1. Frailty, Reablement and Falls Prevention on The Isle of Arran
Deena Jane Dean 2016

2. Hospital
In hospital patients who are frail and at risk of falls are identified by ward staff via admission documentation and by Physio assessment.
Physio performs a standardised balance score (Tinneti), which follows the patient out into the community with domi Physio to monitor progress/highlight any deterioration.
Rehab starts in the ward with Physio, Physio TI, and ward staff.

3. In the community
On D/C from hospital appropriate patients are referred to the Reablement Team by ward Physio.
The Reablement Team consists of Physio, OT and Community Nurse.
Most referrals come from ward Physio and GP.
Other areas that can refer into the team are; SAS, A+E, DN, care homes, social services, consultants, medical imaging and MSK Physio.

4. Referral Process
3 years ago a single point of referral was developed for non-MSK Physio and the Reablement Team.
A clinical mailbox was set up to allow electronic referrals to increase efficiency in the process, reduce time between referral being made and received, allow improved data collection, reduce risk of loss of the referral, and to have better information to aid triage and lone working.

5. The mailbox can be accessed at any computer therefore allowing team members to access it at their different bases.
A Physio data base was also set up to allow closer monitoring of the waiting list with colour coding to highlight urgent patients and patients who have been waiting longer.
The database allowed recording of multiple referrals and Physio intervention.

6. On D/C from Physio an electronic D/C letter is sent to the GP.

7. Case Study’s

8. Case study 1
Urgent referral Friday PM via GP for a 73 year old lady with an acute painful ankle, lived alone in a house, unable to weight bear, risk of admission or further injury.
Physio went out that afternoon with walking equipment.
Reduced ROM, hot and swollen ankle, unable to weight bear.
Patient reports DN is to take bloods post weekend.

9. Assessed with elbow crutches but was unsafe.
Assessed as safe with Zimmer frame.
Unsafe with toilet transfers and would not manage kitchen tasks.
I contacted OT who provided toilet frame and kitchen trolley.
I contacted the Home Care Manager requesting care calls for over the weekend to identify issues and further prevent admission.

10. Domi Physio continued to see at home and this lady improved and was D/C 2 weeks later mobilising with a stick.

11. Case study 2 99 year old lady fell and had a hip hemi arthroplasty.
Transferred to AWMH for rehab.
On the ward 7 days having Physio.
Referred to Reablement on D/C.
Anxiety from patient and family when home re; coping and they felt she had been D/C too soon.

12. All concerns were addressed by Physio and OT at home several days after D/C.
Patient continued to improve and family were happy.