In Canada, 4 out of 5 injury hospitalizations involving seniors were due to falls1. Commencing in 2016, North York Family Health Team (NYFHT) initiated a formalized falls screening program arising as a practice-based issue that could be addressed within an interdisciplinary primary care team, with many worthwhile benefits.
Health Quality Ontario had a chance to catch up with Joyce Lo (Project Manager) and Briar DeFinney (Quality Improvement Decision Support Specialist) to talk about the goals of NYFHT’s falls screening program and the strategies they use to provide care.
Members of the North York Family Health Team
Can you tell us how you got started with your falls screening program?
Our Primary Care Registered Nurse (RN) Lead at the time, Megan Elliott, was interested in formulating a quality improvement (QI) initiative focused on formalizing a standardized falls screening program to be rolled out within a team of 20 NYFHT Primary Care RNs working in 19 physician office locations. Specifically, this RN-led initiative aims to improve the number of FHT patients who are 75 years of age and older who have been screened for falls risk, assessed, and referred to appropriate follow up.
NYFHT serves a population of over 85,000 patients, of which a large portion (20%) consists of seniors. In the beginning, we focused on patients who were 75 years of age and older with osteoporosis. We defined this population in order to keep this quality improvement initiative manageable. Using an audit and feedback strategy, our Data Manager would send lists of patients who were eligible for screening to our nursing team. After focusing on this population for three years, we eventually expanded this to include all patients 75 years and over regardless of whether they have osteoporosis or not.
What does the screening process entail?
We adapted a screening tool that guides the assessment and management of falls in primary care offered through the Geriatrics Interprofessional Interorganizational Collaboration (GiiC) falls screening tool.We tailored it by adding other prompts to support documentation of health promotion and education, as well as referrals to other family health team services and external resources. NYFHT primary care RNs would screen every patient who was over 75 years of age during an appointment, who had not been screened in the last year, as per best practice guidelines. For patients who were found to be at risk during the assessment, the primary care RN provides health promotion and education to the patient using prompts on our assessment template.
What do you do with the screening results?
Depending on a patient’s screening and assessment needs, health promotion and education may be provided to the patient. The patient can be referred onwards for other FHT services, such as one-on-one follow up care with the FHT registered dietitian for nutrition support, FHT pharmacist for medication review, or FHT case worker for patients requiring more complex coordination and navigation of services. Referrals can also be made to NYFHT programs, for instance our nutrition group programs, or our NYFHT homebound program (Nurse Practitioner- led). The homebound program supports the frail elderly patients in the home setting, increasing timely access to primary care.
In addition to our internal NYFHT programs and services, our team also refers patients at risk for falls to external services, such as home and community care, formalized falls programs, and exercise programs depending on the patient’s needs.
Have you had any challenges developing the falls screening program?
The primary care team was in agreement with falls prevention being a priority issue, however a patient centered assessment of falls goes beyond the screening questions: it requires time to provide a thorough assessment and health education tailored to the patient. Because of this, it was challenging to fit a more comprehensive assessment into a patient appointment, amidst other patient care priorities. To facilitate the prioritization of this initiative, we leveraged support from the care team, from the patient’s primary care physician to all levels of FHT leadership, such as our executive director, medical director, clinical manager, quality improvement decision support specialist, and QI committee. To further support engagement of this initiative, the Primary Care RN team lead and other RNs helped to champion this initiative to support our patients in their journey to better health. It is also included as a patient safety quality dimension on our NYFHT QI plan, further demonstrating our commitment as an organization to reducing falls in the community and reducing hallway medicine.
What results have you seen so far?
Our previous indicator tracked the number of patients 75 years of age and older with osteoporosis who have been followed up for falls risk. In 2018/19, we had 590 patients who were eligible for falls risk screening. Our goal was to measure the number of patients who had been followed up with who had screened positive for falls risk.We had set a target of 25% screened for falls and reached 22% by the end of the fiscal year.
This year, we changed our custom indicator to include all patients 75 years of age and older who have been screened and followed up for falls risk. Our goal for the 2019/2020 fiscal year is to have 80% of this population screened for falls risk and to have 100% of those patients screening positive to be followed up with appropriately. We are currently collecting baseline data for this fiscal year and due to the indicator changing slightly, we are conducting several Plan Do Study Act (PDSA) cycles with the primary care RNs to receive continuous feedback and adapting and modifying the falls risk template to better suit the RNs’ workflow as well as each patients’ specific follow-up needs.
What are your next steps?
The literature suggests that a major, powerful predictor of future or recurrent falls is a history of falling. In the future, for patients who have screened positive for falls risk, we would like to incorporate follow up at a year’s time to reassess and provide additional supports to these patients.
We currently do not have the resources to track whether our patients end up in the emergency department, however, this year we are tracking 7-day post-hospital discharge follow ups and we would like to potentially combine these initiatives in the near future to determine if our falls screening program is making an impact on emergency department visits.
Read more posts in the fall prevention series on Quorum.
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1Slips, trips and falls: Our newest data reveals causesof injury hospitalizations and ER visits in Canada