May 11, 2007

In-home care plan cutting risk of falls

Featured Image

Marcia West, right, a physical therapist with Vanderbilt Home Care Services, works with Mary Jane Stacey at her home in Madison. (photo by Susan Urmy)

In-home care plan cutting risk of falls

Vanderbilt Home Care Services (VHCS) has developed and implemented a comprehensive, 16-point in-home assessment that has significantly lowered the incidence of falls among its patients.

The risk of falling while at home is a serious and frequent problem for older adults.

According to the American Academy of Family Physicians, falls are the leading cause of injury-related visits to emergency departments in the United States and the primary cause of accidental deaths in individuals over 65. Also, elderly persons who fall are 10 times more likely to be hospitalized and eight times more likely die as a result of a fall.

“In 2000 and 2001 we began to receive data that compared us to other home health care agencies throughout the country, and it indicated we were above average for the adverse event of hospitalizations related to falls or accidents in the home,” said Patricia Flemming, D.Sc., physical therapy coordinator for Vanderbilt's Pi Beta Phi Rehabilitation Institute.

“We were not happy with this finding. As an agency we began to look for a tool we could use to screen our patients for fall risk and could not find any validated tool available in the literature to screen homebound individuals,” Flemming said.

The existing tools had been developed for use in nursing homes and hospitals and were reliable predictors only in those settings. VHCS's multidisciplinary team then developed a test using evidence-based risk factors for falls, with Flemming as the primary researcher.

To assess the tool's reliability and validity, Flemming and the team did a retrospective analysis of the records of 307 older, former patients to see which of them fell during the time they were treated in home care.

“It's not usually one specific thing that causes someone to fall, but rather a constellation of factors, or how these factors all impact one another,” said Janie Parmley, administrator for VHCS.

The indicators of fall risk assessed include a history of falls, a fall resulting in injury, the presence of environmental hazards, decreased vision or mobility and taking four or more medications.

“We found a statistically significant difference in the initial screening scores of the “ fallers” vs. the “ non-fallers,” said Flemming. “Also, if the patient had eight or more of the 16 risk factors present on initial screening, and/ or a prior history of recurring falls in the last year, they were at much higher risk to fall. The cut-off score of eight was the most sensitive and specific point on the scale.”

Now, if on admission a VHCS patient is found to be at increased risk for falling, a clinical pathway is opened involving appropriate referrals as indicated for physical therapy assessment and treatment.

“If therapy is not already ordered for the patient, then we use the information from the risk assessment to communicate with the referring physician that this patient is at risk for falls and we would like to have a physical therapy intervention,” said Parmley.

Parmley says that depending on a patient's risk factors, such as environmental barriers, an occupational therapist and a physical therapist might become involved to see that things such as loose rugs, clutter or steps without railings are corrected.

“It's a comprehensive program looking at all the risk factors,” she said.

The VHCS fall prevention initiative has been so successful, a comprehensive article authored by Flemming, including the study's design and methodology, was published in a recent edition of Home Health Care Services Quarterly.

Flemming says the assessment tool was designed to be quickly performed by the home health professional opening the case.

“With an additional five minutes, the nurse or therapist can ask a few specific questions and — combined with information from the initial assessment — can complete the multi-factorial falls risk assessment.”

Parmley said since VHCS has instituted the Falls Risk Assessment, most of their patients' fall injuries have been minor and have not required hospitalization.

“This continues to make a difference. And through CMMS data we can benchmark these scores against other home health programs across the nation.”

The agency was recognized for their efforts by Tennessee's Commissioner of Health in the first Tennessee Safety Awards in August 2004.

“I think the important thing about this work is that it follows the basic work principle around plan, do, study and act,” said Laura Beth Brown, president of Vanderbilt Home Health Care Services. “You recognize there is an issue. You research that issue and develop tools. Then you implement them. And then you look to see if they are working. We have received good recognition for this work, but the ultimate beneficiary is the patient.”