The Prevention and Management of Falls in the Community: A Framework for Action for Scotland 2014/2015

Stage 4: Co-ordinated management including specialist assessment

Description (taken 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.
• Before moving from Stage 4 of the pathway, back into Stage 1, interventions have been offered which will support on-going self-management.

Actions to achieve the minimum standard for 2014/15

Action 4.1

Older people identified at high risk of further falls are offered a Level 2 assessment^†.

Principle

• The Level 2 assessment will include taking a falls history and screening for risk factors related to:
  • alcohol intake related to the fall/s*
  • cardiovascular and neurological symptoms
  • cognition*
  • 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*
  • medication
  • nutritional status*
  • vision
• 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 assessment proforma is a useful tool to reliably identify risk factors and a personalised action plan. Successfully implemented proformas:
  • link risks with suggested remedial actions,
  • include red flags for urgent medical assessment, 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.

Action 4.2

Health and social care services providing Level 2 assessment have a governance infrastructure to ensure suitable staff undertake Level 2 assessments.

Principles

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

Action 4.3

Following Level 2 assessment 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 assessment.
• 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)

Action 4.4

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

Action 4.5

Following Level 2 assessment there are referral pathways into services that provide evidence based assessment (Level 3) and intervention.

Principles

• The Falls and Fracture Prevention Action Plan will include one or more of the following elements, dependent on needs identified by the Level 2 assessment.
• 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.
• Management of risk associated with feet and footwear.
• Medication review with modification or withdrawal.
• 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.
• Medical assessment where cardiovascular and neurological problems or unexplained falls are identified.
• Assessment and management of visual impairment.
• Education and information provision as part of a tailored multifactorial intervention.
• Continence management.*
• Nutritional assessment and advice.*
• Assessment and management of anxiety or depression.*
• Where cognitive impairment is recognised, referral for ongoing support, and adaptation of the falls plan to reflect the individual's needs.*
• Assessment of telehealthcare needs.*
• Alcohol intervention.*
• Services providing these interventions are identified and there are referral pathways and protocols in place.

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

Action 4.6

Services providing Level 2 assessment can refer directly into services that provide evidence based 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 assessment have direct access to services delivering falls and fracture prevention interventions.

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.

^†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 1 'The falls and fracture assessment continuum' for further information.

Rationale

Assessment and intervention

For evidence base for standards, see references 1, 2 and 6.

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.

Further guidance on Level 2 assessment can be found in Appendix 1. This has been taken from the draft Care Bundles for the Prevention of Recurrent Falls guidance and information. The content was agreed in consultation with Falls Leads and other subject matter experts in Scotland.

Monitoring and quality assurance

The need for careful monitoring is identified in the AGS/BGS Clinical Practice Guideline. 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 effective².

Further Information

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

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

Guideline 71: Management of osteoporosis. Produced by SIGN (2004). Currently being reviewed and updated. Expected Summer 2014.

Managing Falls and Fractures in Care Homes for Older People, produced by the Care Inspectorate & NHSScotland, 2011. Access at: http://www.scswis.com/index.php?option=com_content&view=article&id=7861:managingfalls-and-fractures-in-care-homes-for-older-people-&catid=246:Consultations&Itemid=570