Safer Care North East: Falls Group

Recommendations for Good Practice and Mapping of Existing Services Against Recommendations:

Falls Services North East Strategic Health Authority

Introduction

Safer Care North East is an enabling strategywhich aligns to and complements the North East Our Vision, Our Future Strategy and the North East Transformation System (NETS). It provides a focus on specific clinical safety issues,one of which is Falls. The membership of the Safer Care North East Falls Group consists of key individuals from the Falls and Osteoporosis Services across the North East Strategic Health Authority and representatives from the North East Ambulance Service, Pharmacy Services and the Voluntary Sector.

Meetings in early 2009 established a consensus view to agreeRecommendations for Good Practice for a Whole Systems Falls Service under the headings:

  1. Organisational Issues.
  2. Services Delivered.
  3. In-patient / HospitalFalls.
  4. Care Homes.
  5. Training.
  6. Information.
  7. Quality Metrics.

The Falls Services then rated themselves against individual recommendations and provided narrative comment to further describe their service.

Good Practice Recommendations

The Good Practice Recommendations agreed by the Safer Care North East Falls Group are as follows:

1. Organisational issues

  1. Falls Strategy which all organisations (health -hospital and PCT, social care, voluntary sector and others) have ownership of and are working to achieve.
  2. Individual or group who have responsibility for Falls Strategy / other Falls initiatives and the enthusiasm, time and mandate to implement them.
  3. Formal communication mechanism between all organisations involved in Falls / Falls Prevention / Falls Service Delivery.
  4. Good links with Commissioners and Public Health Physicians.
  5. Referral mechanism into Falls Services that gives access to range of health and social care professionals, the voluntary sector and older people themselves.
  6. Standardisation of documentation.
  7. Good links with community initiatives as ‘step-down’ from Falls Service.
  8. Good links with local Telecare services.
  9. Good links with community pharmacy services.
  10. Older people themselves have a key role in planning, implementing and delivering Falls Services.
  11. Robust referral pathway from the Ambulance Service.
  12. Robust referral pathway from the Accident and Emergency Department.
  13. Robust referral pathways from Orthopaedics (including Fracture Clinic) and other services e.g. Medical Admissions Unit, Neurology where fallers present.
  14. Osteoporosis link nurse (or similar) working closely with Fracture Clinic / Orthopaedics and the Falls Services.

2. Services Delivered

  1. Multifactorial assessment and intervention following NICE guidelines.
  2. SpecialistFalls and Syncope Service.
  3. Falls Services screen for and treat osteoporosis.
  4. Falls Services delivered in the community, close to / in older people’s own homes.
  5. Community based targeted strength and balance exercise programme following evidence based protocols.

3. In-patient / HospitalFalls

  1. Commitment to falls prevention at board / senior management level.
  2. Commitment of front line manager to implement risk reporting and falls assessment and intervention protocols.
  3. Accurate and complete falls reporting (e.g. via Datix).
  4. Contribute to the National Hip Fracture Database.
  5. Falls assessment documentation coupled with interventions to prevent falls / refer for further assessment.
  6. Staff training in falls risk reporting / assessment of falls risks / falls prevention interventions / referral pathways.

4. Care Homes

  1. Training package for care homes on falls prevention and on when and how to refer to falls services.
  2. Good links with care homes to encourage uptake of training and referral to falls services.

5. Training

  1. Training for health and social care professionals and others in management of falls. and on when and how to refer to falls services.
  2. Training package around inpatient falls – see above.
  3. Training package for care homes – see above.
  4. Training package for sheltered housing schemes and day care on falls prevention and on when and how to refer to falls services.

6. Information

  1. Provision of falls prevention information for older people and their carers.

7. Quality metrics

  1. Data collection that allows development of clinically relevant quality metrics.

Mapping of Existing Falls Services Against Good Practice Recommendations

Services / areas rated themselves broadly against their own recommendations using the following scale:

 - outstanding good practice;  - established good practice;  - some areas of good practice; & - something similar / work in progress; Gap -not available.

The outcomes are summarised in the table below according to trusts / geographical areas in order to reflect patient experience of the Falls Service. Areas of service delivery are summarised as:

CountyDurham and Darlington (CDD);

Newcastle (NCL);

North Tees and Hartlepool (NT&H);

Northumberland (N’bria);

Gateshead (Ghead);

South Tees (Sth Tees);

Sunderland (S’drl’d);

North Tyneside (Nth T’side);

South Tyneside (Sth T’side).

For most areas (indicated by *) more than one trust contributed to services delivered and information supplied. For some areas, particularly CountyDurham and Darlington, it was difficult to provide an overview of patient experience as there was a wide variation in service provision. In Northumberland some parts of the service previously provided by the FISHNETS project were not fully funded and are indicated as such in the table. The NewcastleFalls and Syncope Service takes referrals from across the region.

The information represents the knowledge of service provision in their area by the members of the group. There is no information for South Tyneside as despite several attempts to contact key people from the Falls Service there is no representation from this area. Representation from North Tyneside has been limited and the information for this area may be a reflection of this.

1

Mapping of Existing Falls Services Against Good Practice Recommendations

Good Practice / CDD* / NCL* / NT&H* / N’bria* / Ghead / Sth Tees* / S’drl’d* / Nth T’side / Sth
T’side
1. Organisational issues
Falls Strategy which all organisations (health -hospital and PCT, social care, voluntary sector and others) have ownership of and are working to achieve /  /  / f /  /  /  / 
Individual or group who have responsibility for Falls Strategy / other Falls initiatives and the enthusiasm, time and mandate to implement them /  /  /  /  /  /  /  / 
Formal communication mechanism between all organisations involved in Falls / Falls Prevention / Falls Service Delivery /  /  /  / f /  /  /  / 
Good links with Commissioners and Public Health Physicians /  /  /  /  /  /  /  / 
Referral mechanism into Falls Services that gives access to range of health and social care professionals, the voluntary sector and older people themselves /  /  /  / f /  /  /  / 
Standardisation of documentation /  /  /  /  /  /  /  / Gap
Good links with community initiatives as ‘step-down’ from Falls Service /  /  /  / f /  /  / 
Good links with local Telecare services /  /  /  / Gap /  /  /  / 
Good links with community pharmacy services / Gap / Gap / Gap / Gap / Gap
Older people themselves have a key role in planning, implementing and delivering Falls Services / Gap /  /  / f / 
Robust referral pathway from the Ambulance Service /  /  /  /  /  /  / 
Robust referral pathway from the Accident Emergency Department /  /  /  /  /  /  /  / 
Robust referral pathways from Orthopaedics (including Fracture Clinic) and other services e.g. Medical AdmissionsUnit, Neurology where fallers present /  /  /  /  /  /  /  / 
Osteoporosis link nurse (or similar) working closely with Fracture Clinic / Orthopaedics and the Falls Services /  /  /  /  / Gap / 
2. Services Delivered
Multifactorial assessment and intervention following NICE guidelines /  /  /  /  /  /  /  / 
SpecialistFalls and Syncope Service /  / + /  /  /  /  /  / 
Falls Services screen for and treat osteoporosis /  /  /  /  /  /  / 
Falls Services delivered in the community, close to / in older people’s own homes /  /  /  /  /  /  /  / 
Community based targeted strength and balance exercise programme following evidence based protocols /  /  /  / f /  /  / 
Good Practice / CDD* / NCL* / NT&H* / N’bria / Ghead / Sth Tees* / S’drl’d / Nth T’side / Sth
T’side
3. In-patient / HospitalFalls
Commitment to falls prevention at board / senior management level /  /  /  /  /  /  /  / 
Commitment of front line manager to implement risk reporting and falls assessment and intervention protocols /  /  /  /  /  /  /  / 
Accurate and complete falls reporting (e.g. via Datix) /  /  /  /  /  /  / 
Contribute to the National Hip Fracture Database /  /  /  /  /  /  /  / 
Falls assessment documentation coupled with interventions to prevent falls / refer for further assessment /  /  /  /  /  /  /  / 
Staff training in falls risk reporting / assessment of falls risks / falls prevention interventions / referral pathways /  /  /  /  /  /  /  / 
4. Care Homes
Training package for care homes on falls prevention and on when and how to refer to falls services /  /  /  / f /  /  / Gap
Good links with care homes to encourage uptake of training and referral to falls services /  /  / f /  /  /  / Gap
5. Training
Training for health and social care professionals and others in management of falls and on when and how to refer to falls services /  /  /  /  /  /  /  / 
Training package around inpatient falls – see above /  /  /  /  /  /  /  / 
Training package for care homes – see above /  /  /  / f /  /  / Gap
Training package for sheltered housing schemes and day care on falls prevention and on when and how to refer to falls services /  /  /  /  /  / Gap
6. Information
Provision of falls prevention information for older people and their carers /  /  /  /  /  /  /  / 
7. Quality metrics
Data collection that allows development of clinically relevant quality metrics /  /  /  /  /  /  /  / 

* More than one trust represented in comment(hospitals and PCT)

KEY:  - outstanding good practice;  - established good practice;  - some areas of good practice; & - something similar / work in progress; Gap –not available; f = input previouslyprovided via FISHNETS in Northumberland – pilot funding ended – ongoing work not fully funded; + Newcastle Falls and Syncope Service takes referrals from across the region

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Noteson Mapping of Existing Falls Services Against Good Practice Recommendations

1. Organisational issues

  • Falls Strategy which all organisations (health -hospital and PCT, social care, voluntary sector and others) have ownership of and are working to achieve
  • Individual or group who have responsibility for Falls Strategy / other Falls initiatives and the enthusiasm, time and mandate to implement them
  • S’drl’d: City wide and Hospital based Strategy Group. Strong leadership from both Falls Coordinator and Consultant Geriatrician.
  • Sth Tees: Close working between Clinical Lead/falls coordinator and hospital senior nurse. Consultant Geriatrician member of Falls Strategy and Osteoporosis Steering Groups.
  • NCL: Newcastle Falls Clinical Network: Acute Trust, PCT, NEAS, Social Services, Voluntary Sector, Osteoporosis Service. Also within organisation groups for falls e.g. PCT services working to common strategy.
  • NT&H: Individual multi-agency steering groups which span across Health and Social Care and patient representative. The aims of the groups are to develop the falls strategies and initiatives and service improvements for both localities.
  • CDD: CDD wide monthly meeting takes place, also locality based meetings which include voluntary social services and NEAS. Osteoporosis Steering group established across primary and secondary care.
  • Ghead: Close working between falls team and risk management. Reducing Harem from Falls Steering Group. Aim to implement recommendations from Patient Safety First document. Falls Prevention identified as a priority of SafeCare Council.
  • NthT’side: Via North Tyneside Falls Prevention Service DH Integrated Care Pilot; multi-organisational service involving NuTH acute trust, PCT, General Practice, Social Services, NEAS, Age Concern and Newcastle University. Monthly steering group meetings, regular updates for GPs.
  • Formal communication mechanism between all organisations involved in Falls / Falls Prevention / Falls Service Delivery
  • S’drl’d: City wide and Hospital based Strategy Group with multi-agency representation.
  • Sth Tees -Middlesbrough, Redcar & Cleveland Community Services (MRCCS) Falls Team hold central falls register and multi-agency strategy group.
  • NCL: via Newcastle Falls Clinical Network. Also good informal links at PCT medical staff work into acute trust falls service.
  • N’bria: FISHNETS project.
  • NT&H: Hold individual falls databases of fallers referred into falls services in order to establish trends and gaps. The two falls coordinators work closely together to develop an integrated service.
  • Ghead: Falls Strategy Group.Also hold falls database of all people who are referred to the falls service
  • CDD: Falls Prevention Service in place, working closely with community, health and social care and voluntary agencies.
  • NthT’side: Via NorthTynesideFalls Prevention Service DH Integrated Care Pilot as above.
  • Good links with Commissioners and Public Health Physicians
  • Sth Tees: good links with commissioner; elderly care pathwaysgroup involving commissioner.
  • NCL: links with new commissioner and public health being established.
  • NT&H: North Tees as above.
  • CDD: Service has been going through review with the commissioners, gaps have been identified and funding was agreed through the AOP, however this has currently been frozen.
  • Ghead: Links with Public Health being further established.
  • NthT’side: Excellent links with commissioners: lead commissioner for elder care and deputy director of commissioning for North of Tyne PCT both steering group members for North Tyneside Falls Prevention Service.
  • Referral mechanism into Falls Services that gives access to range of health and social care professionals, the voluntary sector and older people themselves
  • S’drl’d: 2 referral and assessment tools: ‘Trigger Tool’ (NEAS) for quick referral and more detailed assessment for community matrons / district nurses to allow to manage falls as well as refer.
  • Sth Tees: 2 referral tools as above. Self – referral from A&E as well as stage one screen A&E, MAU, ambulance and GP referral. Stage 2 multi-factorial assessment/intervention tool carried out by community staff.
  • NCL: 2 referral tools as above. PCT (all services) and AcuteTrustDayHospital take referrals from all health profs / care homes / NEAS / care alarms / A&E. Acute trust falls service – GP and A&E.
  • N’bria: Well organised referral mechanism, including self-referral.
  • Ghead: Well organised system of open referrals inc. wardens, home helps, care alarms and nursing homes
  • NT&H: Use FRAT (Stage 1) and Multifactorial Falls Assessment Tool (Stage 2) recommended by NICE guideline as referral form. Falls services receiving referrals from Primary and Secondary Care and other community services etc.
  • CDD:Community based falls service with robust working links to Health & Social Care, Warden services, Care homes and voluntary agencies.
  • NthT’side: Falls Prevention Service refers to Age Concern-run strength and balance training classes; Social Services refer to the Service and vice versa. In process of trying to replicate NEAS success in other areas.
  • Standardisation of documentation
  • All: Standard documentation for referrals from NEAS.
  • S’drl’d: Standard documentation across PCT / acute trust.
  • NCL: Across PCT organisations but different to acute trust.
  • Ghead: Standardised document and Falls Risk Assessment tool used across acute trust. Standardised Home Safety assessment used by OT teams across acute trust and PCT.
  • N’bria: as part of FISHNETS.
  • Sth Tees: Standardised documentation across Acute, Community and Social Care.
  • NT&H: Both PCT areas use same referral forms and procedures.
  • CDD: Five areas all use SAP.Standardised local referral forms, slightly altered for professional/ non-professional referrals, i.e. we ask for more detail from professionals referring into the service.
  • Good links with community initiatives as ‘step-down’ from Falls Service
  • NCL: Links with step-down exercise project just established. 36 week evidence based programme based on FAME protocol.
  • N’bria: Good links with community activities as part of FISHNETS.
  • S’drl’d: Health Trainer / Community Development Workers.
  • Sth Tees: Good links with postural stability classes in community run by sports development (does not cover all areas).
  • NT&H: Hartlepool: Falls prevention full day event in UHH hospital every 3 months to recall past fallers during that period for clinical assessment, but they also receive fun, interactive sessions from a wide range of agencies on falls prevention including information on local physical activity opportunities, podiatry, physio, healthy eating, fire service, NEAS etc. These sessions also provide feedback from past fallers which help to shape future service development.
  • CDD: Good links established eg Established links with PCT ‘Get Active Team’ who provide exercise classes, walking groups and swimming. Useful step-down for some of our clients. Also links with Age Concern befriending service and benefit advice. All clients receive a pack with useful information about falls prevention and contact details for useful agencies on discharge. PSI x2 weekly for 6 weeks courses are run by our physiotherapist as part of the patient’s step-down process.
  • NthT’side: Falls Prevention Service Age Concern-run strength and balance training classes run courses of 10 hour long weekly sessions with personal trainer using evidence based targeted exercises; participants then referred into existing Age Concern classes per ability.
  • Good links with local Telecare services
  • NCL: established direct referral pathway from community care alarm service directly to falls services (PCT and Acute Trust). Referrals from falls services to community alarm service.
  • NT&H: established direct referral pathway from community care alarm service directly to falls services.
  • CDD: Good established links with Telecare Provider, all requests for fall detectors are referred to us and we frequently request telecare for complex fallers. Six week review appt is a joint telecare / falls team visit.
  • Ghead: Links with Telecare being further established.
  • Good links with community pharmacy services
  • Sth Tees: some initial work done.
  • NT&H: exploring possibilities.
  • S’drl’d: exploring possibilities.
  • Older people themselves have a key role in planning, implementing and delivering Falls Services
  • S’drl’d: Monitor patient outcomes / patient feedback questionnaire.
  • Sth Tees: Patient satisfaction questionnaire including falls related outcomes, focus groups, discovery interviews.Clinical Lead attends LINK falls sub group.
  • NCL: Patient feedback Questionnaires, input from patient groups and voluntary sector to service planning.
  • N’bria: Fantastic involvement of older people in FISHNETS pilot – planning, budget, acting as volunteers to deliver services but this has not continued after project.
  • NT&H: Patient feedback – see above. Also working on patient satisfaction questionnaire – roll out May 2009. Hartlepool use local groups of older people ‘Encore’ who provide falls prevention information in song and sketch format.
  • CDD: Patient survey carried out in January, also linking to Age concern and local groups.
  • NthT’side: Falls Prevention Service patient feedback questionnaires and wider associated staff questionnaires on rolling basis; input from STARS syncope patient support organisation and Age Concern.
  • Robust referral pathway from the Ambulance Service
  • All services have this except North Tyneside – being addressed.
  • CDD: Agreed documentation, some issues around communication within pathway this is being worked on, eg in Easingtontheprocess agreed and appears to be working satisfactorily.
  • Robust referral pathway from the Accident and Emergency Department
  • Sth Tees – self referral using questionnaire version of Cryer Tool.
  • NCL: Acute trust plans for Falls Liaison Nurse in A&E ?implementation. Some links via Primary Care Response Team. Referral pathway to Falls Services in Acute Trust and PCT but under-used.
  • NT&H: Links established with A&E therapy teams at both site (UHH and UHHT). The team assesses patients in A&E, EAU and MAU and refer to falls services if necessary and with patients consent. Gap for orthopaedics.
  • N’bria: Falls nurse screens casualty cards daily (Mon – Fri).
  • S’drl’d: Falls coordinator has trained all staff in A&E to use the trigger tool and refer although number of referrals are often spasmodic and not representative of attendance in A&E.
  • Ghead: Good links with walk-in centre. Referrals to OT in Falls team for people who fall via OT OOH service for A & E. Links established with A & E staffincreased referrals to the Falls team but numbers still not representative of numbers presenting. Monthly information received by Falls Service from information department re people over 55 years attending A & E as the result of a fall.
  • CDD:Fracture Liaison service established across CountyDurham and Darlington, also established good practice at Sunderland Royal as part of Joint initiative with Sunderland Falls Service. Other areas Hartlepool, Durham – pathways not established yet.
  • Robust referral pathways from Orthopaedics (including Fracture Clinic) and other services e.g. Medical Admissions Unit, Neurology where fallers present
  • Sth Tees: Robust referral mechanism for inpatients to falls services (across trusts for registration only). Referral pathways from A&E and MAU (for over 65s).
  • NCL: Referrals from Orthogeriatrics, Fracture Clinic, OrthopaedicDischarge Team and Medical Teams but can be patchy.
  • NT&H: see above.
  • CDD: Recently established Fracture Clinic link with Sunderland Royal, also receiving Appropriate low trauma fractures via Durham Fracture Liaison Service, these are primarily seen for Osteoporosis risk but falls risks are also addressed if required.Eas. Also some links via Community Matrons – work to do on linking with MAU.
  • Ghead: Referrals form Orthogeriatrics and general Orthopaedics. Robust referral pathway and joint working with Community Orthopaedic Rehab Team.Further work to be undertaken with MAU for fallers over 65 years.
  • Osteoporosis link nurse (or similar) working closely with Facture Clinic / Orthopaedics and the Falls Services
  • NCL: Fracture Liaison Nurse based in Fracture Clinic – DEXA at time of Fracture Clinic attendance and refer to falls services as needed. Also Orthogeriatric Service review all IP Fracture on Orthopaedics and refer to falls services as needed.
  • CDD: Fracture liaison service – community based with links to fracture clinic.
  • N’bria: Fracture liaison nurse just appointed.
  • Ghead: Fracture Liaison Nurse covers all orthopaedic wards including Orthogeriatrics. She also runs Osteoporosis clinic with physician and directs referrals to the team.
  • Sth Tees – Osteoporosis Nurse now recruited within MRCCS Falls Team and to set up community based osteoporosis liaison service.
  • NthT’side: Falls Prevention Service – all attendees at the Service are FRAX-screened with treatment/DEXA referral according to need.

2. Services Delivered