Prevent patient falls, reduce readmissions
Prevent patient falls, reduce readmissions
Program ups patient, hospital, MCO satisfaction
"My patient fell." Unfortunately, that was what directors at Melrose-Wakefield Hospital Home Health Care Services in Melrose, MA, were hearing far too frequently from staff.
So the hospital-based home care agency has incorporated physicians and hospital pharmacy in a Falls Prevention Program for its patients that it hopes will not only reduce falls at home -- and thus hospital readmits -- but also increase the satisfaction rate of patients, their families, and MCOs.
Like many home care agencies, many of Melrose-Wakefield's patients are elderly and therefore have a greater risk of falling.
"We started this program because there were falls occurring among patients, and we weren't sure why," says Nancy Mathews , RN, Home Health Performance Improvement Nurse at Melrose-Wakefield.
"We're dealing with more managed care patients, and many of the managed care companies were looking for ways to promote health and prevent hospitalization," says Patricia Finocchiaro , RN, director of Home Health Care Services. "They were looking to us to educate patients and families on how to stay well, and we thought this was one of the areas [falls prevention] we could make a difference."
Step One: Gather facts and establish a plan
The agency took several steps to implement its Falls Prevention Program, such as:
1. Form a committee to research and address the problem.
The group consisted of four management staff: Finocchiaro, Mathews, a nursing team leader/ clinical supervisor and a rehabilitation supervisor.
The focus group met weekly from August through December of last year. The meetings typically took up to two hours each, during which the individuals "brainstormed about the feasibility of the program and decided where we wanted to start," says Finocchiaro.
"We were looking at different criteria for preventing falls," says Mathews "We also wanted to focus at first on one particular physician that would allow us to screen his patients for risk factors." Review of patient cases would come after choosing a physician to approach.
Two factors played a key role in selecting a physician whose patients could be studied.They looked for:
* A big referral source.
"The physician we picked was one of our top referring physicians, so we had a lot of his patients," says Mathews. The agency has a team of five nurses that are responsible for the care of this doctor's patients. This gave the agency a statistically valid group of patients to review, rather than a handful of patients to evaluate.
* A big risk.
Because the physician is a cardiologist, his patients were probably more at risk for falling due to the side effects of their medications. Choosing a physician whose patients were at risk to fall were critical to the program. There would have been little sense in working with a physician whose patients in the home health department were not at risk to fall.
2. Sell the physician and your staff on the idea of a formal program.
The team's research uncovered numerous risk factors, the presence of which increases the likelihood of a fall. Armed with several months of research and discussion, the pitch to the doctor was easy, says Mathews.
"He was very much for the whole program. We looked at medicines that can cause side effects such as dizziness; possible hazards of patients home environments such as footwear or throw rugs; came up with a protocol and showed it to him."
Once the physician allowed the agency to assess his patients, the work fell on the home care agency's staff. First, the doctor's collaborative nursing team and the physical therapists had to be educated on the assessment procedures.
The focus group met with the team and physical therapy staff once a week in January, going over the assessment procedures. Nurses and PTs then went into the field with the procedures and provided feedback.
"Some of the intervention tools were very involved and cumbersome," says Finocchiaro. "The nurses revised pages and pages of the tools to fit their needs and the patients' needs so the process was more concise."
Working the kinks out of the criteria wasn't the only problem -- there were also technological concerns. Home care staff at Melrose-Wakefield use hand-held computers, so the program had to be incorporated into the computers' programs.
"We have a computer liaison nurse on staff who was able to evaluate all the information and make sure it would fit into the computer," says Finocchiaro.
3. Finalize the program, and implement it on a test basis.
The Falls Prevention Program consists of four home nurse visits (by the same nurse, whenever possible)and two physical therapist visits. These visits are typically incorporated into each patient's regular visit schedule, so extra visits are not required. When this can t be avoided, such as when PTs must come in after the initial screening and such visits weren't ordered by the physician, the program calls for the agency to call the physician and get him to order the visits.
The initial visits call for assessing the patient's health, medication, and environment regarding fall-risk factors. (See fall prevention pathway, inserted in this issue.) Patients are rehabilitated during ensuing visits. The amount of rehab required for patients varies depending on the amount of education needed by each.
"The fewer risk factors the patient has, the shorter the amount of time required to complete the program," says Mathews.
When medication is assessed and a risk factor identified, the nurse turns to the physician, who can offer alternatives such as lower dosage or a change of schedule. But it's not just the physician who is involved.
"We also have a pharmacy piece to the program," says Mathews. "We fax a list of medications of the patients we are seeing on this program to the pharmacist, who makes recommendations related to the time the meds are given, whether certain meds should be given with other meds, and then we bring it to the physician, so he knows we've had some input from a pharmacist. That's been a unique part of the program."
Getting the physicians and pharmacy involved were critical to the success of the program. Getting family members involved was also crucial.
Studies show that various environmental risk hazards, such as poor lighting, throw rugs, a cluttered house or poor footwear, can increase the risk of a fall. Staff suggestions following the environmental assessment can range from taping down throw rugs to installing hardware such as grab bars in the bathroom. Suggestions on improving the environment are often given to a family member who can assist the patient in making the improvements.
Getting the various individuals and departments involved was made easier by the fact that the home care agency is hospital based.
"We're hospital based, so the resources are all available," says Finocchiaro. "It was a matter of getting people together and telling them what our plans were. Everybody was interested because it was a great preventive program. People were looking at not only the potential cost-savings but also keeping people out of the hospital.
"The important thing was to educate everyone -- the patient, the caregiver, the pharmacy, and the physician -- that certain risk factors increase the risk of falls," says Mathews.
4. Monitor the program, and implement it on a wider scale.
The program currently involves just the one doctor's patients, although it was recently approved for CEU and will be presented to the entire staff, so all 650 of the agency's patients may be assessed.
A total of 10 patients have been screened thus far, of which a third had previously fallen and all of which were at risk to fall. Of those 10 patients, none have fallen since their assessment in January; however, the reduction of falls isn't the only benefit to patients.
"It has been important that patients are expressing an increased confidence in mobility and awareness," says Mathews. "All of them have increased confidence and less fear of leaving the house."
Such results are measured through a "Confidence in Mobility" survey, given before the assessment and again once the program is complete. (See sample survey, inserted in this issue.)
Mathews adds that patients families, many of whom don't live with the patients, also feel more secure as a result of the program because of the improved safety and education.
In doing follow-up assessment, the agency called each family member or patient a month after the assessment was completed. Not only was patient and family confidence up, but 100% of the staff recommendations had been followed through.
"We don t expect that level of compliance when we screen the entire homecare population," says Mathews. "However, we know we've educated the patients, families, and caregivers. *
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