Multiagency Falls Collaborative for Wales Change Agent Team

How did we get here? Falls linked to DToC, CHC, unscheduled, acute, secondary, intermediate, primary, social care and housing across public, voluntary and commercial services.

Chris Jones … We are already doing many of the things that we aspire to! We are already doing many of the things that we aspire to! It is difficult to talk about the vision in a common language! It is difficult to talk about the vision in a common language! People instinctively know that this is the right thing to do! People instinctively know that this is the right thing to do! We are already doing many of the things that we aspire to! We are already doing many of the things that we aspire to! It is difficult to talk about the vision in a common language! It is difficult to talk about the vision in a common language! People instinctively know that this is the right thing to do! People instinctively know that this is the right thing to do!

Sorry Chris … To work with people earlier on and closer to home

Political Ker Plunk … 1.Service pressure and targets 2.Unscheduled care and the big 3 3.More policy, rules and regulations 4.More perverse incentives 5.Initiativitis & redisorganisation

Doing the wrong thing … Who lives in a house like this?

NHS Approach

Doing the right thing … Care has changed and individual practitioners, professions and services are less and less able to meet the needs of people in isolation.

The right thing … Services vary across Wales 35% of over 65s fall each year 45% of over 80s fall at home each year 60% in nursing homes fall repeatedly Falls use bed days per year Cost to Health & Social services in Wales - £84 million PA just on bones 16% of WAST calls are due to falls with 53,000 calls per year with 17,000 people not transported to hospital

60,000 hip fractures in over 65s pa and 12,000 osteoporotic fractures in Wales 90% hip fractures fail to fully recover Less than 50% of older people with hip fracture return to their usual home Hip fracture is the commonest cause of accident related death! 7% of people with hip fracture die within 1 month and 25% die within 1 year Falls are estimated to increase by 50% by 2020! The right thing …

Doing things right … 1.Changing needs in the population 2.Older longer and wiser younger 3.New ways to respond to needs 4.Focus is turning back to people 5.Invest in good ahead of new

Mulitfactorial Assessment 1.Falls history including falls experience over six months 2.gait and balance, mobility and muscle strength 3.Measure and assess osteoporosis risk 4.Perceived functional ability and fear of falling 5.Visual impairment 6.cognitive impairment and neurological examination 7.urinary continence 8.Living environment and home hazard assessment 9.Cardiovascular examination 10.Medication investigation and administration review 11.Nutritional status 1.Falls history including falls experience over six months 2.gait and balance, mobility and muscle strength 3.Measure and assess osteoporosis risk 4.Perceived functional ability and fear of falling 5.Visual impairment 6.cognitive impairment and neurological examination 7.urinary continence 8.Living environment and home hazard assessment 9.Cardiovascular examination 10.Medication investigation and administration review 11.Nutritional status Mulitfactorial Intervention 1.Advice, education and signposting for preventing and living with falls 2.Strength and balance training or physiotherapy assessment 3.Diagnosis and management of osteoporosis 4.Therapy to improve perceived functional ability and fear of falling 5.Correction of visual impairment 6.Cognitive impairment specialised referral and adapt the falls plan 7.Continence training 8.Home hazard assessment and safety intervention including footwear 9.Appropriate medical referral 10.Medication review with modification or withdrawal 11.Nutritional assessment and plan 1.Advice, education and signposting for preventing and living with falls 2.Strength and balance training or physiotherapy assessment 3.Diagnosis and management of osteoporosis 4.Therapy to improve perceived functional ability and fear of falling 5.Correction of visual impairment 6.Cognitive impairment specialised referral and adapt the falls plan 7.Continence training 8.Home hazard assessment and safety intervention including footwear 9.Appropriate medical referral 10.Medication review with modification or withdrawal 11.Nutritional assessment and plan

The Impact … 16% of % of A&E 50% to LTC 50% of NOF Falls is a way in! Eifion’s Story! What’s your story?

Make a start!

Are you in ? Who? What? Where? How? And by when?

Who ? Petal Diagram … Who’s in your Falls team? Who’s not in your Falls team? Who needs to know what you’re up to? Who’s affected by what you’re up to

Falls driver diagram

What? Your Assessment … What change can we make that will result in an improvement? What are we good at? How do we know? What are we missing? What shall we do? What shall we do 1 st ? What help do we need?

What next? Which bundles? Who is your executive sponsor? Who are your stakeholders – professionals / patients /clients/ service users? Who will refer to you, Who will you refer to? Who will be your coordinator? Who are your ‘team’ Who will collect the data? What else do you need to be in place eg documentation, referral protocols and a communication plan

When? Your plan … What will we do and by when? – 1 – 2 – 3 – 4 – 5

Collaborative plan 2010/11 Multi-agency Learning together / networking Evolving and getting better over time Data collection to show how your doing Not benchmarking & not performance management! Action focused Find a place to start

What can you expect from the collaborative? Peer support and expert advice Access to specialist knowledge National learning events Monthly webex meetings Local bespoke support from CAT Support from 1000 lives programme Raised profile within your organisation Evidence of improvement / gaps in service

Lunch & Networking