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

2. 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

3. 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

4. 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?

5. 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

6. 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

7. 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

9. 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)

10. 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.)

11. 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

12. 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

13. Feedback from MDs
See Survey Monkey

15. 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

16. 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

17. 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), DOI: /j.mcna
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),