Fall Prevention in the SNF/LTC Setting:It Takes a Village!

Corrie Dyson, MS, CCC-SLPClinical Excellence Coordinator

Therapy Management Corporation

Fall Statistics Recap• More than 1/3 of adults 65 and

older fall each year in the United States

• Among older adults, falls are the leading cause of injury deaths.

• Falls are also the most common cause of nonfatal injuries and hospital admissions for trauma.

• About 5% of adults over 65 live in nursing homes, but nursing home residents account for about 20% of deaths from falls in this age.

Common Outcomes from Falls

• 20-30% of people who fall suffer moderate to severe injuries

• Falls are the most common cause of traumatic brain injuries (TBI).

• Most fractures among older adults are caused by falls

• 90% of all hip fractures are a result of a fall.

Paradigm Shift: Fall Intervention to Fall Prevention

Prevention = A PROACTIVE, forward-thinking concept that promotes a fall-free environment

Intervention = A REACTIVEconcept, in which we wait for an incident to occur, then intervene

Impact of Fall Prevention

PatientsFamily Members

StaffSurveyors

Cost

Health

Satisfaction

Safety

Key Concepts in an Effective Fall Prevention Program

• Prevention of falls and/or injury from falls • Improved regulatory compliance • Increased nursing-therapy communication and referral stream • Specialized screening to capture fall risk • Evidence-based risk identification and interventions for

patients• Improved function for patients at risk for falling and

recovering from falls • Improved discharge planning with patient education and re-

screening at 30 days.

Hake Experimental Design Concept: Work to Continually Improve!

Collect Data

Investigate Data

Collected

Compare Outcomes

Add in additional variables

TMC Fall Prevention

119 SNFs with an Active Fall Program • Quality Measure is: Percentage of long-stay residents experiencing one or more falls with major injury• Average at Q2 2017- 4.058%• Average at Q1 2018- 3.410%• Reduction of 16.0%

3.13.23.33.43.53.63.73.83.9

44.1

Falls with Injury BaselineQM%

Falls with Injury CurrentQM%

Falls with Injury

Falls with Injury

The Role of Therapy in Fall Prevention

PHYSICAL THERAPY OCCUPATIONAL THERAPY

SPEECH THERAPY

• Balance Training• Lower Body

Strengthening• Gait Training• Transfer Training• Coordination Training• Assistive Device

Training

• Assistive Device Training

• Upper Body Strengthening

• Balance Training• Transfer Training• Positioning Assessment

• Cognitive Training• Memory Strategy

Implementation• Orientation Training• Education for Safety

Prevention Strategies

Factors Impacting Fall Risk

• What risk factors should we be looking for?

• Physical Impairment• Cognitive Impairment• Medication-Related Risks• UTI/Incontinence• Pain• Recent History of Falls• Impaired Sensation• Visual Deficits• Changes in Medical Status

New

PreviouslyUnaddressed

Changed

Pt ID’d as Risk for falls, or experiences a fall

Pt screened using Prevention/Intervention Screen:

• Screen gait, strength, balance• Screen Cognition• Screen for risk indicators (fall Hx, expressed

fear of falling)

Gait, Strength or Balance problem evident OR

Positive Risk Indicator (Hx of falls, expressed fear of falling)

Cognitive deficits present

No Cognitive deficits

No positive indicators on

screen

Recommend LOW RISK interventions:• Pt Education• Activity-based Exercise Program• Quarterly Screens

Recommend MODERATE RISK Interventions:

• PT and/or OT referral• Medication review by Medical Staff• DC to RNA program• Re-screen in 30 days

Recommend HIGH RISK interventions:• PT and/or OT referral• ST referral• Medication review by Medical Staff• DC to RNA program• Re-Screen in 30 days

Root Cause Analysis: PT• Balance Issues• Sensory Issues• Lower Extremity Weakness• Gait Disturbance• Transfer Difficulties• Coordination Deficits• Assistive Device Training

Needs• Functional Mobility Issues• Postural Deficits• Effects of Medications/

Polypharmacy

Root Cause Analysis: OT• Functional Mobility Issues• Transfer Issues• Toileting Issues• Incontinence Issues• Positioning Issues• Closet Management Issues• Safety/Cognitive Issues• Environmental Issues• ADL/Clothing Management Issues• Sensory Issues• Effects of

Medications/Polypharmacy

Root Cause Analysis: ST

• Dementia• Cognitive-Linguistic Deficits

• Safety-Awareness Issues• Sequencing• Problem-Solving• Reasoning• Executive Functioning

• Memory Issues• Sensory Issues• Effects of

Medications/Polypharmacy

Interdisciplinary Focus to reduce Falls: Bridging the Communication

Gap In most cases, the “communication gap”

is created by:• The difference starting vantage point

that the patient is viewed with nursing vs therapy

• The fact that we are confronted with our own “Tower of Babel” with inability to realize we are often saying the EXACT same thing, just utilizing a different dialect

• Assumption of Interdisciplinary Understanding

• Criteria for qualification for reimbursement

• Discipline specific terminology variance• Charting/ documentation strategies and

trainings variances between disciplines

Bridging the Gap:Speaking the Same Language

To bridge the language gap, Therapy and Nursing should:

First- Listen: Stop and take the time to hear what the other person is saying.Second- Ask: Ask for clarification/ further details related to any areas of ambiguityThird- See: Take the initiative and the time to go and see the resident. This will assist in having a better understanding of the situation that is being referred.

Maintaining Best Ability to Function through the Continuum of Care

Maintaining Best Ability to Function through the Continuum of Care

FMP = Functional Maintenance Plan

• Carried out by CNAs, Nurses, Activities, or trained Caregivers

• Created by Therapists during last week of intervention

• Training provided with staff, family, etc., with return-demonstration

• Can focus on any intervention area needed• No requirements for interventions• No time limits for length of provision

RNP = Restorative Nursing Plan

• Carried out by a designated, trained Restorative Nurses’ Aide

• Requires 2 interventions or focus areas• Oversight by Nursing Staff/Nurse Manager• RNPs can be created by a Therapist upon DC from

Therapy, but this is not required.• RNPs are performed until the resident discharges to

“the floor”.

Where do we go from here???

How do we get this started in our facility???

Create a Game Plan for the IDT

• Assess where you stand currently

• ID key blocks to effective communication

• ID key team members to begin bridging the gap

• Create accountability and focus through a consistent High Risk Meeting

Accountability

FocusConsistency

Communication

Fall Risk/RNA Review Meetings

• Who should attend???

• How often?• Should be held weekly, on the same

day and same time.• What is discussed?

• Recent Falls & Fall Risk Screens• Rehab progress & participation• Restorative progress & participation• Upcoming Quarterly MDS

Assessments

• Administrator• Rehab Representative• RNA Representative

• DON/Nurse Manager• MDS Coordinator

Walking Rounds

Purpose:• ID residents at risk for falls• Address specific resident needs

through an IDT approach• Improve consistency of

documentation and communication between Nursing and Rehab

• Streamline screening processes• Improve the visibility of the

Rehab Team within the facility• Strengthen the communication

and relationships within the interdisciplinary team.

Walking Rounds

• Process• Identified Risks/Declines are noted and recorded by

Nursing. • Nursing enters documentation pertaining to decline

into the patient record.• Nursing issues a Screening Request to Rehab, using a

“Hey, Therapy!” form. • Rehab completes the Screen. • Patient is evaluated, if indicated. • Walking Rounds should occur on the same day each

week• Walking Rounds are based on facility

need/identification of residents at risk for developing problems.

• Walking Rounds should last no longer than 45-60 minutes per week, depending on facility census and the number of residents screened/discussed.

Sample Nursing-to-Therapy Referral Forms

SNF Wellness• Wellness Exercise

Classes• General Exercise• Tai Chi• Chair Yoga

• Walk/Wheel to Dine Program

• Health Fairs• Wellness

Presentations/ Seminars

SNF Wellness & Restorative Exercise Disclaimer

• ALL Exercises should be performed in a seated position, unless otherwise designated, such as:

• Walk-to-Dine• Walk-to-Exercise• Sit-to-Stand, as directed by PT/OT, and performed by trained RNA Staff• Parallel Bars or Standing Exercises, as directed by PT/OT, and performed

with trained RNA Staff

• RNA Exercises should be general, or unskilled, in nature, meaning that they should be designed to maintain function and prevent decline, unless otherwise specified by a skilled therapist.

• Restorative Aides should receive training from skilled therapists prior to providing services, including a skills check, with return-demonstration.

• Restorative plans should include, at the very least, some level of recommendations/feedback from skilled therapists, to ensure safety of the residents, and to consider any contraindications and precautions that might come into play

Examples of Safe, Seated Exercises for RNA/Wellness

• March in place with alternating legs, then one leg at a time

• Ankle/Leg Circles

• Ankle Pumps/Toe Raises

• Cross 1 arm across the chest and twist waist side to side, keeping the back as straight as possible

• Bring both arms out to the side and raise (“flap”) up and down

• Bring arms straight out in front, then lift wrists up and down

• With arms extended, rotate between palms up/palms down

• Extend one leg out completely; repeat on opposite leg

• Bring elbows behind you, squeezing shoulder blades together

• Punching exercises (straight, then across the body)

• Head Turns/Shoulder Raises

An interdisciplinary approach is key to preventing Falls in any

facility!

QUESTIONS????