Hamilton Niagara Haldimand Brant (HNHB) LHIN has seen a
steady decline in their rate of falls with injury among home care patients.
This indicator - first introduced in their 2017/18 Quality Improvement Plan (QIP)
- continues to be a focus within their organization and has resulted in an
approximately 50% rate reduction after 2 QIP cycles.
Focusing on high risk patients has been key to their success.
Health Quality Ontario had a chance to catch up with Heike Ben Sofia, RN, BScN,
MTS, LSSGB, HNHB LHIN’s Manager of Quality and Patient Safety to find out more.
How did you begin your falls prevention strategy?
It was important to first narrow down our falls prevention
efforts and prioritize patients who are at highest risk. We realized that
trying to prevent falls across all of our home care patients wasn’t achieving
results since the population was so large.
We completed dozens of Quality and Safety Reviews including a Patient
Record review of significant falls. We recognized that it takes considerable
effort on everyone’s part to prevent a single fall with injury.
We decided to leverage our partnership with the University
of Waterloo (U of W) to conduct some research together. We used Emergency
Department National Ambulatory Care Reporting System (ED NACRS) data to
identify the characteristics of injurious fallers and linked it to our adult client
health records (which includes RAI HC assessment data).
We looked at all patients with one or more days of adult
home care services during a defined period of time. In a table, patients were
divided by age group and number of falls resulting in injury per year. Within each
age group, we were able to determine the percentage of patients who fell with
injury. The rate of injurious falls by age group was compared when adjusting
for other risk factors and the elevated risk persisted for patients who were above
age 65 years of age, living in a retirement home. This helped us narrow down our
efforts to those patients at the highest risk of future falls.
Initially, when we looked at RAI HC assessment data alone,
it was capturing too many patients considered at risk, and so looking at patients
with the highest rate of falls with injury by age group narrowed the scope.
We created a custom falls indicator to track the percentage
of adult long-stay home care patients who had a fall with injury (instead of
tracking all falls) to identify the impact our interventions were making to the
highest risk group.
What tools do you use in your falls prevention efforts?
The research enabled us to create a Falls Monitoring Report
that is used by Care Coordinators and Patient Care Managers to track at-risk patients
based on inclusion and exclusion criteria. These criteria are informed by the
- Patient must have two completed RAI-HCs
- Number of documented falls greater than 0 on either both or
the last RAI-HC OR patient had a fall event (i.e. a fall with injury)
documented in the incident reporting system
- Age 65 and over
- Patient with 0 documented falls on both RAI-HCs
- Patient whose number of documented falls had decreased between
the first and second RAI-HC
- Age under 65 years
The Falls Monitoring Report is colour coded to identify patients
who meet the inclusion criteria so we can quickly identify and prioritize them.
The Falls Monitoring Report triggers Care Coordinator
interventions/actions to take and indicates what actions are outstanding. Our Care Coordinators take the lead in
organizing the falls prevention actions by educating the patient and family,
assessing and referring to appropriate services, and communicating and tracking
falls interventions. Our service providers in the field carry out the actions,
and monitor and report the effectiveness of their interventions.
The interventions must include:
- Completing a Falls Alert. This is a form sent to primary
care providers (the physician and those in the patient’s circle of care) that includes
the date a fall occurred, the level of harm that occurred, any interventions
and/or changes in the service plan required, risk factors identified, any
request for physician follow up if required, and a request for a medication
- Completing a Falls Risk Code and a Falls Referral Code.
These are required to communicate falls interventions with service providers
through the patient’s electronic record.
- The Falls Risk Code indicates that a patient is at risk for
a fall, and includes information about the risk and strategies to mitigate the
risk. It is shared with the service providers involved in the patient’s care.
- The Falls Referral Code is added to identify that the
patient is at high risk for falls with injuries and that fall prevention
interventions are to be carried out by service providers.
- Ensuring the Patient Falls Event is entered in our shared
(LHIN and Service Provider) incident reporting system.
- Completing documentation of falls strategies that have been initiated
and sharing notes with all contracted service providers who are assigned to the
- Educating the patient and family members about patient
specific falls prevention strategies, and the use of least restraints.
- Putting in place required care to prevent a subsequent fall
including referral to services.
As appropriate, interventions may also include:
- Completion of a Timed Up and Go (TUG) Score
- Referral for medication reconciliation to be completed by
our internal pharmacist, rapid response nurse, contracted nursing service
provider, or community pharmacist
- Referral to a community exercise and falls prevention
- Completion of a home safety assessment
- Assessment for mobility aid needs
- Recommendation of vitamin D supplementation
Our Care Coordinators have a dashboard that is also colour
coded to easily identify priority patients, actions taken, and actions that are
outstanding. It acts as a “checklist” to
ensure strategies have been implemented.
What strategies are you working on now?
We’ve seen success with using digital tools such as the
Falls Monitoring Report and Care Coordinator dashboard and now, we’re working
on creating a Falls Care Pathway to improve the flow of information between Care
Coordinators and service providers.
These tools will be leveraged in the development of a Falls Care
Pathway in collaboration with HNHB LHIN service provider organizations and
community support service organizations such as adult day programs and retirement
Falls prevention is often a complex undertaking with many
moving parts that require coordinated efforts. The Falls Care Pathway that we
are working on now, will help to clarify the responsibilities of everyone
involved and include timelines for completion and check back to review the
effectiveness of the strategies.
HNHB LHIN Falls Care Pathway (DRAFT)
Click here for PDF version.
Can you tell us about your Falls Communication Model?
Our Falls Communication Model provides a framework for
optimizing the use of digital tools/platforms and appropriate communication
with those in the patient’s circle of care:
Tools and Platforms used to communicate falls reports and
- Our Client Health Record Information System (CHRIS) is our
patient record where we document assessments, risk codes, referral codes, and
collect provider reports regarding progress on the care plan goals.
- Health Partner Gateway (HPG) is our platform for sharing
information about the fall from CHRIS with Service Providers.
- Incident Management System is a tool used to report and
communicate details of a patient fall incident, the contributing factors, root
cause analysis, and preventative actions.
- Fax is the platform for communicating Falls Alerts to
- Patient Care Dashboard is used by Care Coordinators to
identify high risk patients at a glance, review the Falls Monitoring Report,
tracks falls interventions completed and outstanding, and evaluate progress on
falls prevention for the specific patient.
Our focus is on building a patient-centered care plan based
on the information that is shared within the Circle of Care, working together
to prevent falls for a high risk patient. That Circle of Care includes:
- The Patient and Caregivers
- Hospital and Community Care Coordinator
- Service Providers
- Primary Care Providers
- Community Support Services
Click here for PDF version.
What are your next steps?
Our next steps are to get feedback for this next phase of
development from our patients and families and increase the oversight that our
Patient Care Managers have to their team’s completion of falls prevention
Patients on the Quality and Patient Safety Committees have
had input into the falls prevention strategies, report and dashboard and will
be continuing to provide input. The HNHB LHIN’s Patient and Family Advisory
Committee will be providing feedback at an upcoming meeting.
The Patient Care Managers will provide ongoing feedback to
the care coordinators on their teams about the performance of the staff member
and the team regarding this indicator and the completion of the falls
prevention activities for high risk patients using the Falls Monitoring Report
and the Patient Care Manager Dashboard.
We have been tracking the relationship between medication
reconciliation efforts and falls, and tracking the impact of our medication
reconciliation efforts on hospitalizations and/or emergency department visits. We
will be improving the accuracy of our measurement of the impact of completing
falls prevention activities on return to hospital for an injurious fall.
What advice would you give to home care organizations
wanting to improve falls prevention efforts?
Give Care Coordinators a way to organize themselves around
high risk patients by providing them with ongoing data via a digital dashboard.
The Care Coordinator plays a key role in preventing a serious fall with injury
by managing all of the falls prevention activities. The Care Coordinators
appreciate using their dashboard since it acts like a “checklist” that
organizes tasks done and those that are outstanding.
Partner up with primary care. We consulted with physicians
prior to creating our updated falls alert form so that we captured what they
wanted to know and what we are asking the physician to follow up on, when a
patient has fallen.
Falls prevention strategies go hand-in-hand with medication reconciliation
(MedRec) policies. Research shows the connection between MedRec, falls and
hospital readmissions. Ensure your strategies include a focus on MedRec.
Finally, falls prevention must continuously be on everyone’s
mind. It requires an ongoing, collaborative effort and multi-pronged focus.
Since it involves the patient in their own home, it must be patient specific
and every service provider in the home needs to include falls prevention as
part of their patient centred care plan.
Read more posts in the fall prevention series on Quorum.
How do you prevent falls in home and community care? Share your advice and lessons learned by clicking on “ADD A COMMENT” below.