five hills health region home care
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
Five Hills Health RegionHome Care
Apr 22, 2023 Saskatchewan Falls Collaborative 2
BackgroundSite: •Moose Jaw Union HospitalTeam:•Home Care and Community TherapiesPatient Population:•Home Health Service Clients, Team 1 and 2Rationale:•These clients receive more long term service that typically involves personal care support•Higher needs client base, higher risk for falls
Apr 22, 2023 Saskatchewan Falls Collaborative 3
AimPurpose:•To decrease falls by 20% or more by March 2010Goals/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 interventionBoundaries:•Exclude Team 3 home services clients (February 2012 – included Team 3)
Aim• Challenges:- Identifying that falls have occurred- Documenting/tracking of falls reports- Communicating falls between disciplines- Implementing timely falls interventions
Apr 22, 2023 Saskatchewan Falls Collaborative 4
Apr 22, 2023 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
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)
2 Post assessment falls prevention recommendations made (form)
3 Orthostatic hypotension education (new form due to high number of clients with this problem)
4 Exercises targeting balance5 Increased awareness of community resources
and referrals to same (Maguire Centre)
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
HHA is made aware that fall occurred
HHA contacts Team 1 / 2 manager
Manager documents fall, forward info to Therapies
Known client to Therapies?Yes No
Therapist follows-up via phone call
Is visit required?
Yes No
Address falls risks, make recommendations
Has falls risk ax referral already been received from HC?
Yes
Placed on wait list
Falls risk assessment completed
No
Process for Known FallsHome Care Therapies
Post-Fall Nursing Assessment
• Started to implement Feb 2012• Form Adapted from MJ Pioneer Lodge
2. Falls Prevention Recommendation Form
3. Orthostatic Hypotension Form
4. Delegation to PTA/OTA
If PTA visits were declined
or were not appropriate,
home exercises to
work on balance were
provided
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
Results
1. Tracking referrals to therapies (graph)2. Started tracking falls in home services
clients in September 20113. Started receiving falls risk assessments
on a regular basis in December (New home services clients – referral from the Access Centre Intake Coordinator)
Falls Rate per 1000 Home Care Clients
Percentage of Falls Causing Injury
1. Falls Tracking – Referrals To Therapies
0
2
4
6
8
10
12
November December January February
Month
Clie
nts New Falls Risk Ax
Had a Fall, Therapies Client
Had a Fall, Refused Services
Had a Fall, New Client
2. Falls Tracking – Home Services Clients
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.
BERG Scores Run Chart
Red = Improvement
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