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#actiononfalls
The studio
customerfirst
Consensus and Commitment Workshop
May 2018
HAVE A MORE
JOINED UP
APPROACH
Agree roles and
contributions to
coordinated
management and
support
Improve support for
people going home
after a fall-related
hospital attendance
or stay
Participants
said we need
to…
Optimise recovery
following a fall
Enable more people to
participate in exercise for
falls prevention and bone
health
Link risk identification of
frailty and falls
Support the work
force to do the right
thing
Support the
workforce to work
differently Coproduce
services
More community-
based support
Data and local intelligence to better
understand how to improve services and
understand if we’re making a difference
Working collaboratively to support people to participate in evidence based exercise
HSCP Falls Leads Meeting
20th September 2018
Working collaboratively to support people to participate in evidence
based exercise Progress since December 2017
• What’s changed?
• What has worked well and why?
• What has been more challenging and why?
• What are your next steps?
https://www.hqsc.govt.nz/our-programmes/reducing-harm-from-
falls/publications-and-resources/publication/984/
https://www.hqsc.govt.nz/our-programmes/reducing-harm-from-
falls/publications-and-resources/publication/1263/
Working collaboratively to support people to participate in evidence
based exercise A national data set?
Collecting common data across the HSCP areas
would enable us to:
• build a national picture in relation to strength and
balance provision and its impact on falls prevention
• give us all a stronger database with which to plan
and make the case for future investment into falls
prevention
• strengthen the argument for strength and balance
activity as a key component of falls prevention plans
and programmes
• provide a clear picture of what is being delivered and
how it makes a difference
• add to evidence of how strength and balance
programmes help to increase independence and
confidence, and reduce fear of falling
Working collaboratively to support people to participate in evidence
based exercise A national data set?
Next
step:
Survey?
Working collaboratively to support people to participate in
evidence based exercise
• Actions for you?
• Who do you need to have a conversation with locally?
• What needs to be done nationally?
Falls and Frailty
HSCP Falls Leads Meeting
20th September 2018
What is the level of frailty of people accessing assessment and
rehabilitation services following a fall? Four services: Ayrshire and Arran (ICES), Aberdeen City (CAARS), Inverclyde
(RES) and GGC Community Falls Prevention Programme
Mild Mod Severe
Falls and frailty: prevention, screening, management How do approaches and interventions dovetail?
• How could or should falls prevention fit in
when a person is identified as living with
mild, moderate or severe frailty?
• Should the falls multifactorial screening
we undertake be augmented/changed to
focus more on frailty? Or are you doing
this already? How would this change
interventions/referrals post screening?
Living Well in Communities
Jo Thomson Improvement Advisor
Enabling health and social care improvement
Introducing Living Well in Communities
- Background to Living Well in Communities - Regional working - Background to frailty work - Frailty in the North
Introducing Living Well in Communities
We work in partnership with health and social care organisations to enable people to live well for longer at home or in a homely setting.
Supporting people to live well in their communities
Enabling people to live well in their community for longer
Implementing preventative
models of care
Identifying people before
crisis
Planning for the future
Regional working
Regional working
Nathan Devereaux [email protected]
Jo Thomson [email protected]
Michelle Church [email protected]
Why work as a region?
• Access to resources
• Efficiency- economies of scale, avoid duplication
• Mutual learning
• Moral imperative- really important issues facing society cannot be tackled by one organisation on its own
Background to frailty work
Individuals with potential for preventative support
Data provided by ISD.
Key population groups for preventative support
People with
frailty
People with palliative
care needs
People living with multiple long term conditions, such as
COPD
People with chaotic
lifestyles
Identifying people before a crisis
Community
Acute
Individuals at the front door
Earlier reactive individual
Planned population
Introducing Living Well in Communities
Electronic Frailty Index
People registered with test GP practices aged 65 and over.
Risk of hospitalisation
20% 40% 70%
How the eFI works…
442W.
66AS.
N097.
G20z.
8BL2.
9N2Q.
C10F.
Mild Frailty
Moderate FrailtySevere Frailty
Multi-dimensional falls and frailty assessment
Evidence
Regional working Frailty in the North
Living Well in the North
“We will collaborate to improve identification of people with frailty and develop evidence-based
targeted care and support to improve their outcomes.”
Linking identification with services/support
?
Examples of interventions
Mild Moderate Severe
Nutritional interventions
Reablement Bed based intermediate care
Exercise and physical activity
Polypharmacy review
Community-based geriatric services
Smoking cessation Primary care MDT Palliative care
Reduce alcohol Immunisation Hospital at home
Falls prevention Anticipatory care planning
Anticipatory care planning and carers
support planning
Regional working
Nathan Devereaux [email protected]
Jo Thomson [email protected]
Michelle Church [email protected]
Thoughts and reflections
Measuring impact
Evaluation – focus on outcomes
People Staff Organisation
Find out more…
Enabling health and social care improvement
website: ihub.scot
twitter: @LWiC_QI
blog: www.livingwellincommunities.com
National Falls Leads Event What does Lifecurve tell us?
Susan Kelso
AHP National Lead Early Intervention
Time since starting on ‘curve’
Rehab/reablement
Reactivation
Compensation
Care and support
© 2003-2018
Gore, Jagger, Johnson,
Kirkwood,
Kingston
Compression of functional decline (CFD)
Reasons for undertaking the National Survey Taking a ‘snapshot’ of current interventions
Understanding the economics of intervention and cost consequence
of when this happens ‘late’
Plan for the future – workforce, activity and partnership - by 2050 1 in 5 people in the world will be 60yrs or over (1M in Scotland)
Encouraging a shared dialogue – what matters most?
How can we mitigate against barriers to ageing well?
Ref: https://academic.oup.com/ageing/advancearticle/doi/10.1093/ageing/afy145/5079486
Survey data collected from the person using services
ADL Questions – randomised order + time
Additional Questions – living circumstances
Lifecurve Survey Questions
Process/Governance
• Permission to gather and use CHI details PBPP/Privacy Impact Assessment
• People without capacity to consent contributed where Guardian/Power of Attorney in place
• Information provided in easy read version – in partnership with SLT AAC and Healthy Literacy colleagues
• Testing over 5 month period
• FAQs and background information on COP
• 100 Communication leads identified
Practitioner/Service Questions
• Where are you seeing AHP?
• Travel method?
• Who referred?
• First or Return appointment?
• Intervention type?
• Board/Partnership
• Profession/Grade
Linked data for 2010/11 – 2016/17 includes:
– Hospital activity (physical, mental and
women's health) and costs.
– GP prescribing.
– Long term conditions.
– Derived variables (age, deprivation, Board,
IJB, urban/rural).
– SPARRA for 2016/17
– In time link social care data.
Age Profile of participants (Survey respondents N= 13448)
Age
of
par
tici
pan
t
Percentage/age
Who took part in the Survey?
Additional living circumstances questions
Number by question
7%
42%
62%
36%
29%
68%
22%
38%
56%
4%
Which AHP..where?
Services at Pre-curve N
um
be
r o
f p
arti
cip
ants
se
e in
eac
h s
erv
ice
25% of total sample (n=3468)
Services at Mid-curve N
um
be
r o
f p
arti
cip
ants
se
e in
eac
h s
erv
ice
13% of total sample (n=1782)
Services at Late-curve N
um
be
r o
f p
arti
cip
ants
se
e in
eac
h s
erv
ice
43% of total sample (n=5750)
Community Rehabilitation returns
• 1641 of total participants (4620 are missing data) – 351 were seen in a first appointment – 1229 were seem in return appointments (75%) – (missing data = 61)
• Reason for intervention – Treatment/Rehab -=886 – Assessment/Review = 644 – Maintenance = 33 – Advice/Education=36 (Missing data = 42)
• Age: 19-44 = 50 45-64 =169 65-74=157 75+=432
Who are the people?
Which AHPs? • 124 dieticians
• 613 occupational therapists
• 536 physiotherapists
• 172 support staff
• 103 SLT
• 54 podiatrists
Participant circumstances • 82 said they were a carer or
both a carer and cared for
• 626 said they were beginning to struggle or needed help to manage at home
• 175 said they have some kind of regular activity
• 477 reported their wellbeing could be better to being very bad
New evidence about preventing falls for older people coming out of hospital
Ref: https://britishgeriatricssociety.wordpress.com/2018/05/21/why-it-gets-harder-to-prevent-falls-when-older-people-leave-hospital/
What works for this group of people?
• Hospital to home is a ‘sensitive transition’ – most have experienced prolonged bed-rest, changes in medications, diet and daily routine
• Unplanned readmission may indicate that not everything was addressed on original admission
• Older people happy to engage in falls prevention at time of discharge – more tailored intervention specific to their risk factors might be more effective
• Home modification and nutritional supplementation for people who are malnourished
• Regular supervision over an extended period may improve compliance and safety
Ref: https://britishgeriatricssociety.wordpress.com/2018/05/21/why-it-gets-harder-to-prevent-falls-when-older-people-leave-hospital/
Heard
Impact example from Aberdeenshire
SAS asked: “What have you stopped doing?”
Relieved
Hopeful
Supported
Encouraged
Fortunate
Emotional Touch Points
62% of the patients referred were NEW to the community services
Services intervening at Lifecurve points
15 ADL Lifecurve markers
Number people seen by AHP at each marker
Service Types
Reactivation
Rehabilitation
Compensation
Care and support
Opportunities for optimizing independence
• Support from Professional bodies eg. CSP – Rehab Matters Campaign; RCOT – Living not Existing Campaign; RCSLT – Interrupting intergenerational cycle
• Request for Assistance model applied to Adult Services eg Forth Valley Single Point of Access – NES Fellowship
• Adult social care: Reform work, Community Led Support, Neighbourhood Care, Care at Home
• Opportunities within MDT in Primary Care
• Partnerships with Council, Third and Independent sectors
Falls and frailty: prevention, screening, management How do approaches and interventions dovetail?
https://www.youtube.com/watch?v=5LacoagyPzo&feature=youtu.be
Falls and frailty: prevention, screening, management How do approaches and interventions dovetail?
1. What is your experience locally of how frailty and falls are joined up? What is
working well? Are there any challenges?
2. What are your thoughts on how the use of the electronic Frailty Index (or other
screening approaches) could join up with existing falls prevention and management
approaches (assessment and interventions)?
3. Does the approach we are currently taking need to adapt so that there is a more
coherent ask of staff, a better experience for the person and less duplication for
both?
• Actions for you?
• Who do you need to have a conversation with locally?
• What needs to be done nationally?
Helping people make healthier choices about alcohol as
they age
Whats the problem?
20% of the over 50’s population are exceeding recommended alcohol units; that’s 4.5 million people • “Baby Boomers drinking more than previous generations • Hospital admissions costs are 12 times more for 55-74 year olds than 16-24 year olds • Drink Driving prosecutions have increased by 40%
Why are we needed?
“Whenever I see articles about you should and shouldn’t be
drinking, I must confess I have to stifle a yawn”
Laurie Graham, Daily Mail • Health Advice can change • Nanny state messaging can be
rejected • Media Portrayal can be dismissive • Binge drinking perceived as a young
person issue • Alcohol use can increase in response
to life transitions • UK Wide policy inconsistent
“Helping people make healthier
choices about their
alcohol use as they age”
What we do:
• Advise
• Connect
• Train
• Support
We do this by:
1. Providing, Campaigning, Education & learning, Building resilience & age appropriate services and interventions.
2. Influencing policy & practice about preventing alcohol dependency in later life
3. Improved health & wellbeing for people aged 50 and over who are at risk of developing alcohol dependency
4. By our person centred approach (always alongside people)
What we do?
KEEP IT SIMPLE !
PRE Who? Anyone aged 50 & over in the community
Where? Glasgow city, community groups,
workplaces, supermarkets, intermediary groups
What? Alcohol information & advice for the individual
or family member
Activity: ABI’s, public stalls, awareness sessions, drop-in
advice
TRA Who? Anyone working with, supporting or in
contact with the over 50’s.
Where? Citywide training wherever needed
What? Helping people recognise & respond to
someone else’s risky drinking
Activity: Peer & Volunteer, Frontline staff & Addiction staff training on Alcohol &
Ageing
RES Who? Anyone aged 50 and over, drinking or at risk of
alcohol related harm & needs alternative coping
strategies
Where? Citywide firmly placed in local communities.
What? A range of interventions that enhance coping and activities that promote improved social networks & participation
Activity: 6 session group work, Social activity, Stand
Alone sessions, Buddy service
DES Who? Anyone aged 50 &
over. Currently drinking or recently stopped. Plus
Family/ concerned others.
Where? Citywide mainly in peoples homes and in the
local community. Assertive outreach.
What? Range of age appropriate alcohol
interventions & support.
Activity: 1-1 Support, brief support, complex support, Mutual Aid support (group work) & 5-step support for families/ concerned others
Delivery model
Engagement with Programme
16,181 People engaged with
DWAW Glasgow
Since 2015
79,811 People engaged with
DWAW website Since 2015
Prevention & Campaigning: Key Stats
2015-2018
1074 ABI/
screenings
106 Public Stalls
7732 contacts @
stalls
2052 contacts @ transport
hubs
3 Peer trainers
recruited 46 Employer awareness
session delivered
526 people attended
Awareness sessions
24 Intermediary orgs engaged
256 marginalised
people supported
4 Local Media
campaign
Training & Workforce Development: Key stats
• People attended Frontline & Peer/Volunteer training 527
• People attended Frontline ½ day training 364
• People attended Enhanced training 85
• People attended Bespoke training 87
Building Resilience: Key stats
293 people completed 6 session CBA course
1461 attended stand alone sessions
920 people attended social & skills activities
482 people attended our social events
56 volunteers recruited & trained
15 people received our befriending service
Direct Engagement & Support: Key Stats
551
people assessed & supported
244
people attend peer support meetings (MAP
5
Peer facilitators recruited & trained
17
family members/ concerned others
supported
DES
• 56% male and 44% female
• Average age at entry to service is 60 years
• 59% late onset drinkers (after the age of 40)
• Drinking the equivalent of 2 bottles of wine (12.5%) on average at assessment (18 units)
• Mean AUDIT score at assessment 22.87 (Higher risk Drinkers)
• Most common referral pathways are self-referral (24%), followed by referral from statutory (18%) and non-statutory substance misuse services (16%)
• People stay in DES for just over four and a half months on average
Direct Engagement & support: Service user characteristics
Improvements in problem drinking, mental health and wellbeing
Differences in AUDIT scores (mean) between demonstration areas
Falls prevention- What we know?
Client view:
“Falls are due to old age, rather than alcohol related”
Staff view:
“traditional treatment services are not always considering falls to be alcohol related”
“not asking the questions”
“treatment service not offering home visits (tailored to their capabilities)
“GPs not always “joining the dots” between falls & alcohol”
DWAW survey:
“15% of the higher risk drinkers said they or somebody else had been inured as a result of their drinking in the last 12 months alone (presumably quite a few of the injuries are caused by falls). Also, we know that older people are more susceptible to imbalance after acute alcohol ingestion making them susceptible to falls and that both alcohol misuse and increasing age are risks factors for osteoporosis (so double whammy)”
Falls prevention- What we do
• PHQ9: Trouble falling or staying asleep, or sleeping too much?
• Audit: Have you or somebody else been injured as a result of your drinking?
• General assessment of need: “more questioning to understand the falls/ injuries”, “where & when are you falling”, “link into OT”
• Alcohol withdrawals: balance is effected, shakes,
existing mobility issues
• Medication check: review of meds & interactions with alcohol
• Physical check of home: handrails & alarm systems etc
• MoCA: cognitive screening tool
Any questions or feedback?
Free & Confidential Service People aged 50 & over
Living or working in Glasgow City
Easy Referral process Webchat via website
TEL: 0800 304 7690
Web: www.drinkwiseagewell.org.uk
Drink Wise Age Well
• Actions for you?
• Who do you need to have a conversation with locally?
• What needs to be done nationally?
Improving transitions from the hospital to the community for people who fall
HSCP Falls Leads Meeting
20th September 2018
Improving transitions between the hospital for people who fall Exploring the system-wide costs of falls in older people in Torbay (Kings Fund,
2013)
• On average, the cost of hospital, community and social care cost services for
each person who fell were almost four times as much in the 12 months after
admission for a fall as the costs of the admission itself.
• Comparing the 12 months before and after the fall, the most dramatic increase
was in community care costs (160%), compared to a 37% increase in social care
costs and a 35% increase in acute hospital care costs.
• While falls patients in this study accounted for slightly more than 1 per cent of
Torbay’s over-65 population, in the 12 months that followed a fall, spending on
their care accounted for 4% of the whole annual inpatient acute hospital
spending, and 4% of the whole local adult social care budget.
https://www.kingsfund.org.uk/publications/exploring-system-wide-costs-falls-older-people-torbay
Improving transitions between the hospital for people who fall Findings of a recent systematic review and meta-analysis
• Falls leading cause of hospitalisation
• Hospital stays are an adverse event, during which older people have faced
prolonged bed-rest, changes in medications, diet and daily routine
• Length of stay increasing with an increase risk of adverse events following
discharge
• General population: 30% fall with 10% resulting in serious injury
• Post discharge population: 40% fall at least once in first 6 months with 54%
resulting in serious injury
Improving transitions between the hospital for people who fall Findings of a recent systematic review and meta-analysis
• Home hazard modification: particularly
if history of recent falls.
• Nutritional supplement: for
malnourished older people.
• Exercise: need for regular supervision
to increase safety, challenge balance
and maintain compliance.
• Falls prevention interventions that are
effective in the general population may
require tailoring to be effective in
older adults recently discharged from
hospital
• Falls prevention education around
time of discharge: tailored to individual
falls risk factors, could improve
engagement in falls prevention
strategies following hospital discharge.
Improving transitions between the hospital for people who fall Following hip fracture: CSP Hip Sprint Audit
https://www.fffap.org.uk/FFFAP/landing.nsf/phfsa.html
Improving transitions between the hospital for people who fall Following hip fracture: CSP Hip Fracture Standards
• Only 1 in 5 services
can maintain the
continuity of hip
fracture care
between acute and
community settings.
• Average wait of 15
days, but could be
as high as 80 days,
before receiving
home rehab.
https://www.fffap.org.uk/FFFAP/landing.nsf/phfsa.html
Frailty at the Front Door Collaborative
September 2018
Enabling health and social care improvement
Aim of the collaborative
Potential benefits for people living with frailty
include:
• Reduction in the need for hospital care through the consideration
of a range of care options
• More likely to be supported in their own home with the
appropriate level of care
• Shorter periods of time in hospital if admission is required
• Reduction in placements in long term care
• Reduction in unnecessary ward moves
• Improved patient experience
Potential benefits for participating NHS boards include: • Reduction in avoidable admissions • Reduction in length of stay • Increased bed capacity • Improved patient flows • Reduction in re-attendance rates • Clearly defined and effective pathway for frailty, and • Significant cost benefits.
Who are our partners?
A coordinated approach
Change concept 1 - Improving recognition
CO-ORDINATE
ASSESS
IDENTIFY
• Choose a suitable frailty screening tool
• Agree your threshold for CGA
• Identify your area of focus
• Test the screening process
1 or more ticks?
Minimum inclusion point?
Change concept 2 - Improving response
CO-ORDINATE
ASSESS
IDENTIFY
• Develop a multidisciplinary CGA team that has the appropriate level of expertise
• Test out competency framework to support the development of advanced roles for ANPs/AHPs
• Ensure early involvement of CGA team
• Commence Comprehensive Geriatric Assessment that include the following domains:-
– Medical
– Mental Health
– Functional capacity
– Social circumstances
– Environment
Change concept 3 - Improving coordination of care
CO-ORDINATE
ASSESS
IDENTIFY
• Develop and test a multi-disciplinary frailty focused huddle aiming for 7 day cover
• Explore the diverse range of services across health and social care
• Use diagnostics from CGA to inform decision making
• Ensure there is sufficient
– Autonomy to make essential care decisions
– Capacity to support decisions and coordinate care across traditional boundaries
2018 2019
Dec
Jan
Feb
Ma
r
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Ma
r
Apr
May
Launch Event
Board Report
Board Report
Board Report
Board Report
Board Report
Board Report
Board Report
2nd site visit – Value stream mapping/diagnostics/progress
WebEx – HIS ‘Think Frailty ‘ tool
development
Steering Group
1st site visit – Pathway
follow/support and challenge sessions
Learning Session 1
Learning Session 2
Delivery group
progress meeting
Progress
Progress
Forth Valley Royal Hospital
St Johns Hospital
Dumfries and Galloway Royal Infirmary
Testing frailty screening, CGA & huddles using FIT nurse
Testing frailty screening with assessment nurses in CAU
Testing geriatrician led MDT huddles for >65’s
Progress
Queen Elizabeth University Hospital
University Hospital Monklands Opened a frailty ward
in August 2018, testing frailty screening in ED
Secured permanent funding for short stay frailty ward, testing increased medical review in specialty wards
Outcome Measures – people over 75 years of age
TIME
Patients No or %
D/C within 24 hrs (from area of focus)
In hospital after 7 days (admitted to DME)
In hospital after 30 days (admitted to DME)
d/c 48hrs
Progress – QEUH (DME average length of stay)
Progress – FVRH (% of over 75’s discharged within 24 hours)
Hospital Falls
#SPSP10
• Teams develop own context specific measures
• Learning from data influences tests of change
• Coaching for accurate recording of falls and falls with harm
• Coaching to individualise risk assessment and care planning
• Education linked to conditions & health needs: delirium, hypotension, continence care, medicines
• Patient & family involvement
• Staff at all levels empowered • Teams choose interventions for testing
based on local context, data, clinical judgement and individual patients
• Assessment & care planning redesigned and individualised
• Care interventions aligned with clinical conditions and activities to improve and maximise mobility & functioning
• Organisational priority and multi-professional leadership • Clear aim using data and patient stories • QI methodology and support to understand causes of
falls • Cycle of testing, learning and data review with clinical
governance, falls groups, frailty networks
• Multi-professional issue • Falls and harm are not
inevitable • Falls can’t be considered in
isolation
Key success factors
Board and ward level
support
Engagement of frontline
staff in design
Education and training
Good quality reporting data and learning
Culture change
© NHS Improvement July 2017
#SPSP10
Outcome Primary drivers
Reduce falls and falls with harm through:
•Individualised risk assessment and care planning based on people’s clinical conditions and health needs and their care setting. •An approach that promotes mobilisation and meaningful activity to enhance cognitive and physical functioning.
Board and ward level support for improvement
Person centred care which is aligned with underlying heath conditions and clinical needs (continence care, hydration, cognitive function, medicines, physical ability)
Effective team working to maintain a safe environment (huddles, post fall review / debrief, communication at discharge)
Promote mobilisation and meaningful activity
Education and QI support, using data to drive improvement
#SPSP10
“The shift from hospital to home is a sensitive transition time. Hospital stays are an adverse event, during which older people have faced prolonged bed-rest, changes in medications, diet and daily routine” Naseri, C et al (2018) Reducing falls in older adults recently discharged from hospital: a systematic review and meta-analysis
#SPSP10
#SPSP10
#SPSP10
Community falls prevention; rehab; discharge support
Hospital Front Door MDT Assessment – Falls, Frailty
Physio / OT Rapid access clinic; Care /Discharge Plan
Community rehab or discharge support
Falls Outpatient Clinic
Falls Prevention Team
E- Frailty in Primary Care
#SPSP10
Table top discussion
Improving transitions between the hospital for people who fall
Questions
• What are the needs of the patient group who are frail
and at risk of falls, and who possibly also experience
cognitive impairment such as delirium? What do we
need to do differently for them in terms of their care
approach to meet their needs?
• What can we do to improve communication and care
experience at the community / hospital / community
interface for people who are frail and at risk of falls:
• Where does this work well just now?
• How can we build on this?
• What can you take forward as next steps?
Improving transitions between the hospital for people who fall
• Actions for you?
• Who do you need to have a conversation with locally?
• What needs to be done nationally?
Any Other Business
HSCP Falls Leads Meeting
20th September 2018
Data Update Local Intelligence Support Team Falls Dashboards
Thank you and safe journey home
