five hills health region home care. 1-oct-15saskatchewan falls collaborative2 background site: moose...

Five Hills Health RegionHome Care

Apr 19, 2023 Saskatchewan Falls Collaborative 2

BackgroundSite:

•Moose Jaw Union Hospital

Team:

•Home Care and Community Therapies

Patient Population:

•Home Health Service Clients, Team 1 and 2

Rationale:

•These clients receive more long term service that typically involves personal care support

•Higher needs client base, higher risk for falls

Apr 19, 2023 Saskatchewan Falls Collaborative 3

AimPurpose:•To decrease falls by 20% or more by March 2010

Goals/Objectives•To have 100% of falls reported to Client Service Managers•To establish a process to identify at risk clients•To ensure that all at risk clients have falls prevention interventionBoundaries:•Exclude Team 3 home services clients (February 2012 – included Team 3)

Aim

• Challenges:

- Identifying that falls have occurred

- Documenting/tracking of falls reports

- Communicating falls between disciplines

- Implementing timely falls interventions

Apr 19, 2023 Saskatchewan Falls Collaborative 4

Apr 19, 2023 Saskatchewan Falls Collaborative 5

Team Members• Home Care

- Pauline Osemlak, DNS (Team Leader)

- Tracey Macfarlane, RN

- Corrie Hordick & Jennifer Erbach, HHAs

• Community Therapies

- Lisa Benson & Dana Philipation, PTs

- Judy Lin, OT

• Team Sponsor

- Bert Linklater, EDCC

Changes Tested (Nov/11 – Feb/12)

1 Process for notification of client falls from Home Care to Community Therapies - currently transitioning to having Home Care nurses go visit client at home (new form)

2 Post assessment falls prevention recommendations made (form)

3 Orthostatic hypotension education (new form due to high number of clients with this problem)

4 Exercises targeting balance5 Increased awareness of community resources

and referrals to same (Maguire Centre)

1. Improving communication and awareness of falls and providing

timely follow-up • Started receiving e-mails regarding falls in

November: HHAs/RNs notify Client Service Managers (CSM); CSMs make note in client’s file and email to Therapists.

• If client is known to therapists - a follow-up phone call/visit as needed

• If client is unknown, they are put on the Community Therapies waitlist for falls risk assessment

HHA is made aware that fall occurred

HHA contacts Team 1 / 2 manager

Manager documents fall, forward info to Therapies

Known client to Therapies?Yes No

Therapist follows-up via phone call

Is visit required?

Yes No

Address falls risks, make recommendations

Has falls risk ax referral already been received from HC?

Yes

Placed on wait list

Falls risk assessment completed

No

Process for Known FallsHome Care Therapies

Post-Fall Nursing Assessment

• Started to implement Feb 2012• Form Adapted from MJ Pioneer Lodge

2. Falls Prevention Recommendation Form

3. Orthostatic Hypotension Form

4. Delegation to PTA/OTA

If PTA visits were declined

or were not appropriate,

home exercises to

work on balance were

provided

5. Using community resources

• Sending referrals to balance program (accepts participants every 2 months)

• PTA/OTAs are sent out between now and initiation of balance program to ensure smooth transition

• Therapists from community and other health region facility communicates

• Brochures/contact info for other local exercise programs as appropriate

Results

1. Tracking referrals to therapies (graph)

2. Started tracking falls in home services clients in September 2011

3. Started receiving falls risk assessments on a regular basis in December (New home services clients – referral from the Access Centre Intake Coordinator)

Falls Rate per 1000 Home Care Clients

Percentage of Falls Causing Injury

1. Falls Tracking – Referrals To Therapies

0

2

4

6

8

10

12

November December January February

Month

Cli

ents

New Falls Risk Ax

Had a Fall, Therapies Client

Had a Fall, Refused Services

Had a Fall, New Client

2. Falls Tracking – Home Services Clients

Results - New BERG Scores• From the analysis (wilcoxon & sign tests) there is a

significant difference between your initial scores and your FU scores. From the descriptive analysis your scores show an improvement.

BERG Scores Run Chart

Red = Improvement

Next Steps• Continue to record stats on falls assessment

referrals• DNS will be tracking % of post-fall assessments

completed• Risk assessment form to be implemented

(considering the Morse) CCCs and RNs will use to screen for high fall risk

• Make falls prevention package for assisted living facilities and personal care homes including recommendations for exercise programming

• Staff in-services on falls prevention literature/recommendations