Cedar Court Healthsouth Rehabilitation Hospital

1. Cedar Court Healthsouth Rehabilitation Hospital “SAFE WALKERS” Outpatient falls prevention and balance program Eryn Wait (Occupational Therapist) Tiana Wong (Physiotherapist)

2. Cedar Court: overview • CCHS started out as a small hospital in the 1930’s, therapy services introduced in 1980 • Purchased by Healthsouth, USA in 1997 • Present day, 80 bed inpatient capacity with orthopaedic/musculoskeltal unit, neurology unit, cardiac-respiratory unit, ABI unit and sleep study unit

3. Outpatient programs • Large outpatient program scope: • Neurological (stroke, parkinson’s/movement disorders, MS, neuropathies & myopathies) • Vestibular (dizziness/vertigo, balance and mobility problems leading to falls)

4. Outpatient programs • Acquired Brain Injury (Traumatic head injury) • Orthopaedic rehabilitation (post-joint replacement or reconstruction surgery, fractures, spinal surgery or multi-trauma)

5. Outpatient programs • Musculo-skeletal rehabilitation (arthritis, fibromyalgia, or back pain) • Pain management (chronic pain) • Cardiac rehabilitation (AMI, CABG’s, cardiomypopathies, stents, pacemaker, other acute events)

6. Outpatient programs • Respiratory rehabilitation (emphysema, chronic bronchitis, thoracic surgery or pneumonia) • Sleep disorder (Ax and Rx of breathing problems during sleep, insomnia or excessive sleepiness)

7. “SAFE WALKERS”Description and aims Run under Neurology outpatient stream A comprehensive team approach for the assessment and treatment of people who suffer from recurrent falls or poor balance affecting mobility and safety. Aims to remediate and improve strength, fittness, balance, as well as retrain balance skills. Educate and provide problem-solving sessions to minimise falls. Use of safety strategies in various environments and situations. Promote confidence and independence.

8. Rehabilitation Team

9. Referral sources GP’s Inpatient referrals (Internal and other Acute private hospitals) Specialist medical consultants Community organisations Referral procedure Referral from GP or medical specialist required in writing Health fund check Assessment by OT/PT Entry to program Referral sources & procedure

10. TARGET GROUPS History of falls General physical deconditioning Reduced ability to cope functionally Emotional/psychosocial difficulties Fear of falling NON-TARGET GROUPS Medically unstable Acute vestibular dysfunction Individuals with significant cognitive/memory deficits Inability to cope in a group setting Admission criteria

11. Assessment • 1 ½ hour subjective/objective assessment with physiotherapist and occupational therapist • Outcome measures (refer to table) • Provision of information /education booklet • Home visit booked • Scheduled to start program MEDICAL REVIEW • Consultants review half way through program • Team meeting with Consultant and therapists fortnightly

12. Balance Master

13. Group structure & content

14. Treatment 6/52 program, twice a week sessions for 2 ½ hours Mondays/Wednesdays or Tuesdays/Thursdays (4/52 program for DVA) • Balance retraining • Strengthening and stretching • General conditioning • Outdoor and community mobility retraining • Assessment and provision of appropriate gait aids • Education on falls prevention • Functional retraining: ADL • Home visit • Psychology assessment • Referral for community services

15. Balance exercises

16. Occupational Therapy: ADL training

17. Education TOPICS Balance Causes of falls Community safety Home safety Energy conservation What to do if you fall Home practical Wellbeing Managing fear of falling: Relaxation Putting changes in to practice Nutrition Preparation for outdoor walking * Outdoor walk & public transport access is conducted every 6/52, or 1:1

18. Outdoor mobility and public transport access

19. Evaluation • On the patient’s final session the outcome measures are taken again • Goals reviewed • Referral to a community exercise program is arranged as appropriate • A 3 month review appointment is given • Discharge summary sent to GP and/or referring specialist

20. Future direction with data collection • Recent development of new database 2005 • Collecting following data using excel spreadsheet format: Gender Step test (ADM,D/C,RV) DOB Functional reach (ADM,D/C,RV) Reason for referral Sit to stand (ADM,D/C,RV) Primary presenting condition Fear of falling scale (ADM,D/C,RV) Timed up and go (ADM,D/C,RV) Mini mental (ADM, D/C) Functional reach (ADM, D/C,RV) Falls 3/12 prior to the program Smart balance master (ADM,.D/C, RV) Private rehab post program 10 metre walk (ADM,D/C, RV) Falls during program (+ 3/12 RV) Psychology referral Community referral Barthel ADL index (ADM,D/C)

21. Project Aims • to compare the efficacy of 4 week v 6 week program • to evaluate the demographics of the patients referred to the program, thus establishing target groups • to assess the long term effectiveness of the program (3 month review) • to identify and track the primary referral sources • to increase suitability of referrals • to determine the effectiveness of Cedar Court’s falls and balance program both qualitatively and quantitatively

22. Project aims • Evaluating compliance by determining the percentage of patients completing the program • Look at trends with outcomes for different patient groups (considering diagnoses, age, gender, supports in place) • Provide insurance providers with evidence of program effectiveness (justification of program length, and disciplines needed) • Implementation of suggestions from patient feedback surveys

23. Methodology • Step 1- Identification of aims • Step 2- Entering of data collected from the past 6 months (n=50) • Step 3- Evaluation and analysis of data • Step 4- Presentation of data internally and externally (Falls Clinic Coalition) • Step 5- Implementation of findings

24. Limitations • No control group • Incomplete data e.g patient unable to do balance master • Extraneous variables e.g patient wearing different shoes on admission and discharge thus reducing reliability • Multifactorial problems

25. References • Cockrell JR & Folstein (1988). Mini Mental Status Examination, Psychopharmacology, 24: 689-692 • Cole,B., Finch,E., Gowland,C., Mayo,N. Physical Rehabilitation outcome measures. Toronto: Canadian Physiotherapy Association, 1994 • Duncan,P., Weiner,K., Chandler,J. et al: Functional Reach: A new clinical measure of balance. Journal of Gerontology 1990; 45: M192-97 • Hill,K., Bernhardt,J., McGann,A. et al: A new test of dynamic standing balance for stroke patients: Reliability, validity, and comparison with healthy elderly. Physiotherapy Canada 1996; 257-62 • Mahoney FI, Barthel,D. “Functional evaluation: the Barthel Index” Maryland State Medical Journal 1965; 14: 56-61 • Podsiadlo,D., Richardson,S: The “timed up and go test”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society 1998;46: 758-61 • Tinetti,M., Richman, D., Powell,L. Falls efficacy as a measure of fear of falling. J Gerontology 1990; 45: P239-43