CISS BAKUP PROJECT Bankstown and Auburn Keep Upright Project Community Independence Support Services

CISS BAKUP PROJECT CISS supports older people, those with a disability and their carers through the provision of individualized support services enabling them to remain living in their own homes. The CISS BAKUP Project (Bankstown and Auburn Keep Upright Project) is an initiative to reduce the risk of falls, falls related injury and admission/readmission to acute or residential care settings amongst CISS clients who are under COPs and Compacks programs.

Services of CISS involved in the project COPS – Community Options Program Case Management for up to 2 years for clients with disabilities, frail older people and their carers who are HACC eligible and living in the community. Compack – A case managed package of support for up to 6 weeks after discharge from hospital.

Background to BAKUP The importance of falls prevention: 1 in 3 older Australians fall each year Falls threaten the health and well being of community dwelling older adults 5-10% of falls cause injury serious enough to require medical attention Falls are the leading cause of deaths from injury for people aged 65years and over

CISS as comprehensive assessors: “A comprehensive assessment process explores all relevant aspects of a client’s situation” (Good Practice Guide for HACC Funded Case Management Projects 2006) Proven relevance of falls risk Demonstrated link between falls risk, quality of life and independence Identified falls risks amongst clients of CISS COPS and Compacks programs Therefore a need to include falls risk assessment in comprehensive assessment

CISS’s ability to work in partnership with other services to address multi-factorial nature of falls prevention Case management links clients into services to meet their identified needs and co-ordinates these services In providing case management services, CISS are in a position to link with other organizations to address falls risk Previously established links with services that can address falls risk such as community health, pharmacists and allied health services

Identified falls risk factors for CISS Compacks and COPS clients The majority of Compacks clients are over 65 years and therefore at increased risk of falling Compacks clients are also at risk due to suffering a recent acute illness episode and being recently discharged from hospital Many COPS clients, whilst not necessarily over 65, are at risk of falling due to factors such as falls history, health status, alcohol abuse, environment, nutritional status and poly pharmacy

The Process Selection of working party: Dietician Provides service to a number of CISS clients and consultancy to Case Managers. Has expertise on how nutritional status effects falls risks Established link between CISS and Bankstown Community Dieticians Area Falls Co-ordinator Has expertise on all aspects of falls prevention including available resources, risk factors, evidence base, training courses, networking opportunities ACAT OT and Health Promotion Officer Have specialist knowledge on the needs of older adults and local services that may address falls risk OT has expertise in how disability impacts upon function and how environments may be modified to reduce falls risk

Decision on eligibility criteria: Discussed the needs of all clients of CISS Discussed available evidence on falls prevention with different client groups Decided to begin assessing all COPS and Compacks clients Limited evidence when project began to demonstrate the benefits of falls prevention interventions to clients with dementia Decided to focus on clients of COPS and Compacks with a view to expanding to other client groups when there is further evidence in this area

Selection of assessment tool: What we were looking for: A tool that was thorough but not too lengthy A scientifically validated tool A tool that wasn’t too demanding on the client as assessment can already be time consuming and confronting for clients A tool that can be repeated when reviewing falls risk status

What we chose and why: A Queensland HACC falls risk assessment tool and risk assessment action plan that is not scientifically validated but is “an assessment upon which to base intervention and treatment planning” Met the above criteria Was designed for use in the community when many other tools were for use in hospitals and residential settings Covers key risk factors without being too time consuming to complete Includes questions and a self-rating scale (subjective and objective components) Scientifically validated tools not considered to be appropriate for a number of reasons including their complexity and the level of expertise and training that is required to use them

Where is BAKUP Now? Established Multidisciplinary working party meetings at least bi-monthly Training provided to CISS Case Managers on use of falls risk assessment and action plan tool CISS Case Managers have started using the selected falls risk assessment and action plan tool for new COPS and Compacks clients Developing a resource that suggests interventions and lists resources that can be used to address identified falls risks Interventions to include referring for medication review, footwear review, linking into physical activity programs, referring for continence management (HACC Slips and Falls Learning Resource 2005) Met with Bankstown GP Division and have since developed a letter template to inform GPs of assessment outcomes if risks is identified

Benefits of partnership working: Sharing of resources and knowledge Better problem solving Ensures a holistic approach is taken to project development Issues raised may cross assist to improve practice in other areas and not just those specific to the project

The future Looking at strategies and networking to reduce duplication of assessments Regular meetings with CISS Case Managers to review project and gather feedback on implementation of BAKUP, assessment tool etc Looking at ways of providing strength and balance training as part of falls risk intervention Considering longer term outcome measurement and data collection Further development of knowledge on falls prevention interventions and evidence base Ongoing identification of training needs amongst staff involved with the project

The challenges so far and how we’ve addressed them… Outcome measurement when using a tool that is not scientifically validated The outcome in the short term is for all new clients of CISS on Compacks and COPS program to have a falls risk assessment and action plan incorporated into their assessment and care plan How to address issue of Vitamin D deficiency as this in not included in the falls risk assessment or the nutritional risk screening tool that is currently used Identified that a question on sun exposure and vitamin D needed to be included in the assessment. Decided to add a falls question related to sun exposure to the nutrition screening form

Difficult to carry out ‘timed get up and go test’ on Compacks clients on a hospital ward Discussion with BAKUP working party and Compacks Case Managers. Decided to complete the falls risk assessment in the clients home when they have been discharged to Con’t

Case Studies Case Study 1: Background Mr G. 60 years old. Receives DSP Limited mobility due to a combination of issues relating to leg, back, neck problems and a previous shoulder injury. Currently prescribed a number of pain relieving medications and presented as low in mood during assessment. Diagnosis of severe depression - Community Mental Health Team involvement Has Meals on Wheels No other services in place No home modifications Lives in second floor unit Socially isolated

Falls Risk Assessment The following risks were identified: Takes 4 or more medications, some of which affect the Central Nervous System Suffers from depression Lives alone with no home modifications Suffers from foot pain and swelling

The following Action Plan was completed with Mr G: TaskBy Whom Write to GP to advise of falls risks that have been identified and steps that have been taken to address these risks CISS Provide Mr G with information on falls preventionCISS Discuss link between falls risk and mental health with mental health teamCISS Discuss housing options with DOHCISS Refer to OT for environmental assessmentCISS Investigate social support services and provide Mr G with details of theseCISS

Case Study 1: Background Mr B 76 years old Recently discharged from hospital following an admission for a severe chest infection Lives with his wife Suffers from poor appetite Recent significant weight loss Accepted onto Compacks program for support with personal care and domestic assistance Falls risks: The following risk factors were identified: Suffers from more than 1 chronic condition Is over 65 years old Reduced appetite and weight loss Reduced exposure to sunlight and therefore vitamin D

The following action plan was completed in collaboration with Mr and Mrs B Action RequiredWho is responsible? Advise GP of identified falls risk and discuss strategies to address this including home medication review CISS Provide walking aid to improve mobility and safety when mobilisingHospital Physiotherapist Refer to community dieticianCISS Provide information on falls prevention strategiesCISS

Conclusion Increased evidence of the significance of falls and falls prevention Falls risk cannot be ignored when completing comprehensive assessments Anecdotally, our Community Care clients display a number of falls risk factors Extensive research into the effectiveness of falls prevention interventions which can now be trialed Working collaboratively with other community services has allowed BAKUP to get off the ground and has provided a sounding board of expertise for problem solving the many challenges that have arisen in the planning process CISS look forward to developing a range of interventions that can be used to further support the independence of our clients Thank you