlomo, Y., Gilbert, R., Whitehead, S. & Todd, C. 2008, How likely are older people to take up different falls prevention activities?, School of Psychology, University of Southampton, Southampton, UK

Kendall Shearer Occupational Therapy Manager Danielle Spencer Senior Occupational Therapist Confident Steps Program Co-Ordinator

Calvary Rehabilitation Hospital/ Calvary Community Rehabilitation 42 North East Rd Walkerville