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Best Practices

Created on August 28, 2017

“Insanity is doing things the way we’ve always done them and expecting different results”
Albert Einstein

Falls in long-stay home patients in home care is a priority indicator for the QIP. This is the percentage of long-stay home care patients who say they have fallen in the last 90 days. In Ontario 31.4% of patients receiving publicly funded home care for at least 60 days (such as chronic/complex illnesses) have fallen at least once during the three months since their last assessment.

Below are best practices for patient involvement in primary care. They are graded according to Type of Evidence. Evidence-informed best practices are based on quality evidence, they can optimize outcomes and should be implemented into practice where possible.

To help you move from best evidence to best practice you can refer to either Health Quality Ontario’s Quality Improvement Road Map to Preventing Falls, the RNAO’s Best Practice Guideline on Preventing Falls and Fall Injuries in the Older Adult or browse the interactive table below for a quick summary of preventing falls in the home.

  1. Bamgbade, S., Dearmon, V. (2016). Fall Prevention for Older Adults Receiving Home Healthcare. Home Healthcare Now; 34 (2): 68 – 75.

  2. Bloch F, Thibaud M, Dugue B, Breque C, Rigaud AS, Kemoun G. Psychotropic drugs and falls in the elderly people: updated literature review and meta-analysis (Structured abstract). Journal of Aging and Health. 2011; 23(2):329-46.

  3. Burton E, Cavalheri V, Adams R, Browne CO, Bovery-Spencer P, Fenton AM, Campbell BW, Hill KD. Effectiveness of exercise programs to reduce falls in older people with dementia living in the community: a systematic review and meta-analysis. Clin Interv Aging. 2015 Feb 9;10:421-34.

  4. Camicioli R, Majumdar SR. Relationship between mild cognitive impairment and falls in older people with and without Parkinson's disease: 1-Year Prospective Cohort Study. Gait & Posture. 2010; 32(1):87-91.

  5. Canadian Patient Safety Institute CPSI. (2014). Resource Guide on Falls Prevention for Clients and Family Caregivers. ISBN: 978-1-926541-63-1. Retrieved from: http://www.patientsafetyinstitute.ca/en/toolsresources/homecaresafety/documents/resources%20for%20family%20caregivers%20and%20clients%20-%20resource%20guide%20on%20falls%20prevention.pdf

  6. Delbaere K, Kochan NA, Close JC, Menant JC, Sturnieks DL, Brodaty H, et al. Mild cognitive impairment as a predictor of falls in community-dwelling older people. The American Journal of Geriatric Psychiatry. 2012; 20(10):845-53.

  7. Desapriya E, Subzwari S, Scime-Beltrano G, Samayawardhena LA, Pike I. Vision improvement and reduction in falls after expedited cataract surgery: systematic review and metaanalysis. Journal of Cataract and Refractive Surgery. 2010; 36(1):13-9.

  8. Glendenning P, Inderjeeth CA. Screening for vitamin D deficiency: defining vitamin D deficiency, target thresholds of treatment and estimating the benefits of treatment. Pathology. 2012; 44(2):160-165.

  9. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146.

  10. Guo JL, Tsai YY, Liao JY, Tu HM, Huang CM. (2013). Interventions to reduce the number of falls among older adults with/without cognitive impairment: an exploratory meta-analysis. International Journal of Geriatric Psychiatry.

  11. Haran MJ, Cameron ID, Ivers RQ, Simpson JM, Lee BB, Tanzer M, et al. Effect on falls of providing single lens distance vision glasses to multifocal glasses wearers: VISIBLE randomised controlled trial. British Medical Journal (Clinical Research ed). 2010; 340:c2265.

  12. Harlein J, Halfens RJ, Dassen T, Lahmann NA. Falls in older hospital inpatients and the effect of cognitive impairment: a secondary analysis of prevalence studies. Journal of Clinical Nursing. 2011; 20(1-2):175-83.

  13. Health Quality Ontario. 2011. Quality Improvement Road Map to Preventing Falls. Toronto, ON. Queens Printer for Ontario. Available from: http://www.hqontario.ca/portals/0/Documents/qi/rf-change-package-falls-en.pdf  

  14. Health Quality Ontario. Aging in the community: summary of evidence-based analyses. Ontario Health Technology Assessment Series. 2008; 8(1). Retrieved from: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/aging-in-the-community

  15. Hegeman J, van den Bemt BJ, Duysens J, van Bimbeek J. NSAIDs and the risk of accidental falls in the elderly: a systematic review. Drug Safety. 2009; 32(6):489-98.

  16. Hill KD, Day L, Haines TP. What factors influence community-dwelling older people's intent to undertake multifactorial fall prevention programs? Clin Interv Aging. 2014 Nov 26;9:2045-53.

  17. Hill AM, Etherton-Beer C, Haines TP. Tailored education for older patients to facilitate engagement in falls prevention strategies after hospital discharge--a pilot randomized controlled trial. PloS one. 2013; 8(5):e63450.

  18. Hill K, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem. Drugs & Aging. 2012; 29(1):15-30.

  19. Ishigaki EY, Ramos LG, Carvalho ES, Lunardi AC. Effectiveness of muscle strengthening and description of protocols for preventing falls in the elderly: a systematic review. Braz J Phys Ther. 2014 Mar-Apr;18(2):111-8.

  20. Kalyani RR, Stein B, Valiyil R, Manno R, Maynard JW, Crews DC. Vitamin D treatment for the prevention of falls in older adults: systematic review and meta-analysis. Journal of the American Geriatric Society. 2010; 58(7):1299-310.

  21. Karkkainen MK, Tuppurainen M, Salovaara K, Sandini L, Rikkonen T, Sirola J, et al. Does daily vitamin D 800 IU and calcium 1000 mg supplementation decrease the risk of falling in ambulatory women aged 65-71 years? A 3-year randomized population-based trial (OSTPRE-FPS). Maturitas. 2010; 65(4):359-365.

  22. Karlsson MK, Magnusson H, von Schewelov T, Rosengen BE. Prevention of falls in the elderly: a review. Osteoporosis International. 2013; 24(3):744-62.

  23. Li F, Eckstrom E, Harmer P, Fitzgerald K, Voit J, Cameron KA. (2016). Exercise and Fall Prevention: Narrowing the Research-to-Practice Gap and Enhancing Integration of Clinical and Community Practice. The Journal of the American Geriatrics Sociaty: 64: 425 – 431.

  24. Lips P, Bouillon R, van Schoor NM, Vanderschueren D, Verschueren S, Kuchuk N, et al. Reducing fracture risk with calcium and vitamin D. Clinical Endocrinology. 2010; 73(3):277-85.

  25. Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD002759.

  26. McClure RJ, Turner C, Peel N, Spinks A, Eakin E, Hughes K. Population-based interventions for the prevention of fall-related injuries in older people. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD004441.

  27. Makizako H, Shimada H, Doi T, Park H, Yoshida D, Uemura K, et al. Poor balance and lower gray matter volume predict falls in older adults with mild cognitive impairment. BioMed Central Neurology. 2013; 13(1):102.

  28. Montero-Odasso M, Muir SW, Speechley M. Dual-task complexity affects gait in people with mild cognitive impairment: the interplay between gait variability, dual tasking, and risk of falls. Archives of Physical Medicine and Rehabilitation. 2012; 93(2):293-9.

  29. Nazir A, Mueller C, Perkins A, Arling G. Falls and nursing home residents with cognitive impairment: new insights into quality measures and interventions. Journal of the American Medical Directors Association. 2012; 13(9):819.e1-6.

  30. Neelemaat F, Lips P, Bosmans JE, Thijs A, Seidell JC, van Bokhorst-de van der Schueren MA. Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older adults. Journal of the American Geriatrics Society. 2012; 60(4):691-9.

  31. Ni M, Mooney K, Richards L, Balachandran A, Sun M, Harriell K, Potiaumpai M, Signorile JF. Comparative impacts of Tai Chi, balance training, and a specially-designed yoga program on balance in older fallers. Archives of physical medicine and rehabilitation. 95 (9):1620-1628.e30, 2014.

  32. Ogama N, Sakurai T, Shimizu A, Toba K. Regional white matter lesions predict falls in patients with amnestic mild cognitive impairment and Alzheimer's disease. Journal of the American Medical Directors Association. 2014; 15(1):36-41.

  33. Palvanen M, Kannus P, Piirtola M, Niemi S, Parkkari J, Jarvinen M. Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: A randomised controlled trial. Injury. 2014;45 (1):265-71.

  34. Reed-Jones RJ, Solis GR, Lawson KA, Loya AM, Cude-Islas D, Berger CS. Vision and falls: a multidisciplinary review of the contributions of visual impairment to falls among older adults. Maturitas. 2013; 75(1):22-8.

  35. Reed-Jones RJ, Dorgo S, Hitchings MK, Bader JO. Vision and agility training in community dwelling older adults: incorporating visual training into programs for fall prevention. Gait & posture. 2012; 35(4):585-9.

  36. Salonen L, Kivela SL. Eye diseases and impaired vision as possible risk factors for recurrent falls in the aged: a systematic review. Current Gerontology and Geriatrics Research. 2012; 2012:271481.

  37. Scott V, Votova K, Scanlan A, Close J. Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings. Age and Ageing, 36. 2007:130-9.

  38. Smulders E, Weedesteyn V, Groen BE, Duysens J, Ejsbouts A, Laan R, et al. Efficacy of a short multidisciplinary falls prevention program for elderly persons with osteoporosis and a fall history: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2010; 91(11):1705-11.

  39. Twigg M, Wright D, Barton GR, Thornley T, Kerr C. (2015). The four or more medicines (FOMM) support service: results from an evaluation of a new community pharmacy service aimed at over-65s. International Journal of Pharmacy Practic; 23: 407-414.

  40. Vogler CM, Menant JC, Sherrington C, Ogle SJ, Lord SR. Evidence of detraining after 12-week home-based exercise programs designed to reduce fall-risk factors in older people recently discharged from hospital. Archives of Physical Medicine and Rehabilitation. 2012; 93(10):1685-91.

  41. Whitney J, Close JC, Jackson SH, Lord SR. Understanding risk of falls in people with cognitive impairment living in residential care. Journal of the American Medical Directors Association. 2012; 13(6):535-40.

  42. Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Archives of Internal Medicine. 2009; 169(21):1952-60.

  43. Yamada M, Takechi H, Mori S, Aoyama T, Arai H. Global brain atrophy is associated with physical performance and the risk of falls in older adults with cognitive impairment. Geriatrics & Gerontology International. 2013; 13(2):437-42.

  44. Yeung PY, Chan W, Woo J. (2015). A community-based Falls Management Exercise Programme (FaME) improves balance, walking speed and reduced fear of falling. Primary Health Care Research & Development; 16: 138 – 146.

  45. Yip JL, Khawaja AP, Broadway D, Luben R, Hayat S, Dalzell N, et al. Visual acuity, self-reported vision and falls in the EPIC-Norfolk Eye study. The British Journal of Opthalmology. 2014; 98(3):377-82.

  46. Zhang XY, Shuai J, Li LP. Vision and Relevant Risk Factor Interventions for Preventing Falls among Older People: A Network Meta-analysis. Sci Rep. 2015 May 28;5:10559.

  47. Zhuang J, Huang L, Wu Y, Zhang Y. The effectiveness of a combined exercise intervention on physical fitness factors related to falls in community-dwelling older adults. Clinical Interventions in Aging. 2014;9:131-140.

Guidelines:


  1. Avin KG, Hanke TA, Kirk-Sanchez N, McDonough CM, Shubert TE, Hardage J, Hartley G; Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Management of falls in community-dwelling older adults: clinical guidance statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Phys Ther. 2015 Jun;95(6):815-34. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25573760

  2. Morris JN, Fries B, Bernabei R, Steel K, Ikegami N, Carpenter I, et al. interRAI Home Care (HC) Assessment Form and User's Manual. Version 9.1. USA: inteRAI, 1994-2009. Available from: http://ebooks.interrai.org/product/interrai-home-care-hc-assessment-form-users-manual-electronic-edition20490

  3. Morris JN, Berg K, Bjorkgren M, Finne-Soveri H, Fries B, Frijters D, et al. interRAI Clinical Assessment Protocols (CAPs) for use with community and long-term care. Version 9.1. USA: interRAI, 2007-2010. Available from: http://ebooks.interrai.org/product/interrai-clinical-assessment-protocols-caps-for-use-community-longterm-care-instruments-electronic-edition

  4. National Institute for Health and Care Excellence. Falls: assessment and prevention of falls in older people. NICE clinical guideline 161. UK: NICE, 2013 June 2013. Available from: http://www.nice.org.uk/nicemedia/live/14181/64088/64088.pdf

  5. Panel on Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatrics Society. Summary of updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatric Society. 2011; 59(1):148-57. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2010.03234.x/abstract

  6. Registered Nurses' Association of Ontario. Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult. Toronto: RNAO, 2011. Available from: http://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries-older-adult

  7. U.S. Preventive Services Task Force. Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Aug 7;157(3):197-204. Available from: https://www.guideline.gov/summaries/summary/37219/prevention-of-falls-in-communitydwelling-older-adults-us-preventive-services-task-force-recommendation-statement?q=Falls

Measurement

Created on August 28, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How do we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another.

Indicator Falls in long-stay home patients
Topic Patient Safety and Never Events
Quality Dimension Safe
Type of Indicator Outcome
Measure Percentage (%)
Data Source Home Care Reporting System (HCRS)
Data Collection Instrument Collected by the Canadian Institute for Health Information (CIHI)
How to Calculate

The unadjusted indicator is calculated as (Numerator/Denominator) x 100

Numerator: # of long-stay home care patients who record a fall in the last 90 days.

Denominator: Number of all eligible long-stay home care patients.

*excludes patients totally dependent in bed mobility

Target Lower is better
Range 0 – 100%
HQO Reporting Tool Public Reporting, and Quality Improvement Plans (QIPs)

Tools & Resources

Created on August 28, 2017

Safer Healthcare Now! provides a comprehensive resource to help providers reduce falls and injuries in the home care, hospitals and long-term care settings: Safer Healthcare Now!’s Reducing falls and injuries from falls: Getting started kit

Tools


Resources

Background

Created on August 28, 2017

Issue

A fall is defined as an event or unintentional change in position that results in a person coming to rest inadvertently on the ground or floor, or other lower level (Morris et al., 2010; RNAO, 2011). The frequency of falls increases with age, and in Ontario the average age of the home care client is 78 years old (CIHI, 2016). Fall-related injuries are among the most serious and common occurrences experienced by older adults. Falls can lead to a loss of independence and deterioration in one’s quality of life (RNAO, 2011).

Ontario home care (HC) nursing visits, personal support and homemaking is provided to approximately 650,000 people per year. Estimates indicate that approximately 30% of home car (HC) clients - close to 200,000 people per year will fall in the home (Bansal, et al., 2016). Having a recent fall – within six month to one year, has reliably been identified as a strong risk factor for subsequent falls among older adults (Bamgbade & Dearmon, 2016; Bansal, et al., 2016). For clients in the home who have some type of cognitive impairment and dementia the annual prevalence of falls is approximately 60% (Bansal et al., 2016).

In 2011-2012 28% of long-stay home care clients had a fall in the 90 days prior to their last assessment, this figured has changed very little, and has actually increased to 31.4% in 2015-2016. Figure 1 illustrates the slow steady increase in percent of Ontarians receiving publicly funded home care who fell one or more times in the past three months.

FIGURE: 1 The percentage of Ontario patients receiving publicly funded home care for at least 60 days (such as chronic/complex illnesses) who fell at least once during the three months since their last assessment.

Source: Home Care Reporting System (HCRS), provided by the Canadian Institute for Health Information (CIHI).

When considered by Local Health Integration Network there is a ten percent difference between the LHIN region with the highest fall rate and the one with the lowest falls rate.

FIGURE 2: The percentage of Ontario patients receiving publicly funded home care for at least 60 days (such as chronic/complex illnesses) who fell at least once during the three months since their last assessment, by LHIN region.

Source: Home Care Reporting System (HCRS), provided by the Canadian Institute for Health Information (CIHI).

Causes and Consequences of Falls

The occurrence of falls and the risk factors associated with falling vary based on a client’s clinical profile, and the home setting. Persons over age 65 have the highest mortality rate from injuries, and injuries from falls cause about one-half of deaths due to injury - more than either pneumonia or diabetes (MOHLTC, 2016). In Ontario the number of patients admitted to the emergency department (ED) due to a fall related injury has been steadily increasing. Figure 3 illustrates that the number of fall related ED visits are increasing by approximately 10% every two years.

FIGURE 3: Number of Ontario patients admitted to the emergency department (ED) due to a fall related injury in 2013, 2014, 2015

Source: Ambulatory Emergency External Cause (2013-2015), Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO

Call to Action

In Ontario 84% of home care clients are over the age of 65, with an average age of 78 (CIHI, 2016). Various types of rehabilitation services and therapies are provided in the home, however 78% of the care being provided is personal support or home making. Furthermore, 97% of home care clients in Ontario have an informal family caregiver present (CIHI, 2016; Home Care Ontario, 2016). Preventing falls and injuries in frail seniors is imperative, as it will allow seniors to remain at home and maintain their quality of life, reduce hospital admissions and readmissions, and delay entrance into a long-term care home. Furthermore, injury prevention is a cost-effective strategy for reducing the indirect and direct health care costs associated with falls and can reduce injury-associated demand for extra care.

  1. Accreditation Canada, Canadian Institute for Health Information, and Canadian Patient Safety Institute.
    Preventing Falls: From Evidence to Improvement in Canadian Health Care.
    Ottawa, ON: CIHI; 2014.
    Retrieved from: https://secure.cihi.ca/free_products/FallsJointReportAugust6_2014_CPHI_EN_web.pdf

  2. Bamgbade, S., Dearmon, V. (2016).
    Fall Prevention for Older Adults Receiving Home Healthcare.
    Home Healthcare Now; 34 (2): 68 – 75.

  3. Bansal, S., Hirdes, J.P., Maxwell, C. J., Papaioannou, A., Giangregorio, L. M. (2016).
    Identifying fallers among Home Care Clients with Dementia and Parkinson’s Disease.
    Canadian Journal on Aging; 35 (3): 319 – 331.

  4. Canadian Institute for Health Information.
    Home Care Reporting System.
    Quick Stats. Ottawa: CIHI, 2007-08, 2008-09, 2010-11, 2011-12, 2012-13, 2013-14, 2014-15, 2015-16.
    Retrieved from: https://www.cihi.ca/en/quick-stats

  5. Community Care Access Centre.
    How we care. 2012-2013 CCAC Quality Report.
    Toronto: CCAC, 2013.
    Retrieved from: http://oaccac.com/Quality/Documents1/2012-2013-CCAC-Quality-Report-EN.pdf

  6. Dorresteijn, T. A.C., Zijlstra, G.A.R., Ambergen, A.W., Delbaere, K., Vlaeyen, J.W.S., Kempen, G.I.J.M. (2016).
    Effectiveness of a home-based cognitive behavioral program to manage concerns about falls in community-dwelling, frail older people: results of a randomized controlled trial.
    BMC Geriatrics; 16 (2): 1-11.

  7. Health Quality Ontario.
    Aging in the community: summary of evidence-based analyses.
    Ontario Health Technology Assessment Series. 2008;8(1).
    Retrieved from: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/aging-in-the-community

  8. Home Care Ontario. (2016).
    Facts & Figures: Publicly Funded Home Care.
    Retrieved from: http://www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare

  9. Ministry of Health and Long-Term Care (MOHLTC).
    (2016) Initial Report on Public Health.
    Fall-Related Hospitalizations Among Seniors.
    Retrieved from: http://www.health.gov.on.ca/en/public/publications/pubhealth/init_report/fhas.html

  10. Morris JN, Berg K, Bjorkgren M, Declercq A, Finne-Soveri H, Fries BE, et al.
    interRAI Community Health (CHA) Assessment Form and User's Manual.
    Version 9.1. Canadian Edition. Washington, DC: interRAI; 2010.
    Retrieved from: http://ebooks.interrai.org/product/interrai-community-health-cha-assessment-form-users-manual-electronic-edition

  11. Registered Nurses' Association of Ontario.
    Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult.
    Toronto: RNAO, 2011.
    Retrieved from: http://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries-older-adult

  12. Safer Healthcare Now! Reducing falls and injuries from falls. Getting started kit.
    Registered Nurses Association. Canadian Patient Safety Institute, 2013.
    Retrieved from: http://www.patientsafetyinstitute.ca/en/toolsresources/pages/falls-resources-getting-started-kit.aspx

  13. Scott V, Wagar L, Elliot S.
    Falls and related injuries among older Canadians: Fall -related hospitalizations and prevention initiatives.
    Prepared on behalf of the Public Health Agency of Canada, Division of Aging and Seniors. Victoria, BC: Victoria Scott Consulting, 2011. Retrieved from: http://www.hiphealth.ca/media/research_cemfia_phac_epi_and_inventor_20100610.pdf