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Five Hills Health Region Home Care

Five Hills Health Region Home Care. Background. Site: Moose Jaw Union Hospital Team: Home Care and Community Therapies Patient Population: Home Health Service Clients, Team 1 and 2 Rationale: These clients receive more long term service that typically involves personal care support

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Five Hills Health Region Home Care

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  1. Five Hills Health RegionHome Care

  2. Background Site: • Moose Jaw Union Hospital Team: • Home Care and Community Therapies Patient Population: • Home Health Service Clients, Team 1 and 2 Rationale: • These clients receive more long term service that typically involves personal care support • Higher needs client base, higher risk for falls Saskatchewan Falls Collaborative

  3. Aim Purpose: • To decrease falls by 20% or more by March 2010 Goals/Objectives • To have 100% of falls reported to Client Service Managers • To establish a process to identify at risk clients • To ensure that all at risk clients have falls prevention intervention Boundaries: • Exclude Team 3 home services clients (February 2012 – included Team 3) Saskatchewan Falls Collaborative

  4. Aim • Challenges: • Identifying that falls have occurred • Documenting/tracking of falls reports • Communicating falls between disciplines • Implementing timely falls interventions Saskatchewan Falls Collaborative

  5. Team Members • Home Care • Pauline Osemlak, DNS (Team Leader) • Tracey Macfarlane, RN • Corrie Hordick & Jennifer Erbach, HHAs • Community Therapies • Lisa Benson & Dana Philipation, PTs • Judy Lin, OT • Team Sponsor • Bert Linklater, EDCC Saskatchewan Falls Collaborative

  6. Changes Tested (Nov/11 – Feb/12) 1 Process for notification of client falls from Home Care to Community Therapies - currently transitioning to having Home Care nurses go visit client at home (new form) • Post assessment falls prevention recommendations made (form) • Orthostatic hypotension education (new form due to high number of clients with this problem) • Exercises targeting balance • Increased awareness of community resources and referrals to same (Maguire Centre)

  7. 1. Improving communication and awareness of falls and providing timely follow-up • Started receiving e-mails regarding falls in November: HHAs/RNs notify Client Service Managers (CSM); CSMs make note in client’s file and email to Therapists. • If client is known to therapists - a follow-up phone call/visit as needed • If client is unknown, they are put on the Community Therapies waitlist for falls risk assessment

  8. Process for Known FallsHome Care  Therapies HHA is made aware that fall occurred HHA contacts Team 1 / 2 manager Manager documents fall, forward info to Therapies Yes Known client to Therapies? No Therapist follows-up via phone call Has falls risk ax referral already been received from HC? No Is visit required? Yes Yes No Placed on wait list Address falls risks, make recommendations Falls risk assessment completed

  9. Post-Fall Nursing Assessment • Started to implement Feb 2012 • Form Adapted from MJ Pioneer Lodge

  10. 2. Falls Prevention Recommendation Form

  11. 3. Orthostatic Hypotension Form

  12. 4. Delegation to PTA/OTA If PTA visits were declined or were not appropriate, home exercises to work on balance were provided

  13. 5. Using community resources • Sending referrals to balance program (accepts participants every 2 months) • PTA/OTAs are sent out between now and initiation of balance program to ensure smooth transition • Therapists from community and other health region facility communicates • Brochures/contact info for other local exercise programs as appropriate

  14. Results 1. Tracking referrals to therapies (graph) 2. Started tracking falls in home services clients in September 2011 3. Started receiving falls risk assessments on a regular basis in December (New home services clients – referral from the Access Centre Intake Coordinator)

  15. Falls Rate per 1000 Home Care Clients

  16. Percentage of Falls Causing Injury

  17. 1. Falls Tracking – Referrals To Therapies New Falls Risk Ax Had a Fall, Therapies Client Had a Fall, New Client Had a Fall, Refused Services

  18. 2. Falls Tracking – Home Services Clients

  19. Results - New BERG Scores • From the analysis (wilcoxon & sign tests) there is a significant difference between your initial scores and your FU scores. From the descriptive analysis your scores show an improvement.

  20. BERG Scores Run Chart Red = Improvement

  21. Next Steps • Continue to record stats on falls assessment referrals • DNS will be tracking % of post-fall assessments completed • Risk assessment form to be implemented (considering the Morse) CCCs and RNs will use to screen for high fall risk • Make falls prevention package for assisted living facilities and personal care homes including recommendations for exercise programming • Staff in-services on falls prevention literature/recommendations

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