This is an integrated multi-agency service, combining NHS (Dudley Group Foundation NHS Trust), CCG (Dudley Clinical Commisioning Group), local authority and public health services (Dudley Metropolitan Borough Council) to provide multifactorial assessment and intervention to prevent falls. Whilst the service accepts referrals for any age, the majority of the caseload are older adults, aged 65 and over.
NICE into Action 2019 Award Runner Up, Chief Allied Health Professions Officer Awards (CAHPO)
Aims and objectives
Dudley was an outlier for the rate injurious falls requiring admission and hip fractures, compared to both national averages and demographically matched populations, as detailed in the Right Care report. Three separate services existed for managing falls: a local authority team, an NHS-based therapy team and a consultant-led falls and syncope clinic.
We integrated services into one pathway, where patients are now triaged to the relevant service based on clinical need. We developed one multifactorial assessment based on NICE guideline CG161 and Quality Standard QS86, which includes a tool to identify individuals at risk of loneliness and social isolation, in line with the Campaign to End Loneliness. This is completed by all streams, ensuring equity of provision. If a patient needs to access another stream, their assessment can be sent, to save duplication.
Following assessment a universal summary of the assessment is sent to GPs, detailing the outcomes and any actions for them.
The pathway has seen:
- Admissions with falls rate reduced by: 29.4% for over 65s and 25.2% for 80+.
- Admissions with hip fracture rate reduced by: 19.2% for over 65s and 23.5% for 80+.
These are all the lowest rates for eight years.
The main aims of the initiative were:
- To integrate multi-agency services into one collaborative falls pathway with a Single Point of Access (SPA).
- To standardise evidence-based holistic falls assessment and interventions across the pathway,
- Implementing NICE guidance, whilst still retaining each contributor’s specialist skills.
- To help patients access the most appropriate service for their individual needs.
- To improve patient experience of the pathway through reduced waiting times and avoid duplication.
- To improve utilisation of falls prevention services across the Dudley borough.
- To establish a falls MDT meeting, to discuss complex cases.
- To develop a shared, electronic database to track patient journeys and monitor service outcomes.
- To provide an individualised patient journey through clinical interventions, into local authority exercise and into local, long-term, Public Health exercise opportunities.
- Provide care closer to home, through the establishment of our falls clinics in both the north and south of the borough; and the development of postural stability exercise classes at multiple locations across the entire borough.
- To have a Falls Co-ordinator sitting across all 3 streams of the service.
Reasons for implementing your project
Falls prevention services were fragmented, with different teams working in isolation, poor inter-service communication and limited inter-service resource utilisation. The service a patient accessed was decided by which service their GP/consultant knew, rather than clinical need. Patients were often referred to multiple services simultaneously and were frustrated by having to repeat themselves during separate services’ assessments. Additionally, there was no means of knowing if/when a patient was accessing another element of the local falls prevention services, therefore duplication was common.
Each service completed their own assessment, which was not shared if patients went on to access another. There was no clear link between the assessments and best evidence, as outlined in NICE CG161 and QS86.
How did you implement the project
A task-group was established to redesign the service comprised of CCG, public health, local authority (LA), NHS staff and patient representatives. As progress was made, this changed into a task and finish group, to target specific components, which required work.
Significant factors included NHS clinicians providing training for SPA staff, and collaboratively developing a triage tool, to help the process of directing patients to the most indicated stream of the service. This triage process had some understandable teething issues, which were resolved through regular SPA meetings to review and identified cases to maximise correct allocation.
Implementing the new assessment form also required significant training, to up-skill staff across the pathway in completing areas of best practice (e.g. blood pressure readings, FRAX scores, cognitive assessments, balance/mobility assessments, high-risk medications and/or polypharmacy). We utilised the knowledge and skills of the clinicians working within the pathway- physiotherapists, occupational therapists, pharmacists and falls nurses to deliver this. Additionally, we developed a Falls Assessment Guide, with embedded links to referral forms, to support staff completing the assessment and simplify the onward referrals, particularly for those to services previously under-utilised.
The first fully operational year, saw 1827 patients come through the pathway.
Last year’s acute admission statistics have started to show the effectiveness of Dudley Falls Prevention Service:
- The rate of falls in 17/18 for the 65+ and 80+ cohorts are the lowest in the past 8 years.
- This equates to 433 fewer falls compared to peak rate- saving estimated £3.4million.
- Emergency admissions to hospital for hip fracture for the 65+ and 80+ cohorts are the lowest in the last 8 years.
- This equates to 91 fewer hip fractures compared to peak rate- saving estimated £1.3million.
- Compared to the Right Care report figures (for 14/15), rates were lower for all groups:
- Over 65 admissions with falls= rate reduced by 29.4%
- Over 80 admissions with falls= rate reduced by 25.2%
- Over 65 admissions with hip fracture= rate reduced by 19.2%
- Over 80 admissions with hip fracture= rate reduced by 23.5%
Patients' responses have also been extremely positive, as captured through our friends and family feedback.
The wide nature of this project, and having AHPs as leaders of change in this project, has helped it deliver each of the four impacts, priorities and commitments as outlined in NHS England's 'AHPs into Action' strategy.
Key learning points
Some lessons learned include:
- That multi-agency working brings multiple benefits for both staff and patients, but also can mean alterations or adjustments can take time to implement due to the multiple governance structures in place.
- The importance of data quality for providing an up-to-date snapshot on service performance.
- How involving staff in the process of change (e.g. assessment form), helps buy in to the alterations to that service.
If we were to do it again:
- Developing/launching the assessment guide at the same time the new assessment form, could have
helped staff feel more confident completing the assessment earlier on.
- Extra time training staff on the new database, may have avoided some data quality issues that needed rectifying at a later date.
- Developing a process with Telecare for pendant alarm referrals from the outset, to prevent duplicate or inappropriate referrals.
Spread and Adoption
- Training provided on the pathway to multiple speciality groups including GPs and acute sector inpatient
- therapy staff.
- Work with local care home providers and care staff on reducing falls risks and providing falls prevention
- The work on developing the falls pathway was recognised by winning one of the 'Dudley Group NHS Foundation Trust Healthcare Hero awards'.
- An abstract was accepted for and presented at Health Services Research and Pharmacy Practice conference, regarding work within the falls pathway on osteoporosis management in primary care.
- The work undertaken to identify patients for falls medication reviews has been shortlisted as a finalist for the chemist and druggist awards in the 'Health Initiative of the Year' category.