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An Integrated Care Approach to Community Falls Prevention
Ken Stewart Canterbury Clinical Network
New Zealand Sept 2015
In 2008 we recognised we had to change the way we delivered
health services and agree on a new direction
Fundamental reorientation to bull provide tailored individual care bull provide population based care bull provide support over the full range of a personrsquos life bull Support and enable self-care
The health system sees the primary point of continuity is based in the community
Specialist services are for acute episodic and complex care
We needed to make health priorities and the cost of health funding clear to everyonehellip
bull The competing demands for care far exceed our ability to fund
or resource them
bull Every new procedure denies care to someone else
bull As we continually explore better ways of working we need to
maximise the value of our resources (get more for the same)
bull To do this we need to prioritise how we invest
A connected system
Centred around people
That aims not to waste their time
Utilising health system data helped us focus our attention on those people most at-risk of ending up in hospital
Where do older persons falls occur
Community
How do we know that community falls prevention is a key programme for a health system
Canterbury population over 75 years
0
5000
10000
15000
20000
25000
30000
35000
40000
2008 2009 2010 2011 2012 2013 2014
Falls presentations to ED for people 75 years amp over (2008- Jan 2012)
Hospital admissions for NOF for people 75 years amp over (2008- Jan 2012)
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
In 2008 we recognised we had to change the way we delivered
health services and agree on a new direction
Fundamental reorientation to bull provide tailored individual care bull provide population based care bull provide support over the full range of a personrsquos life bull Support and enable self-care
The health system sees the primary point of continuity is based in the community
Specialist services are for acute episodic and complex care
We needed to make health priorities and the cost of health funding clear to everyonehellip
bull The competing demands for care far exceed our ability to fund
or resource them
bull Every new procedure denies care to someone else
bull As we continually explore better ways of working we need to
maximise the value of our resources (get more for the same)
bull To do this we need to prioritise how we invest
A connected system
Centred around people
That aims not to waste their time
Utilising health system data helped us focus our attention on those people most at-risk of ending up in hospital
Where do older persons falls occur
Community
How do we know that community falls prevention is a key programme for a health system
Canterbury population over 75 years
0
5000
10000
15000
20000
25000
30000
35000
40000
2008 2009 2010 2011 2012 2013 2014
Falls presentations to ED for people 75 years amp over (2008- Jan 2012)
Hospital admissions for NOF for people 75 years amp over (2008- Jan 2012)
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
We needed to make health priorities and the cost of health funding clear to everyonehellip
bull The competing demands for care far exceed our ability to fund
or resource them
bull Every new procedure denies care to someone else
bull As we continually explore better ways of working we need to
maximise the value of our resources (get more for the same)
bull To do this we need to prioritise how we invest
A connected system
Centred around people
That aims not to waste their time
Utilising health system data helped us focus our attention on those people most at-risk of ending up in hospital
Where do older persons falls occur
Community
How do we know that community falls prevention is a key programme for a health system
Canterbury population over 75 years
0
5000
10000
15000
20000
25000
30000
35000
40000
2008 2009 2010 2011 2012 2013 2014
Falls presentations to ED for people 75 years amp over (2008- Jan 2012)
Hospital admissions for NOF for people 75 years amp over (2008- Jan 2012)
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
A connected system
Centred around people
That aims not to waste their time
Utilising health system data helped us focus our attention on those people most at-risk of ending up in hospital
Where do older persons falls occur
Community
How do we know that community falls prevention is a key programme for a health system
Canterbury population over 75 years
0
5000
10000
15000
20000
25000
30000
35000
40000
2008 2009 2010 2011 2012 2013 2014
Falls presentations to ED for people 75 years amp over (2008- Jan 2012)
Hospital admissions for NOF for people 75 years amp over (2008- Jan 2012)
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
Utilising health system data helped us focus our attention on those people most at-risk of ending up in hospital
Where do older persons falls occur
Community
How do we know that community falls prevention is a key programme for a health system
Canterbury population over 75 years
0
5000
10000
15000
20000
25000
30000
35000
40000
2008 2009 2010 2011 2012 2013 2014
Falls presentations to ED for people 75 years amp over (2008- Jan 2012)
Hospital admissions for NOF for people 75 years amp over (2008- Jan 2012)
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
Where do older persons falls occur
Community
How do we know that community falls prevention is a key programme for a health system
Canterbury population over 75 years
0
5000
10000
15000
20000
25000
30000
35000
40000
2008 2009 2010 2011 2012 2013 2014
Falls presentations to ED for people 75 years amp over (2008- Jan 2012)
Hospital admissions for NOF for people 75 years amp over (2008- Jan 2012)
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
How do we know that community falls prevention is a key programme for a health system
Canterbury population over 75 years
0
5000
10000
15000
20000
25000
30000
35000
40000
2008 2009 2010 2011 2012 2013 2014
Falls presentations to ED for people 75 years amp over (2008- Jan 2012)
Hospital admissions for NOF for people 75 years amp over (2008- Jan 2012)
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
Canterbury population over 75 years
0
5000
10000
15000
20000
25000
30000
35000
40000
2008 2009 2010 2011 2012 2013 2014
Falls presentations to ED for people 75 years amp over (2008- Jan 2012)
Hospital admissions for NOF for people 75 years amp over (2008- Jan 2012)
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
Falls presentations to ED for people 75 years amp over (2008- Jan 2012)
Hospital admissions for NOF for people 75 years amp over (2008- Jan 2012)
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
Hospital admissions for NOF for people 75 years amp over (2008- Jan 2012)
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
An integrated care approach to community falls prevention needed to be bull evidencendashbased and delivered in homes bull meets patients carers and clinicians needs bull Promotes independence amp confidence and also reduces fear of
falling bull included carers working in a restorative way bull Connected clinicians together Healthpathways bull Contracted 4FTE Falls Champions bull Keep the primary care team in the centre
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
How did we measure improvement for participants clinicians and health system bull Outcome metrics hellipindividual clinician ED
NOF LOS amp mortality bull Process metricshellipindividual system bull Balancing metricshellipambulance system
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
Falls presentations to ED for people 75 years amp over (2008- July 2015)
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
Hospital admissions for NOF for people 75 years amp over (2008- July 2015)
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
OUTCOME SUMMARY
5500 people referred to programme in 3 years (16 of population)helliphellip5545 PrimarySecondary) Based on expected outcome trends bull 1083 fewer falls to ED bull 373 fewer NOF bull 86 fewer deaths 180 days discharge after NOF bull A ward reduction in hospital beds each year
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
OUTCOME SUMMARY
Total cost of programme over 3 years $18 m
Savings at bed-day rate $18 m
