How to fall-proof your Medicare consumers

Lahey Clinic program reduces hip fracture risk

Each time a Medicare enrollee of the Burlington, MA-based Lahey Clinic suffers a hip fracture, the facility is at risk for $35,000 worth of treatment — just for openers. The odds of full recovery from a hip fracture are only one out of four, notes the clinic’s 1998 Quality Report. This is why Linnea Briand, MEd, PT, Lahey’s manager of rehabilitation services recently converted the findings from fall prevention studies into the clinic’s Fall Risk Reduction Program (FRRP).

The FRRP is one of more than 25 programs in Lahey’s Accelerating Clinical Improvement project designed to rapidly convert science into patient care improvements. Nearing completion of the first phase, the FRRP shows fall-risk reduction among 94% of its participants. (For key studies behind the FRRP, see "Need More Information?" p. 166.)

Lahey’s geriatric task force facilitated design and implementation of the FRRP. Task force members include physicians, physical therapists, nurses, pharmacists, dietitians, administrators, and a statistician.

Early detection and consumer-friendly fixes

Many people go into the FRRP from Lahey’s orientation sessions for the capitated Medicare plan. Consumers answer questionnaires which cover many of the mobility issues cited below as red flags.

Briand admits that the FRRP was a little too zealous in its initial attempts at early detection. "It made people nervous when we pulled them aside in the orientation program and sent them to PT [physical therapy] for an evaluation," Briand observes. "Now we wait and call them at home after the fact."

The other FRRP entry point is referral through the general internal medicine outpatient clinic. Briand taught the clinic’s providers and ancillary staff to make same-day PT referrals directly from the examining rooms when they identify fall-risk red flags such as:

o Inability to talk while walking due to intense concentration on balance — the "walkie-talkie test" as Briand calls it.

o Fall in the recent past.

o Recent dependence on an assistive device like a cane or walker. "Often people just start using a cane they get from someone," Briand explains, "and it isn’t the right size or they’re not trained in its usage."

o Difficulty in walking.

In PT, the evaluation consists of a Tinetti test. (See p. 166, "Tinetti Assessment Tool: Balance Tests.") Risk ratings and recommended interventions are based on a normal Tinetti score of 28 points: low fall risk, 20 to 24 points; intervention, ongoing outpatient PT to improve balance and strength, and high risk, 19 or lower; intervention, in-home PT. Why in-home PT? "Some people are so compromised," explains Briand, "that we don’t want them trucking to our facility for therapy."

For the in-home component, an FRRP liaison arranges a plan with an affiliated home care agency. Lahey’s staff has trained home care providers to administer the Tinetti, conduct home safety assessments, and suggest remedies. Throw rugs and dim stairway lighting, for instance, are hazards to a person with dizziness or unsteady balance. To date, 17 of the 24 home-based consumers have improved their Tinetti scores.

Program is a keeper’

Although it’s too early for statistically valid outcome data, all indications tag the FRRP as a keeper. The average number of visits, both home care and outpatient, is 12 per participant. The geriatric task force’s statistician is currently calculating first-phase cost savings.

Of the program’s first 78 participants, post-intervention Tinetti scores are available on 34; 94%, or 32, have improved scores. In fact, the FRRP is so promising that it will eventually be implemented in Lahey’s affiliated medical group practices and inpatient institutions.

(For individual improvement scores see graph, "Pre- and Post-Tinetti Scores for 34 Patients with Complete Follow-up," p. 166.)

In launching the FRRP, Briand has made discoveries about all of its "customer" bases.

o Providers and consumers like the convenience of same-day PT referrals. For low-risk consumers, interventions involve little more than a brief educational discussion, home exercise plan and a post-intervention Tinetti on a future appointment.

o Consumers appreciate the personal touch. When somebody from the FRRP makes a post-orientation call to suggest FRRP enrollment, Briand says, "patients tell us they like knowing that somebody is paying attention to them and cares enough to call back."

o The FRRP team has learned not to expect full compliance with either the outpatient or in-home interventions. "Some people just tell us that they’ll never stay on an exercise program," notes Briand. In those instances, risk-reduction interventions don’t work.

Briand also discovered the wisdom of simplified data collection. "I stopped doing a long phone survey two months after the initial appointment. I gathered four or five sheets on each patient," Briand notes, "but it was impossible to keep up with the tracking." Now she posts her follow-up information on one sheet. (See copy of the one-sheet "Fall Reduction Tracking Form," p. 165.)