AFFINITY (Activating Falls and Fracture Prevention in Ireland)

National Falls Prevention and Bone Health Implementation Project

St. Columcille’s Hospital Loughlinstown.

N. Van den Bergh, S. Noёl, S. Doyle, M. Doyle, C. Oak, M.Coakley, M.Ging, R. Doyle

Background

St Columcille’s Hospital (SCH) is a model 2 hospital

that became a pilot site for the National Falls Prevention

and Bone Health Implementation Project known as

“Affinity” in 2013. The purpose of the project is to

implement the “National Strategy for the Prevention of

Falls & Fractures in Ireland’s Ageing population” and to

develop a robust governance framework to monitor

progress and ensure accountability & sustainability.

The Vision of the National Strategy is a “life free from

falls and fractures in our ageing population”. Affinity

aims to prevent harmful falls amongst persons aged 65

years and older, enhance the management of falls and

improve health & wellbeing through a focus on bone

health”.

DXA Referral Results

67% of patients attending the new monthly falls

clinic required a DXA scan. 33% did not require a

scan and 41% were on bone health meds prior. Same

day scanning was introduced as part of the pilot

project. 100% of patients scanned presented with

Osteopenia (62%) or Osteoperosis (38%). 95% of patients (23/24) were on 4 or more medications

when attending the falls clinic .

Future considerations

The National Strategy for the Prevention of Falls &

Fractures in Ireland’s Ageing population building

capacity plan aims to provide access to 100% of the

population aged 65 years and older by 2018. The

current target for this period (Installation 2) is 30%.

The St. Columcille’s Affinity project has been

implemented within current resources and is

successfully targeting between 15 - 30% of the

population over 65 years of age.

Our figures indicate that additional falls clinics (up

to 2-3 per month) will be required to meet the

growing need for the demographics of the area.

Capacity building will have an impact on services in

particular Occupational Therapy, Physiotherapy and

DXA scanning.

Aim To develop a hospital wide falls prevention and

management initiative encompassing the three pillars of

Access, Quality & Value in three stages i.e. Prevention,

Case Finding and Interventions.

Falls Clinic Results We ran 6 clinics during the pilot project, assessing 24 patients. Age range

was 65 to 95years (71% Female). 21% of patients had not had a fall, but

were identified as a falls risk. 70% of patients (n = 17) lived with family,

8% (n=2) resided in nursing homes, and 20% (n = 5 lived alone). The

graph below identified important issues to be addressed in a falls clinic.

Physiotherapy: All patients had a full falls assessment including

musculoskeletal and balance interventions. All 24 patients had either a

BERG or TUG (if wzf is used). See graphs below. Only 2 patients did not

need to return to the Day Hospital for ongoing physiotherapy rehab.

Occupational Therapy: 37% (n=9) required onward referral to COT

for home modifications. Level 3 assessments require completion of the

MMSE however further cognitive testing was required on 12% of patients

reporting new cognitive complaints. 33% of patients required assistance

with PADL’s & 79% were assisted with Domestic ADL tasks.

Conclusion The introduction of a hospital wide case finding

approach successfully identified a cohort of patients

that were not previously identified in the system.

All patients identified as falls risk and discharged

home from the MAU (20% of those screened)

attended the new MDT falls and bone health clinic

benefiting from same day access to DXA,

Occupational Therapy, Physiotherapy, Nursing, and

Medical assessment and interventions. The National

Falls Prevention and

Bone Health Implementation Project Aims:

Case finding: Identifying

individuals at higher risk of falls & fractures who will benefit from individualised

attention

Interventions: Co-ordinated,

person centred intervention for

management and prevention of falls

& fractures.

Prevention: Supporting happy & healthy ageing

& self management.

Method

Access

Hospital wide Case Finding – a pre existing Falls

Multidisciplinary working group expanded its scope with

the aim that going forward a case finding approach

would exist for all hospital patients. The falls risk

assessment tool stratify / level 1 screen was introduced

to the MAU and Day hospital. This was already standard

practice for inpatients.

MAU All patients over 65 years presenting to the MAU

were screened using the stratify. If a patient was

discharged home and considered a falls risk, they were

provided with information and received an appointment

for the new falls clinic.

Day Hospital - A new monthly falls clinic was

established where level 2 and 3 interventions were

provided to ensure all aspects of falls prevention &

management were implemented.

Quality

Policy – Guidelines were developed based on national

and international best evidence.

Education – Teaching sessions for the staff in the MAU

and Day Hospital were organised to include: Factors that

affect falls; Why and how to assess falls risk; What can

be done to prevent falls & What to do if someone falls.

Value

In Patient

• Assessment compliance

• Number of falls

• Number of staff attending education

MAU

• Assessment compliance

• Number of Referrals versus attendance of over 65’s to MAU

Day Hospital

• Number of attendees to falls clinic

• Interventions required

0

10

20

30

40

50

60

70

80

1 2 3 4

seco

nd

s

patient

TUG scores

0

10

20

30

40

50

60

1 3 5 7 9 11 13 15 17 19

BE

RG

sco

re

patient

BERG scores

Issues identified during Level 3 assessments on 24

patients

196 6

11 9

02468

1012

Eye

rev

iew

Low

moo

d

Foot

prob

lem

s

Urin

ary

inco

ntin

enc

e

CO

T re

ferr

al

sent

Com

mun

ity

Phy

sio

Issues identified

No

of p

atie

nts

Results Referral rate from MAU: Pilot period On average 155 patients over 65 years presented to the MAU each month

during the pilot period. The Stratify completion rate was 13% on average

(Range from 8% to 22%). Compliance with the screening improved as the

project progressed reaching 29% after the pilot period. Of the

patients screened on average 56% were found to be at risk of falls

(range 29% - 73%). 20% of those screened and discharged home from the

MAU were found to be at risk of falls. These patients were invited to

attend the monthly Falls & Bone Health Clinic. A Falls and Bone Health

Booklet with workbook pages was developed and provided to each

attendee.

Cognitive impairment based on MMSE scores

16, 66%

3, 13%

5, 21%

normal mild moderate

Self reported ADL ability

16

7

1

17

6

1

5

14

5

0 2 4 6 8 10 12 14 16 18

Ind P.ADL

Assist P.ADL

Dependent P.ADL

Ind Transfers

Assist Transfers

Dependent Transfers

Ind D.ALD

Assist D.ADL

Dependent D.ADL

Results from DXA referrals

29%

41%

25%

4%

not required osteopenia osteoperotic DNA

References Health Service Executive (2008) Strategy to Prevent

Falls and Fractures in Ireland’s Ageing Population

Report of the National Steering Group on the

Prevention of Falls in Older People and the

Prevention and Management of Osteoporosis

throughout Life. June 2008

National Strategy for the Prevention of Falls &

Fractures in Ireland’s Ageing population”

National Institute for Health and Care Excellence

(2013), Falls assessment and prevention of falls in

older people .Manchester, NICE

COLLAGE (2013) National Strategy on Falls &

Bone health

Health Service Executive (2012) Quality and Safety

Prompts for Multidisciplinary teams