Falls Risk Screening Program- Project Update QI Facilitators: Christy Johnson and Maria Muraca North York Family Health Team February 9, 2018

Background Each year, approximately 30 to 40% of people aged > 65 years fall, of which most result in injury and high medical costs1 Age and osteoporosis-related factors further increase the risk of falls2 Primary care providers play a critical role in reducing fall risk factors among their older patients Guidelines recommend annual screening to identify patients at increased risk and perform a comprehensive risk assessment3 North York Family Health Team (NYFHT) serves 9,329 active patients age > 75 years Therefore, as part of a quality improvement initiative, a falls risk screening program was introduced by our nursing team

Goal 50% (1,123/9,329) of North York Family Health Team Active patients age > 75 years who have been diagnosed with osteoporosis or low bone mass will be screened for falls risk by the end of March 2018

Falls Risk Screening Data Manager Physician’s Office EMR Nurse Community referral 1. Generate report identifying patients 75+ with osteoporosis Data Manager Nurse 4. Document in Falls Risk Template Physician’s Office 3. Screens patients Communicate Patient List Confirmed Patient List Detailed assessment Patient education Screening questions Follow up appointment 2. Team reviews list & identifies patients EMR 5. Next Step -Possibly some changes to DM flow sheet in accuro -how will we flag charts?

Measures Outcome Measures: Process Measures: Balancing Measures: % of patients age 75+ with osteoporosis screened for falls risk % of patients age 75+ with osteoporosis who screened positive % of patients screened positive who were referred to community resources Process Measures: # of Registered Nurses received training in falls risk screening program # of patients received education # of referrals made to community services Balancing Measures: Provider and patient experience with the program

Project Review –PDSA cycles PDSA 1 (April - June 2017) Falls Working Group established; Baseline data collected Refined screening tool, adapted algorithm, standardization of process across the FHT, created EMR accessible content Addressed barriers to screening, pre-work to refine list: dx low bone mass vs osteoporosis PDSA 2 (June 19th - July 12th) New screening process pilot Refinement of template and tools Formal (survey) and informal feedback from RNs and MDs

Project Review – PDSA cycles PDSA 3 (July 15th - Aug 26th) 4 RNs, 5 MD offices Data clerk –audited patient charts for confirmed osteoporosis vs low bone mass Improved patient list Spread planning – RN meeting Sept 14th, 2017 RN education planning Communication planning – Senior management, MDs, RNs Senior Leadership communication Review the project updates with our Executive Director Physician communication Medical Director’s EMR messaging FHT QI Overview – FHT Leadership visit with individual MD offices Nursing meetings Office huddles/meetings Template -add more text box space to document assessment (specifically nutrition and ADLs), add tick box for phone or office assessment Update Falls Risk Screening Algorithm, list refinement, role of RN

Outcome Measures Indicator PDSA 1 (Baseline) PDSA 2 PDSA 3 Summary Was the Screen Positive? 33% (9/27) 50% (6/12) 17% (1/6) 36% 16/45 Education Provided? 85% (23/27) 100% (12/12) 89% (6/6) 91% (41/45) Reviewed with MD? 56% (15/27) 83% (10/12) 67% (4/6) 64% (29/45) Referral Offered to Community Resources --- 17% (1/6) 39% (7/18) Completed Referral to Community Resources 11% (3/27) (1/ 6) (5/45)

Screen Positive Using Template Indicator Percentage Screen Positive 39% (7/18) Reviewed with MD 100% (7/7) Referrals Offered 71%* (5/7) Referrals Completed 14% (1/7) *Reasons for Declining Referrals: Previously attended a Community/Hospital Falls Risk Program Already attending an exercise class/personal trainer Previous home assessment/current CCAC support/++ home support Currently attending an Osteoporosis clinic Barriers to attending community classes (Driver’s license, caregiver, etc.)

Balancing Measures: Time to Complete Screening Template Indicator Time to Complete Screen (Median + Range)* Negative 10 min (5-20min) Positive - Phone screen or Office visit 15 min (5-20 min) Positive - Phone Screen + Office visit 47.5 min (43-52 min) Discussion of Falls Risk Only 7.5 min (5-52 min) Other Health Concerns Discussed 16 min (7-20 min) *The above data is based on 18 encounters

Balancing Measures: Patient & Provider Experience Patients “Useful” “I’m glad you called…I’ve been wondering what to do about my lack of balance” “I’d wanted to get grab bars installed since I moved in to my condo and didn’t know who to ask” Nurses Template flows nicely Template is easy to use Comprehensive assessment Handouts/Referral info in EMR saves times searching through files Can see which handouts/education has been provided to patients

Feedback from MDs See Survey Monkey

Lessons Learned Senior leadership support and physician engagement were key Adequate amount of time was required RNs and MDs awareness of Falls Risk prevention resources in the community EMR generated patient lists discussed with team to identify eligible patients EMR patient charts audited to confirm osteoporosis vs. low bone mass cases Script beneficial to reduce the risk of patients anxiety as a result of RN’s call Referrals also offered to screen negative patients, likely beneficial Embedded malnutrition screening into falls risk screening Discussions regarding smoking cessation, sedative hypnotic de-prescribing occurred which also aligns with other FHT QI initiatives

Spread & Sustainability Planned evaluation - Pre-Implementation online survey for MDs and RNs Expansion to all 20 offices in September 2017 Communicating plan with respected offices Training nurses and educating physicians Collect and report outcome measures Report and communicate results to all participant offices QI project updates at RN Staff meetings, Medical Director and FHO Lead meetings Controls Standard work, visual controls, education, ongoing measurement Falls Team Continues to meet, feedback and improvement of current process Central LHIN Falls Prevention Strategy

References Phelan, E. A., Mahoney, J. E., Voit, J. C., & Stevens, J. A. (2015). Assessment and Management of Fall Risk in Primary Care Settings. Medical Clinics of North America, 99(2), 281-293. DOI: 10.1016/j.mcna.2014.11.004 Madureira, M. M., Takayama, L., Gallinaro, A. L., Caparbo, V. F., Costa, R. A., & Pereira, R. M. R. (2007). Balance training program is highly effective in improving functional status and reducing the risk of falls in elderly women with osteoporosis: a randomized controlled trial. Osteoporosis International, 18(4), 419–425. Landis, S. E., & Galvin, S. L. (2014). Implementation and assessment of a fall screening program in primary care practices. Journal of the American Geriatrics Society, 62(12), 2408-2414.