The Prevention and Management of Falls in the Community: A Framework for Action for Scotland 2014/15

Stage Four: Co-ordinated management including specialist assessment

Description (adapted from Up and About)

At this stage:

• A person has been identified as being at high risk of falling and/or sustaining a fracture.
• Falls risk and fracture risk management are considered in combination, with services for falls and osteoporosis operationally linked or dovetailed.
• Intervention aims to identify, then minimise, a person's risk factors for falling and sustaining a fracture as well as restoring function following a fall/s.
• Falls risk is not managed in isolation; a person's wider health status is taken into consideration when planning care. For example, the management of falls and frailty may have to be considered in combination.
• The person's GP is kept informed of outcomes of assessments and planned interventions. In many cases, the GP will be involved in, and contributing to the assessment/management process.
• Before moving from Stage Four of the pathway, back into Stage One, interventions and information have been offered which will support on-going self management.

Definitions

Level 3 assessment

A specialist assessment which aims to assess further the risk factors identified, with a view to providing tailored intervention to reduce the risk of falls and/or fractures.

See Appendix 2 'The falls and fracture assessment continuum' for further information.

Rationale

Assessment and intervention

For evidence base for standards, see references seven, nine and thirteen.

In 2011, The National Falls Programme Manager consulted with Falls Leads and other subject matter experts in Scotland to identify key components to be included in a set of 'care bundles' being developed for use in the community to prevent recurrent falls. The consultation contributors agreed that multifactorial risk factor screening was an appropriate and sustainable first step in the process of identifying and meeting the needs of older people identified as at high risk of falling. Blanket referral of everyone identified at high risk of falls to specialist multifactorial assessment, for example at a Consultant-led clinic, was deemed neither necessary nor feasible.

It was agreed that a multifactorial screen tool, developed in collaboration with informed stakeholders and delivered reliably, is capable of identifying the population requiring more specialist intervention.

Monitoring and quality assurance

The need for careful monitoring is identified in the American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline^[7]. Nine out of ten studies in which assessment and intervention processes were carefully overseen and monitored proved to be beneficial. This contrasted with studies which provided only advice, knowledge or unmonitored referral. Recent trials of multifactorial risk assessment followed by referral without assurance of completion of the intervention have not proven effective^[7].

Actions to achieve the minimum standard for 2014/16

Action 4.1

An older person identified at risk of further falls is offered a level 2 screen.

Principles

• The level 2 screen will include a falls history, general health questions and screening for risk factors related to:
  • alcohol intake related to the fall/s*
  • cardiovascular and neurological symptoms (including postural hypotension)
  • cognition*
  • environment
  • fear of falling, anxiety and depression
  • feet and footwear
  • fracture risk
  • function/activities of daily living
  • gait and balance, mobility and muscle strength
  • incontinence including urgency and frequency*
  • medications
  • nutritional status*
  • vision and hearing.
• Falls history includes:
  • Frequency of falls; how many in past week; month; 12 months.
  • Circumstances of the fall and symptoms at the time of fall.
  • Any loss of consciousness.
  • Injuries and consequences.
  • Ability to get up from floor unassisted.
  • Changes to daily function as a result of falling.
• A level 2 screening proforma is a useful tool to reliably identify risk factors and a personalised action plan. Successfully implemented proformas:
• link risks with suggested actions,
• include red flags for urgent medical assessment (such as loss of consciousness, dizziness, unexplained falls), and
• are developed by, and agreed with, the local multidisciplinary team.

*Indicates a recommendation not included in published guidelines but agreed by the development group as good practice.

Implementation note

A number of services providing a level 2 screen:

• accept self referrals
• operate a triage process to manage referrals appropriately, both in terms of urgency and clinical need
• communicate routinely with the person's GP to share information
• have a management protocol for recurrent referrals.

Action 4.2

Health and social care services providing a level 2 screen have a governance infrastructure to ensure suitable staff undertake the screen.

Principles

• Level 2 screeners have the skills, knowledge, understanding and support to undertake their role.
• Screeners' ongoing training and supervision needs are identified and met.

Action 4.3

Following a level 2 screen the person is provided with a personalised Fall and Fracture Prevention Action Plan.

Principles

• The Fall and Fracture Prevention Action Plan is a tailored multifactorial action plan, agreed with the person (and carers, if appropriate), which addresses risk factors and issues identified in the level 2 screen. The plan reflects the person's needs, goals and choices. A person's perception and beliefs regarding their ability and motivation are taken into account when developing the plan.
• The tailored plan will include:
  • Agreed actions (including actions the person or his/her carer/s have agreed to take, and referrals to other services).
  • Reasons for recommended actions and which service is responsible for which intervention.
  • A copy of the Falls and Fracture Prevention Action Plan is provided to the person (and carers, if appropriate) in a format and language they can understand.
  • Additional information provided should be relevant and available in a format and language the person can understand.

Action 4.4

Following a level 2 screen there are referral pathways into services that provide specialist assessment (level 3) and intervention.

Principles

• Services providing these interventions are identified and there are referral pathways and protocols in place.

Action 4.5

Services providing a level 2 screen can refer directly into services that provide specialist assessment (level 3) and intervention.

To minimise duplication of assessment and remove unnecessary steps in the person's journey of care, there is local agreement that services providing level 2 screen have direct access to services delivering falls and fracture prevention interventions.

Action 4.6

Level 3 assessment and interventions offered are in line with current and emerging evidence.

Principles

• The Falls and Fracture Prevention Action Plan includes interventions to manage the known risk factors identified by the level 2 screen. Interventions may include:
  • Assessment of fracture risk +/- management of osteoporosis.
  • Detailed assessment of gait, balance and mobility levels and lower extremity joint function.
  • Strength and balance training, which is individualised, progressive, challenges balance and is of at least 50 hours duration (not all of which need be supervised directly).
  • Assessment of the home environment for falls hazards with safety intervention.
  • Assessment of activities of daily living (ADL) skills including use of adaptive equipment and mobility aids, as appropriate.
  • Therapeutic interventions to improve the person's functional ability and minimise fear of falling.
  • Management of risk associated with feet and footwear.
  • Medication review with modification or withdrawal.
  • Vitamin D supplementation.
  • Medical assessment where cardiovascular and neurological problems or unexplained falls are identified.
  • Management of postural hypotension.
  • Management of heart rate and rhythm abnormalities.
  • Assessment and management of visual impairment.
  • Assessment and management of hearing impairment.*
  • Education and information provision as part of a tailored multifactorial intervention.
  • Continence assessment and management.*
  • Nutritional assessment and advice.*
  • Assessment and management of fear of falling, anxiety or depression.*
  • Where cognitive impairment is recognised, refer for ongoing support as required. The action plan is adapted to reflect the individual's needs. Information provided is in a format and language the person can understand.
  • Assessment of telehealthcare needs.*
  • Alcohol intervention.*
• Assessments and interventions are provided by staff with suitable qualifications, knowledge and skills.
• Community-based options for on-going support and advice for self management are accessed where they are available and appropriate. Self management empowers a person to reduce their falls risk and improve their health and well being. Support may be needed to encourage a person to (a) take decisions and make the right choices to improve their health-related behaviours, and (b) adopt a positive approach to balancing risk and activity. 'Support' includes emotional support as well as information and practical support^[14].
• Services providing falls prevention interventions to people with one or more long-term condition take into consideration other professionals and services involved in their care and liaise as necessary to deliver the most appropriate Falls and Fracture Prevention Action Plan and a joined-up, holistic approach.

*Indicates a recommendation not included in published guidelines but agreed by the development group as good practice.

Further information on evidence based interventions can be found below.

Action 4.7

There is a quality assurance process which monitors whether or not Fall and Fracture Prevention Action Plans are implemented.

• There is a reliable process which monitors on a regular basis whether or not interventions recommended in the Falls and Fracture Prevention Action Plan are implemented as planned and agreed, and in line with the person's wishes.

Further information on evidence based interventions

Assessment of fracture risk +/- management of osteoporosis

The Scottish Intercollegiate Guidelines Network (SIGN) are currently updating Guideline Number 71 Management of Osteoporosis, with a provisional publication date of Autumn 2014.

Strength and Balance Training

Practice note

Effective exercise programmes:

• target strength, balance and gait, and challenge balance.
• are individually-tailored, taking into account the physical capabilities and health profile of the person.
• are prescribed by suitably qualified professionals or fitness instructors.
• include regular review, progression and adjustment of exercise prescription as appropriate.
• are of at least 50 hours duration (not all of which need be supervised directly).
• may be performed in groups or as individual (home) exercises.

Implementation note

There are a number of models of exercise delivery, such as group exercise or home exercise programmes. To deliver exercise classes of sufficient duration NHS services work in partnership with local authority (and other) leisure services to provide a continuum of exercise opportunities.

Further information:

Guidelines for the physiotherapy management of older people at risk of falling. Produced by AGILE, Physiotherapists working with older people in 2012. Access at: http://agile.csp.org.uk/news/2012/08/16/guidelines-physiotherapy-management-older-people-risk-falling (access for Chartered Society of Physiotherapy members only)

Falls Prevention Exercise - following the evidence. Produced by Age UK in 2013. Access at: http://www.ageuk.org.uk/Documents/EN-GB/For-professionals/Research/Falls_Prevention_Guide_2013.pdf?dtrk=true

Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. Authors: Sherrington, Tiedemann, Fairhall, Close and Lord. Published in Vol. 22(3-4) 2011 NSW Public Health Bulletin Vol. 22(3-4) in 2011

Assessment of the home environment for falls hazards with safety intervention.

Assessment of activities of daily living (ADL) skills including use of adaptive equipment and mobility aids, as appropriate.

Therapeutic interventions to improve the person's functional ability and minimise fear of falling.

Further information:

Falls Management. Produced by the College of Occupational Therapists (2013) Available to buy from: http://www.cot.co.uk/publication/books-z-listing/falls-management

The College of Occupational Therapist's practice guideline, 'Occupational therapy in the prevention and management of falls in adults' will be available in January 2015.

Guidelines for the physiotherapy management of older people at risk of falling. Produced by AGILE, Physiotherapists working with older people (2012). Access at: http://agile.csp.org.uk/news/2012/08/16/guidelines-physiotherapy-management-older-people-risk-falling (access for Chartered Society of Physiotherapy members only)

Management of risk associated with feet and footwear

Further information:

Best foot forward, healthy foot supplement. Produced by Age UK for National Falls Awareness Week in 2013.
Access at: http://profound.eu.com/wp-content/uploads/2014/01/Age-UK-ID201259-Falls-Awareness-Week-2013-Supplement-Feet.pdf

The Knowldege Network's Personal Footcare portal. Access at: http://www.knowledge.scot.nhs.uk/home/portals-and-topics/personal-footcare.aspx

Medication review with modification or withdrawal

Medical assessment where cardiovascular and neurological problems or unexplained falls are identified

Management of postural hypotension

Management of heart rate and rhythm abnormalities

Supplement Vitamin D

Further information:

Clinical practice guideline: prevention of falls in older persons. Produced by the American Geriatrics Society, British Geriatrics Society in 2010.
Access at: http://www.medcats.com/FALLS/frameset.htm

Assessment and management of visual impairment

Further information:

Focus on Falls. Produced by the College of Optometrists in 2014. Access at:
http://www.college-optometrists.org/en/EyesAndTheNHS/focus-on-falls.cfm

Falls, Dementia and Sight Loss Practice Note. Produced by RNIB in 2014. Access at: http://www.knowledge.scot.nhs.uk/fallsandbonehealth/the-national-falls-programme.aspx

Further information on other interventions and approaches

Supporting self management

Further information:

Improving Self Management Support. Produced by the Scottish Government's Long Term Conditions Collaborative in 2009. Access at:
http://www.scotland.gov.uk/Resource/Doc/274194/0082012.pdf

Falls and dementia

Further information:

Preventing falls among people living with dementia Webinar. Hosted by Age UK in 2012. Access at: http://view6.workcast.net/register?pak=2398992394693073

Physiotherapy works. Dementia Care. Produced by the Chartered Society of Physiotherapy in 2011. Access at: http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-works/dementia-care

Falls, Dementia and Sight Loss Practice Note. Produced by RNIB in 2014. Access at: http://www.knowledge.scot.nhs.uk/fallsandbonehealth/the-national-falls-programme.aspx

Good practice in the design of living spaces for people living with dementia and sight loss. Produced by the University of Stirling. Access at: http://dementia.stir.ac.uk/system/files/filedepot/12/good_practice_in_the_design_of_homes_and_living_spaces_for_people_living_with_dementia_and_sight_loss_final.pdf

Assessment of telehealthcare needs

Further information:

Telehealthcare and falls. Using telehealthcare effectively in the support of people at risk of falling. Produced by the University of Stirling and the Joint Improvement Team and Dementia Services Development Centre in 2011.

The Scottish Telehealth and Telcare Community. Access at: http://www.knowledge.scot.nhs.uk/telehealthcare.aspx

Falls in Care Homes

Further information:

Managing Falls and Fractures in Care Homes for Older People. Produced by the Care Inspectorate and NHSScotland in 2011. Access at: http://www.scswis.com/index.php?option=com_content&view=article&id=7906:falls-and-fractures&catid=328&Itemid=725

Living Well through Activity in Care Homes, produced by the College of Occupational Therapists, 2014. Access at: http://www.cot.co.uk/living-well-care-homes

Care… about physical activity. Produced by the Care Inspectorate and the BHF National Centre Physical Activity and Health in 2014. Access at: http://www.careinspectorate.com/index.php?option=com_content&view=article&id=8429&Itemid=100214

Good practice in the design of living spaces for people living with dementia and sight loss. Produced by the University of Stirling. Access at: http://dementia.stir.ac.uk/system/files/filedepot/12/good_practice_in_the_design_of_homes_and_living_spaces_for_people_living_with_dementia_and_sight_loss_final.pdf

The Framework in action

Level 2 screen

Level 2 screens are currently in use in the majority of partnership areas. They are delivered in a variety of ways, by a range of services. For example:

Ayrshire and Arran has trained and supervised falls screeners working within their Intermediate Care and Enablement Services.

East Renfrewshire partnership has trained and supervised falls screeners for their community alarm service clients.

Perth and Kinross has a trained falls screener who is employed by Perth and Kinross Council and is supervised by the CHP's Falls Service Manager. The screener carries out level 2 screen for community alarm clients, care at home services, local authority sheltered housing and referrals from Scottish Fire & Rescue.

Edinburgh Health and Social Care has three full-time Band 4 Falls Assistant Practitioners who complete a comprehensive level 2 multi-factorial screen. They form part of the Intermediate Care Health and Social Care team and are well placed to liaise with multiple partners across the community for on-going care and for obtaining referrals.

Greater Glasgow and Clyde has a board-wide falls service, which was the first service in Scotland to deliver level 2 screens. The level 2 screen is carried out by trained Band 4 Occupational Therapy Technical Instructors who are supervised by senior Occupational Therapists.

In Falkirk, level 2 screeners include Falkirk Council's Mobile Emergency Care Service.

In Fife nurses and AHPs from a range of services have been trained to deliver level 2 screens.

Care Homes

Care home staff in Lanarkshire use a level 2 screening tool which was developed by their Care Home Liaison Team. Examples of level 2 screening tools for care home staff can be found in the Managing Falls and Fractures in Care Homes for Older People resource pack produced by the Care Inspectorate and NHSScotland.

In Dundee, older people from care homes who fall, attend the Emergency Department and are not admitted are followed up to ensure that everything is done to prevent a further fall. This includes the Falls Team sharing the outcome of a telephone triage of the patient with the Care Home Liaison team who then provide ongoing support.

Personalised care plan

Fife has developed, tested and implemented a person-held Falls Prevention Plan. The Plan is created with the person who has fallen and their carer/s (where appropriate). It is produced in triplicate; the Integrated Community and Assessment and Support Service and the GP retain a copy.

Exercise

There are a number of examples of health services working with local authority, and other partners to deliver a continuum of evidence based exercise opportunities for people who have fallen or at risk of falling, including:

'Steady Steps' is a 16 week falls exercise programme taking place in nine Edinburgh Leisure Centres across the City of Edinburgh. Referrals are made as people are discharged from falls related community physiotherapy and occupational therapy community programmes, or are referred by their GP. This exercise class uses the Postural Stability Instructor (PSI) evidence-based approach and links with 'Community Connecting' volunteers to ensure the classes can be attended even if the individuals need support to do so.

The Integrated Care and Enablement Service working with Invigor8 in Ayrshire and Arran.

The Community Falls Prevention Programme working with 'Vitality' tiered exercise programme in Glasgow and Clyde.

There are a range of sustainable community exercise programmes in remote and rural areas of Highland.

• Lorn and Oban Healthy Options run Otago classes in remote or isolated villages in the North Argyll area. They will improve community resilience by training local volunteers to deliver classes.
• Highlife Highland have trained their staff to provide Otago in leisure facilities and in Care Homes in North Highland.
• Argyll Voluntary Action provide Otago classes in a variety of community settings including sheltered housing in Cowal and Bute and Lomond areas. They are also involving and training volunteers to deliver exercise in more remote areas.

Other examples

Falkirk Council's Mobile Emergency Care Service has negotiated direct referral to the Day Hospital's Falls Clinic - the person's GP is informed when the referral is made.

The Falls Service, which is part of the Dundee Falls Pathway operates a single point of referral (SPR) - referrals are welcome from anyone - including self-referral. The introduction of the SPR and Allied Health Professional's triage has demonstrated a reduction in waiting times for the Specialist Falls Clinic from over 10 weeks down to 3-4 weeks.

More information and contact details for the examples provided can be found on the Falls and Bone Health Community at: http://www.knowledge.scot.nhs.uk/fallsandbonehealth/the-national-falls-programme.aspx