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Exercise Class Navigation Flow Chart
Encouraging seniors to exercise and to be physically active is an important part of a fall prevention strategy. Exercise programs that promote balance training combined with strength and flexibility have been shown to be effective in significantly reducing falls and the injuries resulting from a fall. LHIN funded exercise and Fall Prevention programs are available across the Champlain region, and different levels of programs for people of different abilities are provided. However, determining which class is the right one is key to ensuring that participants gain maximum benefit from the class. Choosing the wrong level of class can be a lost opportunity to promote increased activity.
To simplify the choices and decisions for older adults, their families and health care providers, the Navigation Working Group of Champlain Fall Prevention Steering Committee has developed a flow chart. Each region has its own flow chart with local class details and contact information, but the descriptions for each level have been standardized across Champlain with consistent wording for each level of class.
List of locations (Renfrew County and District)
On the reverse of the chart is the Staying Independent Checklist and seniors are urged to complete this fall-risk screening tool, although it is not a determinant of exercise and activity levels. This screen is a key first step in the Champlain Fall Prevention Algorithm of Detection, Diagnosis and Intervention. Primary care providers should encourage their older patients to complete the Staying Independent Checklist annually and to bring issues and concerns to the primary care team.
The exercise class flow chart will be launched in November 2016 (Fall Prevention month) and will be distributed to public health units, community support services, primary care providers and other agencies, to encourage seniors to choose an active lifestyle. The flow charts can be found on the www.stopfalls.ca website under the community resources tab, and also on the Champlainhealthline website , under the Exercise Classes for Seniors button, “Which Exercise Class for me?”
For more information contact:
Champlain Falls Prevention Strategy
Regional Geriatric Program of Eastern Ontario
Cell Phone 519 639 3000
Elderly patients who start taking blood pressure medication or change their prescription or dosage have a temporarily increased risk of serious fall-related injury. The findings, published in Circulation: Cardiovascular Quality and Outcomes, included more than 90,000 patients in the United States aged 65 years and older.
Between 2007 and 2012, researchers found that 272 of the patients began taking drugs for high blood pressure, 1,508 added a new drug to their existing blood pressure regimen, and 3,113 had the dose of at least one blood pressure drug increased. The likelihood of a serious fall-related injury went up 36% for patients starting a medication regimen, 16% for patients adding a new drug and 13% for patients increasing a dose.
This increased risk dissipated after two weeks following the medication changes. The authors of the study stressed that, due to its observational nature, the research could only show an association between medication changes and fall risk, not determine cause and effect. However, it identifies a time period during which elderly patients may need closer monitoring for short-term side effects.
Aortic stenosis affects more than 100,000 Canadians over the age of 65. Until recently, surgical replacement was the only treatment option, but over the last several years, TAVI, or transcatheter aortic valve implantation (often referred to as transcatheter aortic valve replacement (TAVR) in the US), has emerged as a viable alternative with advantages over surgery. Because the TAVI valve is inserted through a catheter, the incision is small and recovery times can be much shorter than for the open heart surgical procedure.
First introduced in the early 2000s, TAVI is approved in Canada mostly for use in patients who are inoperable or whose condition makes surgery a high risk. As evidence for TAVI’s safety and durability grows and advanced technology comes on the market, the procedure is poised to become much more common.
Extending TAVI to Lower Risk Patients
“We do patients for whom surgery would be high risk, often higher risk patients than at other centres in the province,” said Interventional cardiologist Marino Labinaz, head of the TAVI heart team at the Ottawa Heart Institute.
The older and sicker high risk patients require hospital stays similar to surgical patients. In Europe, where TAVI is used in a broader range of patients, the time in hospital can be much shorter.
“In low risk patients, we are seeing expedited discharge. There is a trial underway in Vancouver where they are looking at 24-hour discharge,” he said. “Where I see the sweet spot for TAVI in the low-risk patient is in rapid recovery. You’re going to come in, get your TAVI and go home the next day. In our patients, we haven’t reaped the benefit of early discharge yet.”
“The use of TAVI in these patients will be, in part, patient choice. It may also become a societal choice,” he continued, “Because, if you can send a patient home in 24 hours, then TAVI could become very cost effective when compared to a five- to seven-day stay for surgery. This will particularly be true if the cost of the valves comes down.”
TAVI is currently a more expensive option than surgery due to the cost of the valves, but as demand for TAVI grows and as new vendors enter the market and increase competition, costs are expected to decline.
Conscious Sedation Over General Anesthetic
Another emerging benefit of TAVI over surgery is the use of conscious sedation.
“Currently, we give patients a general anesthetic and they are intubated. Conscious sedation means we give them short-acting medication,” he explained. “They are conscious, and they are never intubated. The patient doesn’t have the issue of the anesthetic to recover from, and it saves time so you can do more patients in a day.”
Given the Heart Institute’s emphasis on high-risk patients, conscious sedation is only just getting started in Ottawa.
One of the limitations of TAVI is the size of the catheter. To fit the valve inside, the catheter has to be larger around than those used in angioplasty for delivering stents.
“From a patient perspective, one of the biggest changes is that the valves are becoming smaller in size,” said Dr. Labinaz. “The first generation devices were very large calibre and we would see higher rates of dissections or occlusions in the arteries. Smaller tubes mean fewer vascular complications.”
Another important advancement is retrievability. Until recently, the cardiologist had only one shot to position and deploy the valve. Poor positioning can impact the seal of the valve and cause leaking—known as paravalvular aortic regurgitation—as well as complications that can require a pacemaker. A retrievable valve allows for real-time adjustments to be made.
“They aren’t yet commercially available here, but there are three valves available on special access from Health Canada that have the ability to be retrieved,” he said. “With two of them, you can deploy the valve to 80% to get an idea how it is positioned and functioning, and then retrieve it. The only completely deployable valve that can be retrieved is the new Lotus valve. We will begin using it this spring.”
“Another advance related to leaking is the addition of flexible sleeves on the outside of the valves that provide a better seal with the calcium and nodules and crevices that can create an uneven surface. Preliminary data is positive.”
One complication of aortic valve replacement that’s common to surgery and TAVI is stroke. Material from the calcium deposits in and around the valve can break away during the procedure and travel up the bloodstream to the brain. For both surgery and TAVI, the rate of stroke is 5 to 10%. On the horizon for TAVI is the use of protective filters in the blood vessels to capture that material. Results so far have been mixed.
“TAVI has been a real game changer,” concluded Dr. Labinaz. “We’re getting lots of data now on the durability of the valves in people who have had them for five and 10 years. They have low failure rates and seem to be comparable to the surgical valves.”
“It’s my prediction that TAVI will become a standard way of doing aortic valve replacement in the next five years. In Germany, it already is. Sixty per cent of aortic valve replacements in Germany are now TAVI. That’s the way it’s going. In Canada, cost and funding are the limiting factors.”
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
In this fourth article about the Champlain Falls Prevention Strategy, we look at the 2015-2016 work plan for implementation and current initiatives.
Having established a strong foundational Falls Prevention clinical pathway for seniors to receive the appropriate Falls screening, assessment and intervention in the appropriate setting, work is now being done to promote and support use of the standardized tools in community and primary care settings.
Feedback from clinicians testing the Champlain Falls Prevention algorithm and Staying Independent Checklist told us that it was essential to make them a part of the EMR. A great deal of work has been done with the Practice Solutions group to make this possible on the PS platform – with a go-live date in the near future – followed usage support with Nightingale on Demand. Other clinicians wanted a method of communicating their assessment findings and interventions with other agencies to avoid duplication or gaps in the process. A multifactorial draft work sheet based on the algorithm will be trialed with some community agencies in the fall of 2015 to gather their input.
Training Health Care Providers
Ensuring that health care providers have access to information about best practices in falls prevention is a key part of the work required to make this strategy successful. The Personal Support Worker (PSW) training module is now widely used by Public Health to train staff in Retirement Homes, community agencies, and community colleges in the region. An online accredited CME module for physicians is currently in the final stages of development. A framework that will help organizations to support staff in delivering high-quality falls prevention assessment and intervention to their clients is the focus for this year.
To enable health care providers and their clients to find the right exercise and/or falls prevention classes for their needs in their area, ongoing work is focusing on classes funded through the Champlain LHIN, and providing information and clear steps to assist in the selection of the appropriate class.
Reducing ED visits and hospital admissions
Provincially the Champlain region ranks poorly in regards to numbers of falls related visits to ED and admissions to hospital. Drilling into this data this year will clarify where to focus the next stages of work now that the tools to support teams across health care sectors have been developed and are ready for use. Savings of $1.72 million can be realized across the system with only a 10% reduction in falls related admissions to hospital in Champlain.
This concludes our series of four articles providing background and progress updates about the development and delivery of a Champlain Falls Prevention Strategy. There is a dedicated and enthusiastic group of representatives from many health care sectors in the region, all of whom have made this an excellent example of successful collaboration and achievement. We look forward to bringing you an update in about six months.
Article written by: Christine Bidmead (firstname.lastname@example.org), Project Manager, Champlain Falls Prevention Strategy
Yes, according to this article which describes the effectiveness of a 2 year balance training program to prevent fall induced injuries in women at risk for falls.
This is one of the first randomized control trials to show a decrease in injuries from falls with an intensive exercise program. The participants also had a better perception of their overall physical health than the control group.
Exercise and Falls Prevention in Champlain
Fortunately there are exercise and fall prevention programs available in our region. For Ottawa residents, take a look at the Better Strength, Better Balance program with sessions starting in September.
Information on other exercise and falls prevention classes in the region is available on Champlainhealthline.ca.
Finally, your patients may be interested in these fun falls prevention videos from Ottawa Public Health.
In this second article about the Champlain Falls Prevention Strategy, we look at what’s been done so far to respond to regional issues around falls prevention.
Responding to feedback from a survey held in early 2013, the Champlain Falls Prevention Steering Committee identified the establishment of a suitable Falls Prevention pathway and process for use across the region as a priority. Focusing on the primary and community care sectors, this systemic approach would support practitioners in the management of falls prevention in their daily practice.
Throughout 2013, the Steering Committee developed a strategic framework of six foundational pillars to guide the work required to bring about a system change in the way that Falls Prevention is managed regionally across all care sectors.
The six pillars are:
- Public Awareness and Engagement
- Detection, Diagnosis and Intervention
- Best Practices for Health Care Professionals
- System Navigation
- Performance Management
With funding support from the Champlain LHIN, a clinical working group composed of Community and Primary Care practitioners met in the summer of 2013. Based on current evidence the working group determined that it was imperative to have a tool that would provide screening, assessment and intervention capabilities, and which could assist clinicians and health care providers in identifying and ameliorating fall risk. It also had to be viable in a variety of settings.
The development of standardized screening tools which could be widely used in the community was seen as a valuable component in building consistency throughout the region. Following a literature review the working group identified a model that would be practical and relevant, evidence-based and would promote and support the use of standardized assessment tools. The American Geriatric Society/ British Geriatric Society algorithm was the best match but required some adjustments to make it suitable for local needs. The pathway included the Staying Independent Checklist / Demeurer autonome as a screening tool that could be used by older adults with their families, caregivers or health care providers.
By December 2013 the algorithm and checklist were ready to be tested in the field. Seaway Valley CHC, Pinecrest Queensway CHC (Nepean site), Dr. Helen O’Connor at the Montfort Academic FHT and Dr. Charles Adamson in South Mountain provided invaluable feedback during the trail period when they used the Falls Prevention tools with a total of 108 older adults.
A community information sharing session was held for Renfrew County, and North Lanark, Leeds and Grenville practitioners. A thorough evaluation of the trial took place and informed the refinement and finalization of the algorithm which was completed in the fall of 2014. The documents were translated into French and resources were loaded onto the Champlainhealthline.ca and the Regional Geriatric Program of Eastern Ontario (RGPEO) websites. The website domains stopfalls.ca and arretonsleschutes.ca were linked to the website for ease of access. Work is now being done with the Primary Care Network subgroup, Practice Solutions, to include the algorithm in the EMR.
The Champlain Falls Prevention Algorithm and Staying Independent Checklist are available on the Champlainhealthline.ca Falls Prevention page.
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.
“Nothing can prepare you for what lies ahead,” says Rose Ann. “I was exhausted from worry and anticipation of what was next. My husband did not believe there was anything wrong. So it was up to me to get the answers.”
The Alzheimer Society was initially Rose Ann’s source of information. She accessed helpful education through its First Link® Learning Series, and benefited from a support group especially tailored to wives of people diagnosed with dementia.
But like so many other people dealing with dementia, Rose Ann believes that much more needs to be done to spread information about dementia and to help people to understand it.
That’s why she is helping as a volunteer advisor with a new dementia awareness program called ReThink Dementia, funded by the Champlain Local Health Integration Network as part of its Integrated Model of Dementia Care.
The ReThink Dementia campaign is designed to enhance the public’s understanding of dementia, and to make it easier for people — including health care providers — to get information and support when they are dealing with it.
Visit the “ReThink Health Care for Dementia” section at rethinkdementia.ca for information about:
- How to Care for Persons with Dementia
- Quick tips for a person-centered approach
- Understanding changing emotions and behaviours
- Resources for health care providers
ReThink Dementia is a project of the Champlain Dementia Network that is being led by the Alzheimer Society of Ottawa and Renfrew County as well as the Alzheimer Society of Cornwall & District.