Falls Prevention requires a cross sector and cross team approach and the development and usage of the Champlain Falls prevention algorithm for community and primary care supports that approach. The four regional Public health Units have provided education to over 600 PSW paramedics and college students this year, which allows these staff to play their full role in supporting seniors in their falls prevention journey. This education module will be available on line by early summer 2016. The Staying Independent Checklist is being promoted as a self-screening tool in a several ambulatory care departments across the region, which then links into the regional pathway. Flow charts are being finalized for the exercise and falls prevention classes across Champlain so that there is commonality for seniors accessing these activities.
The Falls algorithm has been incorporated into the Practice Solutions EMR for primary care providers in the Bone Health program and is available on the website:
https://hodgson-public.sharepoint.com/fallprevention There is also a “ how to download” video on this site. These will soon be posted on the TELUS Community Portal.
Several Family Health Teams are using it, or are interested in doing so and an effort is being made to influence inclusion in Nightingale on Demand for CHCs. An online CME Falls prevention Module is being developed with the University of Ottawa to support physicians, with a completion date expected for Fall 2016.
The http://www.Stopfalls.ca website is a resource for healthcare providers to access information about assessments, best practices and local resources.
Communicating assessment findings and interventions taken across sectors and between professionals can sometimes be very difficult which can lead to duplication and omissions. A falls prevention assessment communication tool is being tested between a GEM nurse, CCAC physiotherapist and a retirement home to improve the sharing of information gained by each team member. This in turn will support primary care providers to find the root cause of the fall and provides the right intervention.
Now that there are some firm foundational tools in place that are beginning to be used across the region, data will support the development of a multi year plan so that efforts are targeted appropriately and effectively. This will be linked with the Regional Geriatric Advisory Committee strategy and the Champlain LHIN Integrated Health Service Plan. This plan will form a large part of the Falls Prevention Annual report, which will be completed at the end of March 2016. A summary of the report will be shared in a future article.
written by: Christine Bidmead, Project Manager – Champlain Falls Prevention Strategy , Regional Geriatric Program of Eastern Ontario
Osteoporosis and its complication results in a tremendous cost to the health care system and on patients’ quality of life, and yet simple steps can be taken in both prevention and management of this condition.
Leveraging tools in the EMR can help in many ways such as screening, early identification of patients at risk of falls and fractures, and assessing for adherence to treatment and treatment success.
What is known?
- Osteoporosis fractures are more common than MI, strokes and breast cancer combined
- 1 in 3 women and 1 in 5 men will sustain an osteoporosis related fracture in their lifetime
- Osteoporosis and its complications cost $2.1 billion to the Canadian health care system in 2010
- There are 20,000 to 30,000 hip fractures in Canada every year
- The cost of a hip fracture is estimated at more than $20,000 in the first year following the fracture and at more than $40,000 if the patient is institutionalized
- Following a fracture, less than 20 % of patients are evaluated for osteoporosis or receive appropriate treatment
- 1/3 of patients aged 65 and over fall once a year; 1/4 of these falls will result in injuries
- More than 90% of fractures in elderlies are due to falls
- Falls cost the province of Ontario $2.15 billion in 2004
What can be done?
A) Preventing Falls
All too often in a busy practice, fall assessment is overlooked until a fall occurs. And yet, even following a fall the focus revolves around the management of the trauma rather than the prevention of a future trauma and potential fracture.
With enhanced knowledge of fall screening recommendations and of the available community resources even a small impact could result in tremendous cost savings.
The Champlain LHIN has supported a Falls Prevention strategy and great efforts are underway regarding this.
Some early and easy steps for fall prevention can be:
- Screening patients aged 65 and over with a validated screening questionnaire
- Reviewing and modifying patient medications that are identified with greater fall risk
- Referring patients to community exercise programs
- Informing patients about fall prevention strategies
B) Screening for osteoporosis as per Osteoporosis Canada Guidelines
Appropriate screening with a BMD is an important step in identifying our patients that are at risk. By applying the Osteoporosis Canada 2010 guidelines, primary care providers can avoid unnecessary testing capturing patients that are at risk of fractures.
An often overlooked recommendation is to test not only women but also all men over age 65. While 1 in 10 men will suffer from osteoporosis compared to 1 in 4 women, men have double the rate of mortality at 1 year following a hip fracture (40% compared to 20% for women).
C) Reviewing Bone Density report and correcting fracture risk
The BMD report is non-patient specific and does not take into account other risk factors such as previous fragility fractures and use of corticosteroids. A correction based on the patient’s profile will provide a more accurate assessment of fracture risk. Several fracture risk tools have been developed, such as the FRAX and CARROC. One easy tool is the Osteoporosis Canada Fracture tool on fracture risk assessment.
D) Providing appropriate management for ALL patients
All patients should be counselled on dietary calcium recommendations, vitamin D supplementation and weight bearing exercises. Serum vitamin D levels are found to be low in the great majority of the Canadian population with some studies reporting 85% deficiency.
Below are links to Osteoporosis Canada recommendations for calcium intake. There is also a fun tool patients can use to assess their dietary intake of calcium:
E) Patients at moderate risk with additional risk factors and patients at high risk of fracture should be advised of pharmacotherapies to reduce risk of fracture
The choice of agent will depend on your patient’s profile and choices. A description of these with risk and benefits can be found at http://www.osteoporosis.ca/osteoporosis-and-you/drug-treatments/bisphosphonates/
F) Patients who sustained a fragility fracture should be advised of pharmacotherapies to reduce risk of fracture
Only 20% of patients who suffer from a fragility fracture are assessed for and have pharmacotherapy initiated. Again, the choice of agent will depend on the patient profile and patient’s choice.
G) Patients on pharmacotherapy should have appropriate review of adherence and success of the opted therapy
It is well known that adherence to osteoporosis medications is difficult for many patients. A quick call from your staff at 3 months and 12 months could enhance patients’ adherence and address difficulties encountered with the prescribed medication. This will allow for a discussion with your patient of other treatment options in a timely manner.
Repeat BMD testing should be done 1-2 years following initiation of treatment. Treatment success should be reviewed (0-3% gain in gm/cm2) and if further bone loss is identified other therapeutics options should be reviewed.
H) Leveraging the EMR can provide the necessary tools to achieve best practice results while being effective and efficient
- Addition of reminders to screen all over 65 for risk of falls on a yearly basis
- Addition of reminders when a fragility fracture or other risk factors are identified in the CPP
- Addition of screening tools can improve the screening recommendations of patient under 65
- Addition of an easy link to Osteoporosis Canada recommendations on calcium and Vitamin D to provide easy access to patient information resources
- Addition of an easy link to tools that allows for improved analysis of the BMD and stratification of patients at risk
- Addition of EMR tools that incorporates the algorithm from Osteoporosis Guidelines in the assessment of patients that may benefit from pharmacotherapy
- Addition of delayed messages to assess adherence to therapy
- Addition of delayed recall for repeat BMD testing to allow for the early capture of non-adherent patients
- Addition of tools to easily identify patients who failed therapies
For TELUS Health users, stay tuned for an upcoming article about this on the Champlain Primary Care Digest.
In conclusion, Primary Care Providers are well-positioned to impact the cost of falls and osteoporosis-related fracture with simple steps such as incorporating fall assessment in our workflow, appropriate screening with BMDs, applying tools for BMD review, initiating pharmacotherapy in the appropriate patient and reviewing adherence and success/failure of therapy.
All well-baby visits are comprised of a review of several core elements: parental concerns, nutrition, development and behavior, physical examination, anticipatory guidance, conclusion and plan.
The Government of Ontario, following the advice of an expert panel, has recognized the importance of the 18-month well-baby visit by funding a longer, more in-depth visit.
Tools have been developed to help in the identification of children at risk, to enhance the timely referral to appropriate community resources necessary in early intervention and treatment.
The Nipissing District Developmental Screen is an easy-to-use tool that reviews a child’s skills in the following areas: vision, hearing, speech, language, communication, gross motor, fine motor, cognitive, social/emotional and self-help.
The 18-month Well-Baby Pathway, developed by the 18-month Screening Work group of the Ottawa Best Start Initiative, is an easy-to-use web-based tool that provides a link to community resources based on each of the following domains: speech/language, hearing/vision, nutritional/dental, fine/gross motor development, social/emotional/behavioral/developmental and parenting and family support.
Some EMR can link websites to their system, allowing for the linkage of parents to these resources and services during the 18-month visit.
- www.machealth.ca: Resources available here include the Ontario Rourke Baby Record, the Nipissing District Development Screen™ and the Early Child Development and Parenting Resource System Pathway, which lists community services.
- Ontario Rourke Baby Record: Available at www.machealth.ca, www.cps.ca, www.cfpc.ca and www.rourkebabyrecord.ca
- Nipissing District Developmental Screen™: www.ndds.ca, www.machealth.ca
- Ministry of Children and Youth Services: www.ontario.ca/child
- Ministry of Health and Long-term Care: www.ontario.ca/health
- Ministry of Health Promotion: www.ontario.ca/mhp
- Ontario Early Years Centres: www.ontario.ca/earlyyears