HBPC FALL PREVENTION AND MANAGEMENT TOOLKITSociety) and CDC STEADI (Center for Disease Control &...

HBPCFALLPREVENTION

ANDMANAGEMENTTOOLKIT

JamesA.HaleyVAHospitalFallsClinic

VISN8PatientSafetyCenterofInquiry

TatjanaBulat,MD,CMD

NinaFerguson,MD

YvonneFriedman,MA,OTR/L,CRRC

JasonLind,PhD

LindaCowan,PhD,FNP‐BC,CWS

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ProgramGoalandOverview:

ThepurposeofthisHBPCFallPreventionandManagementToolkitismultifold.TheprimarygoalistosharevalidatedfallriskassessmentscreeningtooloptionswithHomeBasedPrimaryCare(HBPC).ThetoolkitpresentsthreeFallRiskAssessment(FRA)ScreeningToolswhichcanbeusedtoidentifycommunitydwellingadultsatriskforfall.Additionally,thetoolkitutilizesanalgorithm,theHBPCFallPreventionandManagementFlowchart,toprovideinformationregardingnationwideHBPCbestpracticesregardingfallprocesses,HBPCInterdisciplinaryTeam(IDT)specificfallassessmentsandinterventions,caregiversupport,andauditandfeedbackideas.Theappendixofferseducationalandresourcematerialsuggestionsforboththeclinicianandthecaregiverorpatient,highlightsofidentifiednationwideHBPCbestpracticesandalongwithIDTspecificfallassessmentandinterventions,andinstructiveCPRStemplatesdesignedformodification.

Acknowledgements:SpecialthankstoournationalHBPCcontributorswithoutwhomthistoolkitwouldnot

bepossible.ThankyoutothemultipleHBPCteamsfromacrossthecountry,theNationalHBPCDirector,theNationalFallsAdvisoryPanel,andtheGRECCfortheirkindness,generosity,andtalent.

PilotSitesTampa,FLLakeland,FLPasco,FLAugusta,GAAthens,GAAiken,GATomah,WIBestPracticeInterviews Tampa,FLPortland,ORPrescott,AZPhiladelphia,PASeattle,WA

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HBPCFallPreventionandManagementToolkitContents

1. Introduction .............................................................................................. 5

2. HBPC Fall Prevention and Management Flowchart ..................................... 6

(Embedded with Nationwide HBPC Best Practices & IDT Recommendations) a. Validated Fall Risk Assessment Screening Tool Options .............. 7 b. Both Low & High Fall Risk Patients Have Risk .............................. 8 c. Multifactorial IDT Fall Assessment ............................................ 11 d. Caregiver Support and Education .............................................. 17 e. Audit and Feedback Systems ..................................................... 18

_________________________________________________________________

3. Appendix ................................................................................................. 21

a. Educational Materials (HBPC IDT & Patient/Caregiver) ............. 21 b. Nationwide HBPC Best Practices Lists ....................................... 22 Clinical Assessment .................................................................... 22 IDT Member Opportunities Summary ....................................... 23 Caregiver Support ...................................................................... 23 Data Audit and Feedback ........................................................... 23 c. IDT Specific Fall Assessment and Interventions ......................... 24 KT/OT/PT ............. 24, 37 RD ....................... 25, 36 SW ............................. 25 MD ............................ 26 PharmD ............... 27, 37 RN ................. 28, 38, 39 ARNP/PA/MD ...... 29, 33 RT, Chaplain .............. 26 d. Instructional CPRS Templates .................................................... 31 a. FRA Screening Tools Template Samples ........................... 32‐35 b. Initial Post Fall Notification template samples ................. 35‐38

c. Fall Assessment Template Samples .................................. 38‐49

4. References and Website Resources .......................................................... 49

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Introduction

HomeBasedPrimaryCare(HBPC)cliniciansknowfallrelatedinjuriesarenotonlycommon,butarealsodevastatingformanypatients.Fallsaffecttheirabilitytoliveindependentlyandareasignificantcauseofmorbidityandmortality.

Whilenotallfallscanbeprevented,thereisevidencethatassessingandaddressinganindividual’sfallriskfactorscanreducefalls(PreventionofFallsinOlderPersonsAGSClinicalPracticeGuideline2010).ThistoolkitwascreatedinresponsetotheneedforastandardizedandvalidatedfallriskassessmentscreenwithintheHBPCcommunity.ManyHBPCteamshavebeenusingfallriskassessmentscreeningtoolsthatarevalidatedforinpatientpopulations,butnotvalidatedforpatientsinthehomesetting.ThetoolkitmakesrecommendationsforthreefallriskassessmentscreeningtooloptionsthataremorespecificfortheHBPCpopulation.AvalidatedfallriskscreeningtoolforcommunitydwellingadultpatientscanmoreaccuratelyidentifyatriskHBPCpatients,andgatherhelpfulinformationforfindingpreventablecausesoffallandinjuryforallscreenedpatientsbeyondamerenumericalassessment.

Additionally,theVISN8PatientSafetyCenterofInquiry(PSCI)ProjectteamacknowledgesHBPCrequestsforinformationregardingmultifactorialfallevaluation,caregiversupport,andfallauditandfeedback.TheHBPCFallPreventionandManagementFlowchartwascreatedaspartofthetoolkittofacilitateanactionplantoaddresstheseconcerns.TheflowchartwasdevelopedbycouplingliteraturereviewwithinterviewsofseveralHBPCprogramsfromacrossthenation,HBPCleadership,andGRECCforsystemprocessdesign.ThetoolkitwasalsoreviewedbytheVAFallAdvisoryCommitteepriortodissemination.TheflowchartfacilitatessharingidentifiednationwideHBPCbestpractices,HBPCIDTspecificandgeneralfallassessmentsandinterventions,caregiversupport,andauditandfeedbacksystems.Duetothescopeandlengthofthetoolkit,manyaspectsweremovedtotheappendix.

HBPCteamsareencouragedtotryvariationsofthisHBPCFallToolkittofittheirHBPCteam’sworkflow.

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HBPCFallPreventionandManagementFlowchart

_______________________________________________________________________________________________________

HBPCFallPrevention&ManagementFlowchartSummary(LabeledPartsA,B,&C.1‐6)A.ChooseavalidatedpopulationspecificFallRiskScreeningAssessmentToolMAHC‐10,mJHFRAT,orCDCSTEADI

B.LowFallRiskInterventions‐AfallpreventionplancanbebasedonidentifiedFRAscreeningfactors,injurypreventionstrategies,andCDCSTEADIinterventions.Low‐riskpatientsdoNOTrequireafullmultifactorialfallassessment.Homeenvironmentevaluationisstillneeded,andsomeHBPCtakeOrthostaticvitalsandbaselineTUGmeasurementforfunctionalassessment.

C.1‐6HighFallRisk‐Amultifactorialfallassessmentisindicated.Afallassessmentandinterventionplanforpatientsathigh‐riskcanbebasedonAGS,CDCSTEADIandaddednationalbestpracticesincludingVANationalPatientSafetyCenterFallToolkitinjurypreventionassessmentandcaregiversupport.Fallreportingauditandfeedbackinformationisalsoincluded.

*ThealgorithmforHBPCFallPreventionandManagementFlowchartwasdevelopedcombiningelementsofnationwideHBPCbestpracticeandleadershipinterviews,HBPCHandbook,validatedfallriskscreentools,NationalPatientSafetyGoal9requirements,NationalPatientSafetyCenter(NPSC)FallToolkit,AGSandCDCSTEADIMultifactorialFallAssessmentrecommendations.

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2.HBPCFallPreventionandManagementFlowchartTheHomeBasedPrimaryCare(HBPC)FallPreventionandManagementFlowchartwascreatedtoshareinformationregardingfallassessmentwithspecificinformationregardinginterdisciplinaryteamcontributions,identifiednationwideHBPCbestpractices,caregiversupport,andauditandfeedbacksystems.Additionally,thetoolkitalgorithmincorporatesandreferstoclinicalguidelinesfromAGS(AmericanGeriatricsSociety)andCDCSTEADI(CenterforDiseaseControl&Prevention‐StoppingElderlyAccidents,DeathsandInjuries).InjuryriskevaluationwasalsoaddedinaccordancewiththeNationalPatientSafetyCenter(NPSC)FallToolkit.Theflowchartisflexible,consideringboththeindividualizednatureofamultifactorialfallevaluation,andthedifferentteamcompositionswithinHBPCinterdisciplinaryteams(IDT).TheflexibledesignallowsforvariousaspectstobeutilizedbyIDTmembersdependingontheirscopeofpractice.InstructionalCPRStemplatesareavailableintheappendix.Thetemplatesarecomprehensiveforeducationalpurposesanddesignedtobemodified. (See page 6 for flowchart and summary)

FlowchartComponentA‐ValidatedFallRiskAssessmentScreeningToolOptionsforCommunityDwellingAdults

A. Validated Fall Risk Assessment Screening Tool Options

Fallriskassessment(FRA)screeningstartswiththefirstdayofmeetingthepatientforeachteammember.AllIDTmembersshouldaskaboutfallsandhaveknowledgeregardinghomeenvironmenthazardsandcaregivereducation.Afallriskassessmentscreeniswarrantedduringtheinitialpatientassessmentandduringtheannualpatientassessment,andoftenafterafallisidentified.Thereareseveraloptionsforfallriskassessmentscreeningtoolsthatarevalidated,evidence‐based,andaccessibleforusewiththeHBPCpatientpopulationofcommunitydwellingadults.

Afteranextensiveliteraturesearchandpilottesting,thisHBPCFallsToolkit

recommendsusingoneofthefollowing:‐MAHC‐10(MissouriAllianceforHomeCare‐10questions)‐CDC‐STEADI(CenterforDiseaseControl‐StoppingElderlyAccidents,Deaths&Injuries)‐mjhFRAT(ModifiedJohnHopkinsFallRiskAssessmentTool)Thesethreefallriskassessmentscreeningtoolscanfacilitateaprocesschangefrom

usingascreeningtoolvalidatedforhospitalizedpatients,toonevalidatedforcommunitydwellingadults.SeeAppendixforSampleTemplateswithadditionalliteratureregardingFRAscreentools.

Otheridentifiedtoolsinclude:FRA/FallsRiskAssessmentTool(Flemming),EFSTElderlyFallsScreeningTest(Cwikel);CFRSIComprehensiveFallsRiskScreeningInstrument(Fabre);Fall‐RiskScreeningTest(Tromp);PersonalRiskFactorsFallPreventionChecklist(MinnesotaSafetyCouncil).SeereferencessectionoftheAppendixformoredetails.

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TheflowchartdividestheHBPCpatientpopulationintolowandhigh‐riskforfallsafterusingavalidatedscreen(MAHC‐10,mjhFRAT,orCDCSTEADI)

FlowchartComponentB–LowFallRiskInterventionsExamplesLowRiskInterventionExamples:

1. PatientandCaregivereducationaboutfalls,andaddressingidentifiedFRAScreenToolfindings.

2. IncludeastandardhomeenvironmentalassessmentfromeachIDTmember.‐NCPSFallToolkitFallPreventionatHomeBrochure‐https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf

3.Medicationreviewforfallrisk&injuryrisk,andconsiderVitaminD+/‐Calcium.4.Considerorthostaticvitalsonallnewadmissions&annualassessmentpatients.5.Considermeasurablefunctionalassessmentonallnewadmissions&annual.assessmentpatients(SuchasTUG,4stageBalanceTest,30SecondChairStand)6.Referraloreducationregardingstrengthandbalanceexercisesandactivity.(CommunityorHomeexercises)7.Considerosteoporosisassessment&treatment.(SeeappendixorVANationalFallToolkit)*ConsiderO2‐AGE:(OrthostaticvitalsandOsteoporosisassessment,Alcoholconsumption,Gaitandbalancetest,Environmentassessment) B.BothLowandHighFallRiskPatientshaveRisk

HBPCpatientsconsideredlowrisk,wouldstillbeconsideredatriskforfallandmayhaveinterventionsbasedonidentifiedFRAscreenfactors,injurypreventionstrategies,HBPCbestpracticesandCDCSTEADIlowriskinterventionsrecommendations.

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IdealuseoftherequiredFRAScreenisnottosimplyrecordthenumber,buttoanalyzewhichcomponentsoftheFRAScreenarepositiveandmodifytreatmentplansaccordinglyforamorepatientcenteredapproach.

TheCDCnonspecificrecommendationsforlowriskpatientsinclude:educationaboutfalls(seeaddendumforeducationalmaterials);considerationforVitaminD+/‐Calcium;andreferringforstrengthandbalanceexercise(communityexerciseorcommunityfallpreventionprogram).

InadditiontotheCDCSTEADIrecommendations,considerassessingforinjuryriskinlowriskpatients,suchasscreeningforosteoporosis.InjurypreventionisinalignmentwithidentifiedHBPCbestpracticesandNPSQ09.02.01.SeetheIDTInvolvementOpportunitiessectionoftheappendix,andtheVANPSCFallsToolkitwebsiteformoreinformationregardingevaluationforosteoporosisandinjuryrisk.

NotethatlowriskpatientsdoNOTneedamultifactorialfallevaluation.

‐ItisanidentifiednationwideHBPCbestpracticetocheckorthostaticvitalsonallnewpatientadmissionsandannualassessments,andmonitorfunctionalassessmentyearlywithmeasurableexamssuchasTUG,eveninlow‐riskpatients.ConsiderO2‐AGE:(OrthostaticvitalsandOsteoporosisassessment,Alcoholconsumption,Gaitandbalancetest,Environmentassessment)

‐Additionally,HBPCPharmacistbestpracticeincludesevaluatingallpatientsformedicationswhichmayincreasefallriskandinjuryriskwitheachfallnotification,andwitheachquarterlyreview.

__________________________________________________________________________________________

NationalVAFallsToolkitwebsite:https://www.patientsafety.va.gov/professionals/onthejob/falls.asp

CDCSTEADIwebsite:https://www.cdc.gov/steadi/index.html

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Flowchart Components C.1‐C.6 Summary:

Forpatientsathigh‐risk,amultifactorialfallriskassessmentisindicatedwithcustomizedinterventionsbasedonanindividualizedriskassessment.Afullmultifactorialfallriskassessmentincludesmanyaspectsofadetailedgeriatricassessment.Includedinthisreportisalistofassessmentsandinterventionstoincludewithsuggestionsforvariousteammembercontributions.Thekeytodevelopingasuccessfulinterventionprogramistocustomizethetreatmentrenderedbasedonanindividual’sspecificfallriskfactors.

‐Keepinmindthatidentifyingtheserisksandimplementinginterventionsmayrequireinvolvementoftheentireteamplusthepatientandcaregiver.

‐ItisrecommendedthatIDTMembersthatmakehomevisitsaskaboutfallsandcompleteanddocumentahomeenvironmentassessment.

‐RegularfalldatafeedbacktotheteamforinterventionanalysisisbeingaccomplishedatvariousHBPCinavarietyofwaysincluding;IDTmeetingfalllineitems,post‐fallhuddles,power‐pointpresentations,processimprovementprojectswithbothpostersandpublications.

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HBPC Prevention and Management Flowchart Components C.1‐C.6 Cycle

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C. Multifactorial IDT Fall Assessment

C.1MultifactorialFallAssessmentforRiskFactorsValidatedmultifactorialfallevaluationsforgeriatricpatientsinclude:AGSguidelines

andCDCSTEADI.WeaddedHBPCbestpracticesforbothfallassessmentandinterventions,andforIDTSpecificContributionsthatarenotallvalidated,buthelpuniteteaminfallpreventionandmanagement.ConsiderusingaspectsoftheinformationbelowtofittheneedsofyourHBPCIDTandHBPCpatients.ThenextsectionC.2offersdetailsonusingExtrinsicandIntrinsicRiskFactorsortheHELPacronymtolinkriskfactorswithinterventions.KeepinmindtheJointCommissionNPSG#9whencreatingyourHBPCFallProgram.Seepage20forTheJointCommissionandtheHomeCareNationalPatientSafetyGoal#9‐(NPSG.09.02.01).

HBPCBestPracticesonClinicalAssessmentSummary

Useofafallriskscreeningtoolthatisvalidatedforthecommunitydwellingadultpopulation.

Checkingorthostaticvitalsonallnewadmissionpatients,andduringpostfallevaluationassessments.

UsingastandardizedandmeasurablefunctionalassessmentonallnewpatientssuchastheTimedUpandGo(TUG)test,30secondchairstand,or4‐stagebalancetest‐ordocumentthatthepatientisbedbound.

Injuryriskassessmentshouldbeincludedinadditiontofallriskassessment.Considerosteoporosisassessment,highriskmedicationevaluation,alcoholconsumption,accidentavoidance,ABCSInjuryRisk

Standardizingfallhistoryelements.ConsiderSPLAATT(Symptoms,Previousfalls,Location,ActivityandAlcohol,TimingandTrauma)andaskingwhytheythinkthefalloccurred.

Adding“HistoryofFall”totheActiveProblemList,ifapplicable. UtilizingamultifactorialfallassessmentbasedontheAGSguidelinesor

CDCSTEADIandaddinginjurypreventionassessments,suchasanevaluationforosteoporosis.

HomeenvironmentalassessmentsbyallIDTmembers. Assessmentofwalkingaids,assistivetechnologies,andprotectivedevices

asperscopeofpractice. UsingMotivationalInterviewingtoforencouragement. ConsiderO2‐PAGE(Orthostaticvitals,Osteoporosisrisk,Physicalfrom

EyetoFeet,Alcoholconsumptions,Gait&Balancetesting,EnvironmentalAssessment

Utilizingriskfactoridentificationforpossibleinterventions. ConsiderExtrinsicandIntrinsicFactorsorHELP(Homehazards,

Exerciseandactivity,Limitcomorbidity,Pharmacyevaluation).SeeFlowchartC.2

IDTtemplatesavailableinAppendixusingaboveBestPractices.

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IDTMemberOpportunitiesBestPracticesSummary EachIDTmemberasksaboutfallsandinspectsthehomeforpotential

environmentalfallhazards. https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf UtilizingaKT/OT/PTIDTmemberforvalidfallriskscreeningtool,

ADL/IADL,functionalassessment,detailedhomeenvironmentalassessment,prostheticevaluation,fallhistory,andfallhuddleleader.Theassessmentcanbedoneonnewpatients,patientsdiscussedatteammeeting,aswellasonaddendumstopostfallnotes,andfallassessments.

UtilizingaNutritionistIDTmemberforassistancewithhydrationstatus,missedmeals,Calcium/VitaminDintakeandalcoholuse.Thisassessmentcanbedoneoneachpatientdiscussedatteammeeting,aswellasonaddendumstopostfallnotesandfallassessments.

UtilizingMentalHealthprovidersandSocialWorkerstohelpwithmotivationalinterviewing,encouragingpropersupervision,regularuseofambulatoryassistivedevices,andappropriatealcoholuse.

UtilizingaPharmacisttoassessforincreasedriskofbothfallriskandinjuryrisk(includingOsteoporosisriskmedicationsandAnticoagulation).Additionally,consideringneedforVitaminD/Calcium.Thisassessmentcanbedoneoneachpatientdiscussedatteammeeting,aswellasaddendumtopostfallnotesandfallevaluations.(ConsideronlineCEcourseofferingfromCDC‐SAFEMedicationReviewFrameworkfromCDC:STEADI)

AllIDTcanenterPostFallNotificationNote IDTTemplatesamplesareincludedintheAppendix. IndividualHBPCIDTmemberBestPracticeschartsavailableintheAppendix.

‐AdditionaldetailsonIDTspecificcontributionsandtemplatesuggestionsdividedbyspecialtyareincludedintheappendix.ThetemplatesareforinstructionalandeducationalpurposesandaredesignedtobemodifiedbasedonindividualHBPCteamdesignandneeds.

RecommendedinformationregardingafullfallevaluationcanbefoundusingtheAGSFallEvaluationGuidelines,CDCSTEADIWebsite,andtheNationalPatientSafetyCenterVAFallToolkit.

__________________________________________________________________________________________________

‐American Geriatric Society Fall Evaluation Guidelines

TheAGSrecommendsarelevantmedicalhistory,physicalexamination,cognitiveandfunctionalassessmentwhichincludes:historyoffalls,medications,gait,balanceandmobilitytesting,visualacuity,neurologicimpairmentassessment,musclestrengthevaluation,heartrateandrhythm,posturalhypotensionassessment,feetandfootwearassessment,andenvironmentalhazardsevaluation.

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Afteracompletehistoryandphysical,assessandintervenebasedonthefindings:minimizemedications,provideindividuallytailoredexerciseprograms,treatvisionimpairmentincludingcataracts,manageposturalhypotension,manageheartrateandrhythmhomeenvironment,provideeducationandinformation(AGS2010).SeeAppendixReferencesforadditionalinformation. https://www.aafp.org/afp/2010/0701/p81.pdf

‐CDC STEADI

TheCDCdevelopedtheStoppingElderlyAccidentalDeathandInjury(STEADI)fallriskscreening,evaluation,andinterventionstoolkitwithinformationthatishelpfulforbothcommunityclinicalprovidersandforcommunitydwellingpatients.Forproviders,therearealgorithms,pocketguides,andcasestudies.Forpatients,therearenumerouseducationalhandoutsthatmeethealthliteracystandards.SeeappendixforadditionalinformationundersectionregardingFRATools,websites,andeducationalmaterials(www.cdc.gov/steadi)


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C.2 Interventions Based on Individualized Risk Factors

Multifactorial Fall Assessment and Intervention: Using Intrinsic and Extrinsic Risk Factor categories or HELP prevent falls

Successfulfallinterventionprogramscustomizethetreatmentrenderedbasedonanindividual’sspecificfallriskfactors.Fallriskfactorscanbecategorizedasbeingeitherintrinsicorextrinsicriskfactors.Theseclassicriskfactorscanbelistedseparately,ororganizedunderamnemoniccalledHELP(HomeHazards,Exercise,LimitComorbidity,andPharmacy),whichwascreatedbytheprojectteambasedontherecommendations

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fromtheCDCSTEADI,AGSguideline,NPSG.09.02.01withadditionalinjuryriskassessmentaddedasabestpractice(suchasABCS,medicationreview,orosteoporosischeck).TreatmentinterventionscanbechosenbasedonidentifiedrisksandpartscanbefromallIDTmembers.

a. Intrinsic and Extrinsic Risk Factor Identification:

Belowareriskfactordivisionsandtreatmentinterventionsthatcanbemadeintocheckboxesforamultifactorialassessmenttemplate.

INTRINSICRISKFACTORS

1. ReducedMobility,MuscleWeakness,GaitandBalancedeficita. Intervention:PT/OT/TaiChi/Walkingprogram/Community

exerciseprogram.2. Visionchanges/lowvision

a. Intervention:Consulteyeclinic3. Hypotension/Orthostatic

a. Intervention:Adjustmedications,assessfluidstatus,consideranti‐hypotensiveagent,referraltocardiologyorneurology,providepatientinformationalhandoutfromCDCSTEADI

4. Fearoffallingandhistoryoffallsa. Intervention:Cognitivebehaviortherapy,Mentalhealthconsult,

MotivationalInterviewing,PTconsult.5. Comorbidity:Pain,CognitiveImpairment,Incontinence,Hearing,

Depression,CV(CAD,Syncope,Arrhythmia,Hypotension),CP(COPD),Neurologic(CVA,Seizure,Parkinson’sDiseaseandParkinson’sPlusDisorders,vertigo,neuropathy),Feet,DJD,DM,thyroida. Intervention:PCPoptimizetreatmentsorconsultspecialist.

6.InjuryRiskAssessment:OsteoporosisandAnticoagulation

a. Intervention:Considerhipprotectorsorhelmets,PCPoptimize/considerpharmacologictreatmentsorconsultspecialist.

EXTRINSICRISKFACTORS

1. Environmental/HomeHazards:Stairhandrails,Nograbbarsinbathrooms,DimLights,Obstacles,Slippery/wetsurfaces.a. Interventions:

‐Encourageproperambulatoryassistdevice‐Uselowbed,Petsafetyinformation,hipprotectoruse,helmetuse,non‐slipfootwear‐Clutterremovalandthrowrugssecuredorremoved‐HISAGrantformodifications,ifqualify

2. Medicationsthatincreaseriskoffalling(Psychoactivemedications,

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Antihistamines,Benzodiazepine,Anti‐convulsantagents,Antidepressants,Musclerelaxers,Hypertensives,Anti‐Parkinsonagents,Analgesic,Antineoplastic,Hypoglycemicagents)a. Intervention:PCPadjustmedicationsorconsultspecialist

3. Medicationsthatincreaseriskofinjury(Adrenalglucocorticoids,Anticoagulants,PPIs,Anti‐androgens,Antidepressants,Antipsychotics,etc.)a. Intervention:PCPadjustmedicationsorconsultspecialist

4. IncreasedriskofinjuryduetoOsteoporosisriskfactors,Anticoagulation,High‐riskmedicationsa. Intervention:Considerosteoporosisevaluationandtreatment,

VitaminD/Ca+2supplementation,Hipprotectors,and/orhelmets

OptionsmayincludeusingIntrinsicandExtrinsicRiskFactorsorusingthemnemonicHELPforriskfactoridentificationandtriggeredinterventions.

b. HELP for risk factor identification

HELPPreventFalls

H‐E‐L‐PacronymwithrecommendedguidedinterventionsHomeHazards,ExerciseandActivity,LimitComorbidity,andPharmacyreview

H‐Homeandenvironmentalhazards:(Extrinsicrisk)

•Interventions:

• Footweareducation(Backlessshoesandslippers,highheeledshoes,andshoeswithsmoothleathersolesareexamplesofunsafefootwearthatcouldcauseafall.Wearnon‐skid,rubbersoled,lowheeledshoes).

• Ambulatoryassistdeviceassessmentandeducation,motivationalinterviewing,

• Petsafetyeducation• Prostheticdevicessuchas:Lowbed,floormats,hipprotectors,helmets,

reachsticks,grabbarsinsideandoutsidethetuborshowerandnexttothetoilet,havingraisedtoiletseats,addingrailingsonbothsidesofstairwaysandimprovingthelightingintheirhomes.

• Removeclutter,andprovideroom‐by‐roomsafetyassessmentandinterventions.

• SomeHBPCusetheSTEADIhomeevaluationchecklist.• NCPSFallToolkitFallPreventionatHomeBrochure

https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf• ConsiderHISAGrantformodifications.

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E‐ExerciseandActivity:(Intrinsicrisk)

•Interventions:

• PT/OT,TaiChi,Rehab,Walkingprogram,Activityincreased,Chair‐standhomeexercisehandoutfromSTEADI.

• Focusonincreasinglegstrength,flexibilityandimprovingbalance,andthatactivitygetsmorechallengingovertime.

• MotivationalInterviewing.

L‐LimitComorbidity:(Intrinsicrisk)

•Interventions:maximizetreatmentandconsiderconsultations

1. Reviewandaddressfallriskscreenpositivefindings(suchasMAHC‐10Muscleweakness,Gait/Balance,Vision,H/ofall,#Comorbidconditions,Incontinence,Pain,CognitiveImpairment)

2. Vision‐>consulteyeclinicyearly.Singlevisionlensesarebest.3. OrthostaticHypotension

‐>adjustmedications,assessfluidstatus,limitalcohol,consideranti‐hypotensiveagent,referraltocardiologyorneurology.CDCBrochure“ChangePositionsSlowly:Standingupslowlyafterlyingorsitting”www.CDC.gov/STEADI

4. Fearoffallingandhistoryoffalls,Depression‐>Cognitivebehaviortherapy,MentalhealthconsultMotivationalInterviewing,PTconsult.“WhattodowhenyouFall”brochurefrom


5. Injuryriskassessment(SuchasOsteoporosisassessment,ABCSInjuryrisk)

6. AdditionalComorbidity:Hearingloss,Pain,CognitiveImpairment,Incontinence,Hearing,Depression,CV(CAD,Syncope,Arrhythmia,Hypotension),CP(COPD),Neurologic(CVA,Seizure,Parkinson’sDiseaseandParkinson’sPlusDisorders,vertigo,neuropathy),Podiatricissues,DJD,DM,Thyroiddisorders,Anticoagulation,OsteoporosisandOsteopenia‐>Optimizetreatmentsand/orconsultspecialist

P–Pharmacy:(Extrinsicrisk)

1. Medicationsthatincreaseriskoffalling(Psychoactivemedications,Antihistamines,Benzodiazepine,Anti‐convulsantagents,Antidepressants,Cholinesteraseinhibitors,Musclerelaxers,

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Hypertensives,Anti‐Parkinsonagents,Analgesic,Antineoplastic,Hypoglycemicagents)‐>Taperanddiscontinueastolerated

2. Medicationsthatincreaseriskofinjury(Adrenalglucocorticoids,Anticoagulants,PPIs,Anti‐androgens,etc.)‐>Tailorastolerated

3. ConsiderVitaminD/Ca+2supplementation

D. CaregiverSupportandEducation

Flowchart Component C. 3 ‐ Ensure Caregiver Support and Education

Successfulpreventionoffallprogramsincludeandinvolvepatientsandcaregiversupport.SurveyedcaregiversandpatientsofMedicalFosterHomesinTampaindicatedthattheyappreciatedseveralaspectsofHBPCpostfallprocedures.

‐Patientsandcaregiverslikeinformationregardingfalls:Whattodoafterafall,Howtofall,Howtogetupfromafall(SeeAppendixforhandoutsfromNPSCVAFallsToolkitwebsite:https://www.patientsafety.va.gov/professionals/onthejob/falls.asp).

‐Additionally,theyappreciatecallsandvisitsfromIDTtodiscussinterventionsinmedicalcare,referrals,andmedications.TheyespeciallyfoundhelpfulKinesio‐Therapistevaluationsoftheirhomeformodifications,additionalprostheticdevices,orrecommendationsforgait,balanceandstrengtheningwithPT.Severalarticlessupportusingatherapistforpreventionoffallsduetohomeenvironmentissues.MentalHealthProfessionalsandSocialWorkinvolvementforsupportandeducationwasalsoappreciatedbythecaregiversandpatients.

‐Occasionally,caregiversandpatientsfeelconfusedoroverwhelmedbyhavingmanyfallinterventionsatonce.Forexample,beingtoldtopracticesafetyandsupervisionwithapossibledecreaseofsomeactivities,andalsobeingtoldtopracticestrengthandbalance,whichrequiresincreasedactivity.

‐Requestingmultiplehomemodificationsatoncecancauseresistance.HearingtheinformationusingmotivationalinterviewingfromseveraldifferentIDTmembersmayhelpwithmovementtowardsmakingchangeorchanges.Seeappendixpage51foradditionalMotivationalInterviewinginformation.TheVAHISAGrantoptionhelpswithhomemodificationsforsomepatients.

‐Supportcaregivereffortstoreportfalls.Fallscanmakeboththepatientandthecaregiverfeelashamedandlesslikelytoreport.Caregiversthatfeelstronglythatsupervision,andassistedfallsmaypreventfallwithinjuryaremorepronetoself‐injuryandfeelingsofguiltwhenthepatienthasafall.Considerofferingthemsupport,mentalhealthconsultation,andthebrochure“Whattodoafterafall”fromtheNPSCFallToolkit.

CaregiverSupportandEducationBestPractices “CallIfYouFall”‐magnetsorformswithHBPCphonenumbertoencourage

fallreporting.

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www.CDC.gov/STEADIwebsiteforeducationalmaterialssuchas:Homefallpreventionchecklist,orotherHomeevaluationchecklistliketheHomeAssessmentProfile(HAP)orHomeFallsandAccidentsScreeningTool(HOMEFAST)SeeAppendixforlinks

FocusedCaregiverEducationalhandouts:MedicalFosterHome(MFH)caregiverslikedthePSCIhandouts“Whattodoafterafall”and“FallPreventionatHome”.NationalVAFallsToolkitwebsite:https://www.patientsafety.va.gov/onthejob/falls.asp

DiscusswithcaregivertheirideasregardingfallpreventionwithMotivationalInterviewingTechniques

Educationalmaterialsforcaregiversupportinclude: NPSC:Howtofall,Howtogetupfromafall,Whattodoafterafall,

OsteoporosisRisk,Postfallinstructions,Callifyoufallinformation,Useofhipprotectors,NCPSFallToolkitFallPreventionatHomeBrochureNationalVAFallsToolkitwebsite:https://www.patientsafety.va.gov/onthejob/falls.asp

CDC:Fourthingstopreventfalls,Protectyourlovedonesfromfalling,StayindependentbrochureHomesafetyhttps://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdfCDCSTEADIwebsite:www.CDC.gov/STEADI

E.AuditandFeedbackSystems

Flowchart Component C. 4 ‐ Post Fall Note for Each Fall

Strongcommunicationsystemsalongwithconsistentauditsandfeedbackarevitaltoacomprehensivefallprogram.

‐Tofacilitateauditandfeedback,apostfallnoteforeachknownfallshouldbegeneratedandsharedwiththeIDTforreview.Consideraddendumstoaninitialpostfallnotificationnotefromteammembersforimprovedcommunicationanddocumentation.InTampa,thepostfallnotificationnotewaseditedtoremoveaspectsthatmaybeviewedaspunitivebyMFHcaregivers.ThetitlewaschangedfromFallEventIncidentReport,andaquestionspecificallyaskingifthepatientwassupervisedwasremoved.

‐Asmanypatientsandcaregiversdonotcalltoreportaftereveryfall,eachIDTmembershouldinquireaboutfallsateveryvisitandassessforhomehazards.SomeHBPCteamsgiveout“CallifyouFall”papersormagnetsfortherefrigeratorstofacilitatereporting.

Additionally,HistoryofFall,canbeaddedtotheCPRSproblemlist,ifnotalreadyadded.

Flowchart Component C. 5 ‐ Follow up Call or Visit to Review for Additional Risk Factors

Theteammembersshoulduseclinicaldecisionskillstodecidewhetheracallorvisitisneededtodiscovernewinjuriesoradditionalfallriskfactors.Keepinmindthat

19

anti‐coagulatedpatientsareatparticularlyhigh‐riskforinjury.Timeframesforfollow‐upvisitsshouldbediscussedwiththeHBPCteamphysician.SomeHBPCdiscussfallsatweeklyIDTmeetingsandutilizeachecklistforpreventionitems(suchasfromtheCDC).

Flowchart Component C.6 ‐ Post Fall Huddles, Information Sharing and Intervention Assessment

Regularpostfallhuddlesarerecommendedfordatasharingtodiscusssuccessorfailureofinterventionsandtobrainstormnewideas.TheNationalPatientSafetyGoalregardingfallsincludeshavingaprocessforfalldataevaluationwithauditandfeedbacktotransformthedataintoactionableinformation.TheprojectteamfoundthatdifferentHBPCprogramsusedifferentcriteriaforfallandinjuryreporting.Somereportallfalls,somereportonlyfallswitnessedduringthehomevisit,somereportonlyinjuriousfallsindicatingthatthereisnotastandardizeddatacollectionprocedure.MosttrackfallrelatedhospitalizationsratesinHBPCpatients,suchastoEPIRorcurrentlyJPSR.

Havingaseparatefallreportwithseverityindicatedforeachknownfallwouldprovidethemostinformation.ThefallreportshouldbeastandardizedtemplateinCPRSandsharedwithalltheIDTtoassistwithfallinterventions,andtheFallCoordinatorviaanalert.ConsiderutilizingaKT/OT/PTasFallCoordinator.Anintegrateddecisionforplannedfallriskinterventionsisagoal.Robustfallsdatacollectionanddisseminationofthefindingstotheteamonaregularbasisforfeedbackisparamountforasuccessfulfallprogram.Bestpracticesinclude:fallhuddlesduringIDTmeetings,newfallslineitemonIDTmeetingagenda,documentationofhospitalizedandinjuriousfalls,andseparatefallnotesforeachindividualfall.

Forfuturerecommendationsregardingdatacollectionanddissemination,creatingaformalmechanismofcommunicatingfallandinjuryrates(auditandfeedback)totheHBPCstafftobridgethedisconnectbetweendatacollectionandtransformationofitintousefulandactionableinformationisrecommended.SomeHBPCprogramsusepowerpointpresentationsandprocessimprovementposterstoshareaggregatedatawiththeteam.

AuditandFeedbackBestPractices PostFallNoteintheelectronichealthrecordforeachfall,withaddendums

fromvariousIDTmembers. IncludefallseverityandtriageoneachPostFallNote.MostHBPCteams

trackfall‐relatedhospitalizationsrates.Examples:EPRP(ExternalPeerReviewProgram)orJPSR(JointPatientSafetyReport).

RegularFallHuddlesandDataReportingbacktofrontlinestaffforinterventionassessment.

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TheHBPCFallAssessmentFlowchartsectionsC.1‐C.6forhighriskpatientscyclescontinuouslywithnewfallsandwithannualrecertificationofthepatient.PleaseseetheAppendixforadditionalinformationsuchastemplates,IDTcharts,bestpracticesandeducationalmaterials.

_______________________________________________________________________________________________

Fallpreventionandmanagementiscontinuallyimprovingtobecomemorepatientcenteredandvalueadded.WehopepartsofthistoolkitwillhelpyourHBPCprogramimplementafallprogramthatisinalignmentwithpatientgoalsandwithTJC.UsingavalidatedFRAscreenisthefirststep.ThankyouandallbesttoyourHBPCteamforasuccessfulFallPreventionandManagementProgram.

The Joint Commission and the Home Care National Patient Safety #9 Reduce the risk of patient harm resulting from falls. Reduce the risk of falls.

‐National Patient Safety Goal (NPSG.09.02.01):

Falls account for a significant portion of injuries in hospitalized patients, long term care residents, and home care recipients. In the context of the population it serves, the services it provides, and its environment of care, the organization should evaluate the patient’s risk for falls and take action to reduce the risk of falling as well as the risk of injury, should a fall occur. The evaluation could include a patient’s fall history; review of medications and alcohol consumption; gait and balance screening; assessment of walking aids, assistive technologies, and protective devices; and environmental assessments.

--Rationale for NPSG.09.02.01-- 1. Assess the patient’s risk for falls. 2. Implement interventions to reduce falls based on the patient’s assessed risk. 3. Educate staff on the fall reduction program in time frames determined by the organization. 4. Educate the patient and, as needed, the family on any individualized fall reduction strategies. 5. Evaluate the effectiveness of all fall reduction activities including assessment, interventions and education. Note: Examples of outcome indicators to use in the evaluation include decreased number of falls, and decreased number and severity of fall-related injuries

====================================================

Formoreinformation,pleaseemailtheTampaPSCIHBPCFallProjectTeam.MedicalDirector:TatjanaBulat,MD [email protected]:LindaCowan,PhD [email protected]:NinaFerguson,MD [email protected]:YvonneFriedman,OT [email protected]___________________________________________________________________________________________________

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3. Appendixa. Educational Materials

1.HBPCClinicianhandoutsandresourcesCDCSTEADIwebsite:www.cdc.gov/steadi

CDC:MeasuringOrthostaticBloodPressurehttps://www.cdc.gov/steadi/pdf/STEADI‐Assessment‐MeasuringBP‐508.pdf

CDC:TheTimedUpandGo(TUG)Test)https://www.cdc.gov/steadi/pdf/STEADI‐Assessment‐TUG‐508.pdf

CDC:The30SecondChairStandTesthttps://www.cdc.gov/steadi/pdf/STEADI‐Assessment‐30Sec‐508.pdf

CDC:The4‐StageBalanceTesthttps://www.cdc.gov/steadi/pdf/STEADI‐Assessment‐4Stage‐508.pdf

CDC:StagesofChangeModel CDC:TalkingaboutFallPreventionwithyourpatient CDC:RiskFactorsforFalls CDC:FallRiskFactorChecklistintegratingfallpreventionpractice Handoutlinkingspecificriskfactorassessmenttotargetedintervention

https://www.cdc.gov/steadi/pdf/STEADI‐Algorithm‐508.pdf CDC:TakeStepstoPreventOlderAdultFallsFactSheetforClinicians

NationalVAFallsToolkitwebsite:

https://www.patientsafety.va.gov/onthejob/falls.asp

VANPSCFallToolkitrecommendedinterventionsforchecklist VANPSCinjuryriskinformation VANPSCFallPreventionathome

2.PatientandCaregiverprintableeducationalmaterials

CDCSTEADIwebsitewithitemsbelow:www.cdc.gov/steadi CDC:HomeSafetyChecklist CDC:WhatYouCanDotoPreventFalls CDC:StayIndependentBrochure

https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf CDC:FamilyCaregivers:Protectyourlovedonesfromfalling CDC:ChairSittoStandHomeExercisehandout CDCrecommended:StaySafeStayActiveDailyExerciseProgram

NationalVAFallsToolkitwebsitewithitemsbelow:

https://www.patientsafety.va.gov/onthejob/falls.asp WhattoDoWhenYouFall Howtofall

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Howtogetupfromafall FallPreventionatHomebrochure HipProtectorbrochure BloodThinnerbrochure NIA:AgePageExerciseandPhysicalActivity NOF:Man’sGuidetoOsteoporosis

___________________________________________

b. Nationwide HBPC Best Practices List: Duringthesearchforbestpractices,HBPCprogramsfromacrossthecountrywere

interviewed(Tampa,FL;Portland,OR;Prescott,AZ;Philadelphia,PAandSeattle,WA).TheauthorsofthisHBPCFallsToolkitaregratefulfortheirgenerosity,talent,andtime.PleaseseetheLiteratureReviewSectionforlinkstospecifictoolsandwebsites.

HereisthelistofbestpracticestousewiththeHBPCFallFlowchart:

HBPCBestPracticesonClinicalAssessmentSummary

Useofafallriskscreeningtoolthatisvalidatedforthecommunitydwellingadultpopulation.

Checkingorthostaticvitalsonallnewadmissionpatients,andduringpostfallevaluationassessments.

UsingastandardizedandmeasurablefunctionalassessmentonallnewpatientssuchastheTimedUpandGo(TUG)test,30secondchairstand,or4‐stagebalancetest‐ordocumentthatthepatientisbedbound.

Injuryriskassessmentshouldbeincludedinadditiontofallriskassessment.Considerosteoporosisassessment,highriskmedicationevaluation,alcoholconsumption,accidentavoidance,ABCSInjuryRisk

Standardizingfallhistoryelements.ConsiderSPLAATT(Symptoms,Previousfalls,Location,ActivityandAlcohol,TimingandTrauma)andaskingwhytheythinkthefalloccurred.

Adding“HistoryofFall”totheActiveProblemList,ifapplicable. UtilizingamultifactorialfallassessmentbasedontheAGSguidelinesor

CDCSTEADIandaddinginjurypreventionassessments,suchasanevaluationforosteoporosis.

HomeenvironmentalassessmentsbyallIDTmembers. Assessmentofwalkingaids,assistivetechnologies,andprotectivedevices

asperscopeofpractice. UsingMotivationalInterviewingtoforencouragement. ConsiderO2‐PAGE(Orthostaticvitals,Osteoporosisrisk,Physicalfrom

EyetoFeet,Alcoholconsumptions,Gait&Balancetesting,EnvironmentalAssessment

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IDTMemberOpportunitiesBestPracticesSummary EachIDTmemberasksaboutfallsandinspectsthehomeforpotential

environmentalfallhazards. CDC:STEADIorNCPSFallToolkitFallPreventionatHomeBrochure

https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf UtilizingaKT/OT/PTIDTmemberforvalidfallriskscreeningtool,

ADL/IADL,functionalassessment,detailedhomeenvironmentalassessment,prostheticevaluation,fallhistory,andfallhuddleleader.Theassessmentcanbedoneonnewpatients,patientsdiscussedatteammeeting,aswellasonaddendumstopostfallnotes,andfallevaluations.

UtilizingaNutritionistIDTmemberforassistancewithhydrationstatus,missedmeals,Calcium/VitaminDintakeandalcoholuse.Thisassessmentcanbedoneoneachpatientdiscussedatteammeeting,aswellasonaddendumtopostfallnotesandfallevaluations.

UtilizingMentalHealthprovidersandSocialWorkerstohelpwithmotivationalinterviewing,encouragingpropersupervision,regularuseofambulatoryassistivedevices,andappropriatealcoholuse.

UtilizingaPharmacisttoassessforincreasedriskofbothfallriskandinjuryrisk(includingOsteoporosisriskmedicationsandAnticoagulation).Additionally,consideringneedforVitaminD/Calcium.Thisassessmentcanbedoneoneachpatientdiscussedatteammeeting,aswellasaddendumtopostfallnotesandfallevaluations.(ConsideronlineCEcourseofferingfromCDC‐SAFEMedicationReviewFrameworkfromCDC:STEADI)

AllIDTcanenterPostFallNotificationNote

CaregiverSupportandEducationBestPractices “CallIfYouFall”‐magnetsorformswithHBPCphonenumbertoencourage

fallreporting. www.CDC.gov/STEADIwebsiteforeducationalmaterialssuchas:Home

fallpreventionchecklist,orotherHomeevaluationchecklistliketheHomeAssessmentProfile(HAP)orHomeFallsandAccidentsScreeningTool(HOMEFAST)SeeAppendixforlinks

FocusedCaregiverEducationalhandouts:MedicalFosterHome(MFH)caregiverslikedthePSCIhandouts“Whattodoafterafall”and“FallPreventionatHome”.NationalVAFallsToolkitwebsite:https://www.patientsafety.va.gov/onthejob/falls.asp

DiscusswithcaregivertheirideasregardingfallpreventionwithMotivationalInterviewingTechniques(Seepage51formoreinformation)

Educationalmaterialsforcaregiversupportinclude: NPSC:Howtofall,Howtogetupfromafall,Whattodoafterafall,

OsteoporosisRisk,Postfallinstructions,Callifyoufallinformation,Useofhipprotectors,NCPSFallToolkitFallPreventionatHomeBrochurehttps://www.patientsafety.va.gov/onthejob/falls.asp

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CDC:Fourthingstopreventfalls,Protectyourlovedonesfromfalling,StayindependentbrochureHomesafetyhttps://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdfCDCSTEADIwebsite:www.CDC.gov/STEADI

AuditandFeedbackBestPractices PostFallNoteintheelectronichealthrecordforeachfall,withaddendums

fromvariousIDTmembers IncludingfallseverityandtriageoneachPostFallNote.MostHBPCteams

trackfall‐relatedhospitalizationsrates.Examples:EPRP(ExternalPeerReviewProgram)orJPSR(JointPatientSafetyReport).

RegularFallHuddlesandDataReportingbacktofrontlinestaffforinterventionassessment.

___________________________________________________

c. IDT Specific Fall Assessment and Intervention Opportunities Eachteammembercancontributetofalldetectionbyaskingaboutfallsateachvisit

anddocumentingrecentfallsonaPostFallNote.Duetotheinherentnatureofprovidinghealthservicesinthehome,itisrecommendedthateachIDTmembercheckthehomeenvironmentforpossiblehazardsandfallriskinterventions.Belowisalistofpossiblefallassessmenttasksthatvariousmembersmaycontribute.ThelistsbelowcanbeusedtocreateappropriatetemplatestosuitvariousHBPCteamcompositionsandcomplexities.ThelistsarecomprehensivesuggestionsandshouldbetailoredforindividualHBPCTeamaswellasmodifiedforindividualpatientneeds.

KT/OT/PT(+Nursingforapplicablesections)

• Askaboutfallsregularly• ValidatedfallriskscreeningwithMAHC‐10orCDCSTEADI(mjh‐FRAT

isrecommendedonlyforIDTwithmedicationbackgrounds)• FunctionalAssessment:includingADLSandIADLS/KATZ,Gaitand

BalanceObjectivedata(TUG,4‐StageBalanceTest,30SecondsChairStandTest,ornoteiftheyarebedbound).ConsiderShortPhysicalPerformanceBatteryProtocol.

• EnvironmentalAssessmentwithdetailedroombyroomassessment.“CheckforSafety”checklist,HAP,HOMEFAST,etc.SeeReferencesandWebsitesforlinksandmoredetails)www.CDC.gov/STEADINCPSFallToolkitFallPreventionatHomeBrochurehttps://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf

• AssessforVAprostheticitemsthatmayimprovefunctionalityandsafetysuchashipprotectors,grabbarsetc.

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• UseMotivationalInterviewing(www.motivationalinterviewing.org),andaskaboutfearoffalling(5stagesofchange:https://www.aafp.org/afp/2000/0301/p1409.html)

• Education for caregiver support including: STEADI materials, How to fall, How to get up from a fall, OP Risk, Post fall instructions, Call if you fall information, use of hip protectors. • National VA Falls Toolkit website: https://www.patientsafety.va.gov/onthejob/falls.asp • CDC:STEADI website: www.CDC.gov/STEADI

• ShareinformationwithIDT,serveasFallCoordinator

DIETITIAN

• Askaboutfallsregularly• Fallrelatedhistorycaninclude:missedmeals,fluidintake,alcoholintake,

anddietarycalcium.Evaluationsincluding:dehydration,Ca+2/VitaminD,SomeOsteoporosisriskeducationandassessment.

• EnvironmentalAssessment• NCPSFallToolkitFallPreventionatHomeBrochure• https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf• Observationalinputintofallsevaluation&caregiverandpatienteducation.• MotivationalInterviewing

(http://journals.sagepub.com/doi/pdf/10.1177/0269215515617814https://www.aafp.org/afp/2000/0301/p1409.html)

• Educationforcaregiversupportincluding:STEADImaterials,Howtofall,Howtogetupfromafall,OsteoporosisRisk,Postfallinstructions,Callifyoufallinformation,useofhipprotectors.

• NationalVAFallsToolkitwebsite:https://www.patientsafety.va.gov/onthejob/falls.asp

• CDC.STEADIwebsite:www.cdc.gov/steadiShareinformationwithIDT

SOCIALWORK

• Askaboutfallsregularly• Observationalinputintofallassessment&Caregiverandpatient

education.• MotivationalInterviewing,caregivereducationandsupport(5

stagesofchange,#scales)http://journals.sagepub.com/doi/pdf/10.1177/0269215515617814https://www.aafp.org/afp/2000/0301/p1409.html

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RESPIRATORYTHERAPIST/CHAPLAIN/OTHER

• Askaboutfallsregularly• Observationalinputintofallsassessment&Caregiverandpatienteducation.• MotivationalInterviewing,caregivereducationandsupport(5stagesof

change,#scales)http://journals.sagepub.com/doi/pdf/10.1177/0269215515617814https://www.aafp.org/afp/2000/0301/p1409.html

• Environmentalassessment• NCPSFallToolkitFallPreventionatHomeBrochure• https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf• Educationforcaregiversupportincluding:STEADImaterials,Howtofall,How

togetupfromafall,OPRisk,Postfallinstructions,Callifyoufallinformation,useofhipprotectors.


• CDC:STEADIwebsite:www.CDC.gov/STEADI• ShareinformationwithIDT

MENTALHEALTH

• Askaboutfallsregularly• Depressionscreenwithvalidatedscreeningtool(GDS,PHQ‐2,PHQ‐9.Follow

VAprotocolsforsuicideriskifpositivescreen)• Cognitiveassessmentwithvalidatedscreeningtool(SLUMS,Mini‐Cog,Folstein

Clock)• Explorationintothepatient’sfearoffalling,orlackofinsightaboutfalls,• MotivationalInterviewing,caregivereducationandsupport(5stagesof

change,#scales)http://journals.sagepub.com/doi/pdf/10.1177/0269215515617814https://www.aafp.org/afp/2000/0301/p1409.html

• EnvironmentalassessmentCDC:STEADIandNCPSFallToolkitFallPreventionatHomehttps://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf

Educationforcaregiversupportincluding:STEADImaterials,Howtofall,Howtogetupfromafall,OPRisk,Postfallinstructions,Callifyoufallinformation,useofhipprotectors.

NationalVAFallsToolkitwebsite:https://www.patientsafety.va.gov/onthejob/falls.asp

CDC:STEADIwebsite:www.CDC.gov/STEADI

• ShareinformationwithIDT

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• Environmentalassessment• NCPSFallToolkitFallPreventionatHomeBrochureand

https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf• Educationforcaregiversupportincluding:STEADImaterials,Howtofall,How

togetupfromafall,Whattodoafterafall,OsteoporosisRisk,Postfallinstructions,Callifyoufallinformation,useofhipprotectors.


• CDC.STEADIwebsite: www.CDC.gov/STEADI


PHARMACIST

• Medicationreconciliationwithfocusonbothriskoffallandriskofinjury:‐Medicationsthatincreaseriskoffalling(Psychoactivemedications,Antihistamines,Benzodiazepine,Anticonvulsantagents,Antidepressants,Musclerelaxers,Hypertensives,Antiparkinsonianagents,Analgesic,Antineoplastic,Hypoglycemicagents).CanalsorefertoCDCMedicationListandSAFEFrameworkwww.CDC.gov/STEADI‐Medicationsthatincreaseriskofinjury(AdrenalGlucocorticoids,Anticoagulants,Proton‐pumpinhibitors,anti‐androgens)

• ConsiderVitaminD/Ca+2supplementation• Askaboutrecentfallsandperformanenvironmentalevaluationonvisits• ShareinformationwithIDT.Considerincludinghighriskmedicationsoneach

patientreviewedforteammeeting.• Ifhomevisits:Askaboutfallsandassesshomeenvironmentrisks• https://www.cdc.gov/steadi/materials.html

RN(LPNasappropriateunderScopeofPractice)

• Askaboutfallsregularly• EnvironmentalAssessmentorEducation

https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf• ShareinformationwithIDT• FallRiskScreeningAssessment(MAHC‐10,mjhFRAT,AGS/CDCSTEADI)• StandardizedFallHistoryElements:SPLAATT(Symptoms,PreviousFallsfor

patterns,Location,Activity,AlcoholTiming,Trauma).Plus,askwhytheyfeelthefalloccurred.

• DietandAlcoholintake(ConsiderfromDietitian)• OsteoporosisRiskFactorAssessment(ConsiderpartsfromDietitian)

‐Ageover60‐Familyhistoryofosteoporosisorhip,wrist,orvertebralfractures‐Dietaryrisks:lowcalciumintake,anorexia,bypassessurgery

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‐Lifestylechoices:sedentary,excessivealcoholconsumption,tobaccouse‐Medications(steroids,antidepressants,antiepileptic,anti‐refluxmedications)‐Diseasestates(Menopause,cancer,depression)‐WHOFractureRiskAssessmentTool(FRAX)*Noteagelimitationshttps://www.sheffield.ac.uk/FRAX/tool.jsp

• Orthostaticvitals(lyingfor5min,standingfor1minstandingfor3minutes)

• FunctionalAssessment:includingADLSandIADLS/KATZ,GaitandBalanceObjectivedata(TUG,4StageBalanceTest,30SecChairStandTest,orbedbound)

• EnvironmentalAssessment(CDCchecklist,HAP,HOMEFAST,NCPSFallToolkitFallPreventionatHomeBrochure)

• AssessforpossibleVAprostheticitemsthatmayimprovefunctionalityandsafety(ConsiderKT/PT/OT)

• Depressionscreenwithvalidatedscreeningtool:GDS,PHQ‐2,PHQ‐9.FollowVAprotocolsforsuicideriskifpositivescreen.(ConsiderfromMentalHealth).

• GaitObservation(ConsiderfromKT/OT/PT)

• Vision(20/30),Hearing(whispertest)

• CardiovascularandPulmonaryassessment

• Musculoskeletalassessment(Includingjointassessment,musclestrengthandROM)ConsiderfromKT/OT/PT

• Neurologicassessment

• Feetassessment(includingfootweartype,vascularization,anddeformities)

• Urologicassessment(includingbladderandprostateassessments)

• Cognitiveevaluationwithvalidatedscreeningtool(SLUMS,Mini‐Cog,FolsteinClock)(ConsiderfromMentalHealth).

• Explorationintothepatient’sfearoffalling,orlackofinsightaboutfalls,MotivationalInterviewingandeducationforcaregiversupport(5stagesofchange,askaboutfearoffalling,numberscales)http://journals.sagepub.com/doi/pdf/10.1177/0269215515617814https://www.aafp.org/afp/2000/0301/p1409.html

• Educationforcaregiversupportincluding:STEADImaterials,Howtofall,Howtogetupfromafall,Whattodoafterafall,OsteoporosisRisk,Postfallinstructions,Callifyoufallinformation,useofhipprotectors.


• CDC.STEADIwebsite:www.cdc.gov/steadi

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PCP/MD/PA/ARNP(RNasappropriateunderScopeofPractice)

• Askaboutfallsregularly

• Environmentalevaluation:• NCPSFallToolkitFallPreventionatHomeBrochure• https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf


• FallScreenandMultifactorialFallAssessment

• Validatedfallriskscreenorreviewofscreenfromanotherteammember:(MAHC‐10,mjhFRAT,AGS/CDCSTEADI)

• StandardizedFallHistoryElements:SPLAATT‐Symptoms,PreviousFallsforpatterns,Location,Activity,Alcohol,Timing,Trauma,&askingwhytheyfeelthefalloccurred

• DietandAlcoholintake(maybefromDietitian/RN/LPN)

• IDTObservationalinputfromhuddles,auditandfeedbackinformation

• OsteoporosisRiskFactorAssessment(partsmaybefromDietitian/RN)

a. Ageover60b. Familyhistoryofosteoporosisorhip,wrist,orvertebralfracturesc. Dietaryrisks:lowcalciumintake,anorexia,bypassessurgeryd. Lifestylechoices:sedentary,excessivealcoholconsumption,tobacco

usee. Medications(steroids,antidepressants,antiepileptic,anti‐reflux

medications)f. Diseasestates(Menopause,cancer,depression)

• WHOFractureRiskAssessmentTool(FRAX)*Noteagelimitationshttps://www.sheffield.ac.uk/FRAX/tool.jsp

• Detailedphysicalexamincluding:

a. Orthostaticvitals‐lyingfor5min,standingfor1min,standingfor3min(MaybefromRN/LPN)

b. ObjectiveFunctionalAssessment(TUG,30secChair‐Standtest,FourStageBalanceTest)(MaybefromRN/KT/OT/PT)

c. GaitObservation(MaybefromRN/LPN/KT/OT/PT)itd. Vision(20/30),Hearing(whispertest)(MaybefromRN/LPN)e. CardiovascularandPulmonaryexamf. Musculoskeletalexam(Includingjointassessment,musclestrengthand

ROM)g. Neurologicexam(sensation(5.07microfilament),proprioception,

sensation,vestibularsystem,reflexes)

30

h. Footexam(includingfootweartype,vascularization,anddeformities)i. Considerurologicexam(includingbladderandprostateassessments)

• Considerlabsdependingonpatientgoals:CBC,CMP,TSH,PTH,AlkPhos,Alb,IP,Ca+2,VitD,Testosterone,LH/FSH

• Considerimagingdependingonpatientgoals:X‐rays,MRI,CT,NIVS,DEXA

scan

• Multifactorialfallandinjuryassessment,considerusinganyofthefollowingoptions:

1. AGSguidelines(seeAGSwebsiteorAFPwebsiteforsummarywww.aafp.org/afp/2010/0701/p81.html)

2. CDCSTEADIguidelines(seewww.CDC.gov/STEADIwebsite)3. Fallriskandinjuryrisklistswhichincludeseither:

(SeeHBPCFallAssessmentFlowchartSectionsC.1andC.2)a. IntrinsicandExtrinsicRisksFactorsplusInjuryRiskFactorswith

triggersforinterventionsor

b.PlantoHELPpreventfallsinthecommunitywithtriggersforinterventionswhichincludes:H‐homeenvironmentalassessmentE‐exerciseandactivityrecommendationsL‐limitcomorbidityandinjuryP‐pharmacyreview

• Explorationintothepatient’sfearoffalling,orlackofinsightaboutfalls,MotivationalInterviewingandeducationforcaregiversupport(5stagesofchange,askaboutfearoffalling,numberscales)http://journals.sagepub.com/doi/pdf/10.1177/0269215515617814https://www.aafp.org/afp/2000/0301/p1409.html

• Educationforcaregiversupportincluding:STEADImaterials,Howtofall,

Howtogetupfromafall,Whattodoafterafall,OsteoporosisRisk,Postfallinstructions,Callifyoufallinformation,useofhipprotectors.

NationalVAFallsToolkitwebsite:https://www.patientsafety.va.gov/onthejob/falls.aspCDC.STEADIwebsite:www.cdc.gov/steadiHomeAssessmentBrochures:‐NCPSFallToolkitFallPreventionatHomeBrochure‐https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf

31

d. Sample CPRS Templates with Table of Contents Thefollowingtemplatesareexampleswithvastamountsofeducationalinformationincluded.EachindividualHBPCwillhavevariousIDTmemberswithdifferentscopesofpracticeanddifferentcontributionstooffer.Therefore,eachHBPCteamwillneedtoworkwiththeirInformationTechnologist/CACtobuildtemplatesthatmeettheirspecificneeds.Sometemplatescanserveasaparentnotetowhichothertemplatescanbeplacedasanaddendum

A. FRAScreeningToolsTemplateSampleswithbackgroundinformation:MAHC‐10................................................................................................................32mjh‐FRAT...............................................................................................................33CDC‐STEADI..........................................................................................................34

B. InitialPostFallNotificationTemplatesample......................................................35DietitianPostFallAddendumtemplatesample......................................36PCP/RNPostFallAddendumtemplate(NOTfallassessment)..........37PharmacyPostFallAddendumtemplatesample...................................37KT/OT/PTPostFallAddendumtemplatesample..................................37

C. FallAssessmentTemplateSamples:IDTHomeEvaluationChecklisttemplate..................................................38RN(NotPCP)FallAssessmentTemplate……………………………….……….38 *Abovetemplatewitheducationaldetailsadded.………39PCP/ARNP/PA/MDFallAssessmentandEvaluationTemplate.........42

*EducationaldetailsincludedAdditionalFallAssessmentandEvaluationTemplateSample..........47

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MAHC‐10 (Missouri Alliance for Home Care – Fall Risk Assessment Tool)

TheMAHC‐10iscopyrightedandtheadministratorofthetoolmustnotaltertheincludedwordingfortheinstructions.ThisHBPCToolkitobtainedpermissiontoreproducethetoolfromthecreatorsoftheMAHC‐10inAugust2017,whogavepermissionforallVAtouseif“MAHC‐10”isdocumentedontheToolandthedirectionsarekeptthesameasoriginallyprinted.Thispermissionforreproductionisnotvalidifthedirectionsarechanged.Documentationintheelectronichealthrecordcanbelimitedtothename,“MAHC‐10,”followedbythescoreandanypositivefindings.AnyIDTmembermayadministerthisfallriskscreeningtool.ThepilotedteamsinFlorida,Georgia,andWisconsinfeltthistoolfitstheirworkflowforeaseofuseandscopesofpractice.TheyacknowledgedlimitationsininformationacquiredcomparedtothemjhFRATandCDCSTEADI.

NotethattheMAHC‐10cut‐offscoreforhigh‐riskoffallisofficially4.However,statisticalanalyses(suchasareaundertheReceiverOperatingCharacteristicorROCcurve)revealedacutoffscoreof6maybemoreaccuratetopredictfallrisk.ResearcherssuchasFlemmingsupportthatthenumberisnotasimportantasapositivefinding.Allpositivefindingsshouldbeaddressedforpossibleinjurypreventionregardlessofthecut‐offnumber.Providersshouldconductafallriskassessmentoneachpatientatstartofcareandre‐certification.Assessonepointforeachcoreelement“yes”.Informationmaybegatheredfromthemedicalrecord,assessmentand,ifapplicable,thepatient/caregiver.Beyondprotocolslistedbelow,scoringshouldbebasedonyourclinicaljudgment.

Template for MAHC‐10 – Fall Risk Screening Tool

Conductafallriskscreenoneachpatientatstartofcareandre‐certification.

MAHC 10 ‐ Fall Risk Assessment Tool (assign 1 point for each “Yes”)

CoreElements Yes

Age65yearsandolder

Diagnosis(3ormoreco‐existing)Includesonlydocumentedmedicaldiagnosis

Priorhistoryoffallswithin3months(Anunintentionalchangeinpositionresultingincomingtorestonthegroundoratalowerlevel)

Incontinence(InabilitytomakeittothebathroomorcommodeintimelymannerIncludesfrequency,urgency,and/ornocturia).

Visualimpairment(Includesbutnotlimitedto,maculardegeneration,diabeticretinopathies,visualfieldloss,agerelatedchanges,declineinvisualacuity,accommodation,glaretolerance,depthperception,andnightvisionornotwearingprescribedglassesorhavingthecorrectprescription).

Impairedfunctionalmobility(MayincludepatientswhoneedhelpwithIADLSorADLSorhavegaitortransferproblems,arthritis,pain,fearof

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falling,footproblems,impairedsensation,impairedcoordinationorimproperuseofassistivedevices).

Environmentalhazards(Mayincludebutnotlimitedto,poorillumination,equipmenttubing,inappropriatefootwear,pets,hardtoreachitems,floorsurfacesthatareunevenorcluttered,oroutdoorentryandexits).

PolyPharmacy(4ormoreprescriptions–anytype)AllPRESCRIPTIONSincludingprescriptionsforOTCmeds.Drugshighlyassociatedwithfallriskincludebutnotlimitedto,sedatives,anti‐depressants,tranquilizers,narcotics,anti‐hypertensives,cardiacmeds,corticosteroids,anti‐anxietydrugs,anticholinergicdrugs,andhypoglycemicdrugs.

Painaffectingleveloffunction(Painoftenaffectsanindividual’sdesireorabilitytomoveorpaincanbeafactorindepressionorcompliancewithsafetyrecommendations).

Cognitiveimpairment(Couldincludepatientswithdementia,Alzheimer’sorstrokepatientsorpatientswhoareconfused,usepoorjudgment,havedecreasedcomprehension,impulsivity,memorydeficits.Considerpatientsabilitytoadheretotheplanofcare).

Ascoreof4ormoreisconsideredatriskforfallingTotalpoints:

mjh‐FRAT Template (Modified Johns Hopkins Fall Risk Assessment Tool)

Themjh‐FRATisvalidatedforidentifyingcommunitydwellingpatientswhoareatriskofinjuriousfall.Thisisdifferentfromtheriskofjustfallingasitismorespecifictodetermininglevelofriskforaninjuriousfall,notfall.BasedonfeedbackfromtheinitialTampaHBPCpilot,theadministratorsofthistoolwillneedtohaveascopeofpracticethatallowsforastrongworkingknowledgeofpharmaceuticals,especiallymedicationadverseeffects.Therefore,werecommendthefollowingIDTmembersforthistool:RN,ARNP,PA,MD.VAHospitalsthatcurrentlyusetheJH‐FRATmayfindthisfallriskscreeningtoolaneasytransitionfortheirHBPCprogram.

CoreElements PointsHistoryofmorethanonefallwithin6monthsbeforeadmission HighRiskDeemedahighriskperprotocol(e.g.seizures) HighRiskLackofunderstandingofone’sphysicalandcognitivelimitations HighRiskIfanyoneoftheabovearetrue:StophereandImplementHigh‐RiskFallInterventionsProtocol.Ifnoneabovearetrue,continuewithassessmentbelowFallHistory(selectone)Nofalls 0pointsOnefallwithin6monthsbeforeadmission 5pointsElimination,BowelandBladder(selectonlyone)Noincontinence,urgency,orfrequency 0pointsIncontinence 2points

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Urgencyorfrequency 2pointsUrgency/frequencyandincontinence 4pointsHighRiskMedications:IncludesPCA/opiates,anti‐convulsants,anti‐hypertensives,diuretics,hypnotics,laxatives,sedatives,andpsychotropics(selectone)On1highfallriskmedications 3pointsOn2ormorehighfallriskmedications 5pointsSedationprocedurewithinpast24hours 7pointsPatientCareEquipment:Anyequipmentthattetherspatient,e.g.IVinfusion,chesttube,indwellingcatheters,SCDs,etc.(selectone)Onepresent 1pointTwopresent 2pointsThreeormorepresent 3pointsMobility(Multipleselect,chooseallthatmayapplyandaddpointstogether)Requiresassistance/supervisionformobility,transfer,orambulation 2pointsUnsteadygait 2pointsAvisualorauditoryimpairmentaffectingmobility 2pointsCognition(Multipleselect,chooseallthatapplyandaddpointstogether)Alteredawarenessofimmediatephysicalenvironment 1pointImpulsivity/poorsafetyjudgment 2pointsShorttermmemoryloss 2points(5to11points=ModerateRisk)(>11points=HighRisk)TOTAL:

CDC STEADI (CDC Stopping Elderly Accidents, Deaths & Injuries)

TheCDCcreatedacomprehensivefallscreening,evaluationandassessmentprogramforoutpatientcommunitydwellingadults.TheStayIndependentBrochurehastwelvequestionsdesignedforself‐assessmenttoidentifyfallriskandtheCDCadoptedThreeScreeningQuestionsforclinicianstoaskpatients65andolderasaroutinepartofexams(https://www.cdc.gov/steadi/index.html).Boththeclinicianquestionsandthe12self‐assessmentquestionsfromtheStayIndependentBrochureareincludedbelow.Patientsarestratifiedintolow,moderateandhigh‐riskwithvariousrecommendedinterventionsdelineatedforfallprevention.TheHBPCpilotfeedbackindicatedthefirstthreescreeningquestionslistedbelowwerenotasusefulforriskfactoridentification,andcliniciansusingthetwelvequestionsfromtheself‐screeningchecklistpromptedlonginterviewengagements.Thequestion“Doyouworryaboutfalling?”wasconsideredhelpfulformotivationinterviewing,particularlywithassistivedeviceencouragement.

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Template for CDC STEADI and AGS FRA Screening Tool (use either tool below)

CDC STEADI (CDC Stopping Elderly Accidents, Deaths & Injuries)

ThreeQuestionstoAskYourOlderAdultPatients.Whenyouseepatients65andolder,makethesethreequestionsaroutinepartofyourexam:

Points

1.Haveyoufalleninthepastyear?(ifyes,asknumberoffallsandinjuries)Ifyes,“atrisk”

Atrisk

2.Doyoufeelunsteadywhenstandingorwalking?Ifyes,“atrisk” Atrisk

3.Doyouworryaboutfalling?Ifyes,“atrisk” Atrisk

Ifanyoneoftheaboveareanswered“yes”:Yourpatientisatriskandwarrantsfurtherassessment.Ifall3answerswere“no”stophere.

OR…Alternatively,screenwiththeStayIndependentBrochurefromCDCSTEADIusingthequestionsandscoringbelow:

Ihavefalleninthelast6months 2pointsIuseorhavebeenadvisedtouseacaneorwalkertogetaroundsafely 2pointsSometimesIfeelunsteadywhenIamwalking. 1pointIsteadymyselfbyholdingontofurniturewhenwalkingathome. 1pointIamworriedaboutfalling. 1pointIneedtopushwithmyhandstostandupfromachair. 1pointIhavesometroublesteppingupontoacurb. 1pointIoftenhavetorushtothetoilet. 1pointIhavelostsomefeelinginmyfeet. 1pointItakemedicinethatsometimesmakesmefeellight‐headedormoretiredthanusual

1point

Itakemedicinetohelpmesleeporimprovemymood. 1pointIoftenfeelsadordepressed. 1point(4ormorepoints=increasedfallrisk)TOTAL:

B. Post Fall Notification(ParentNoteforanyIDTmember’suse.Co‐signaturestobedeterminedbyeachHBPCprogram.ConsiderPCP,RN,Pharmacy,KT/OT/PT,FallCoordinator,andpossiblyDietitian,MentalHealthand/orSocialWorker)

Dateandtimeofevent:_____________________________________________

Witnessedfall?______________________________________________YesorNo

Briefdescriptionoffall:_____________________________________________

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Whydoesthepatientorcaregiverthinkthefalloccurred?

___________________________________________________________________________

Symptoms?___________________________________________________________________

________________________________________________________________________________

Activity?______________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Location/Room?_____________________________________________________________

________________________________________________________________________________

Injury?________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

ER?_________________________________________________________________YesorNo

Hospitalization?(ifknownattime)_____________________________YesorNo

911Called?________________________________________________________YesorNo

Previousfallinpast3months?_____Pastyear?_____

============================================================

Dietitian Post Fall Addendum CPRS Template Considerations:

Labs:Mostrecent(Checktoimport) BMP CBC HemoglobinA1C VitaminD

Hydration:(Freetextcommentbox) Handgrip(clicktoactivate)

OverallPOintake(Chooseone) _____Good_____Fair_____Poor Doespatientmeetcriteriaformalnutrition?

(Chooseone)___Yes_____No FallReview:Closed(Chooseone)

Nofurtherrecommendation Recommendation:(Freetextcommentbox).

Providerassignasco‐signertocompeterecommendations)

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PCP/RN Post Fall Notification addendum (separate from Post Fall Assessment)

LabsReviewed:Yes/No.Comments: HashadanyHospitaladmissions,ProceduresorinfectionsinPast30daysYes/No.

Comments: DidPatientGotoER?Yes/NoComments: ERvisitOutcome:Dischargedhome/InpatientAdmission.Comments LevelofInjury:Mild/Moderate/Major/Catastrophic.Comments:

(havedropdownfordefinitionsofeachlevelsforreferenceonly) FallFinaldisposition:Nof/uneededvsf/uneededby_______(discipline) Comments:========================================================================

Pharmacy Post Fall addendum considerations:

Medicationsthatincreaseriskoffallinclude:o Psychoactivemedications,Antihistamines,Benzodiazepine,Anticonvulsant

agents,Antidepressants,Musclerelaxers,Hypertensives,Antiparkinsonianagents,Analgesic,Antineoplastic,Hypoglycemicagents)

Medicationsthatincreaseriskofinjuryo (AdrenalGlucocorticoids,Anticoagulants,PPI,anti‐androgens)

ConsiderVitaminD/Ca+2supplementation,Bisphosphonatetreatmentoptions

=======================================================================

Therapist Post Fall Note Assessment considerations:

Primary method of mobility:

Ambulation Choose one: Independent Supervision/Cueing Caregiver assistance

Non ambulatory

Choose one: Without assistive device

With assistive device (What type?)

Wheelchair Choose one: Manual Power

Choose one: Independent Supervision/Cueing Caregiver assistance

Dependent

Not applicable

Conditions Effecting Mobility (choose all that apply)

Hemiparesis Partial weight bearing

Amputation Impaired Gait Impaired Posture

Impaired vision Impaired balance

Poor endurance O2 user Neuropathy

Pain Inconsistent use adaptive equipment

Poor safety awareness

Tubing tethered to patient

Other:

Was an assistive device being used? If so, what type?

Was an assistive device recommended? _____Yes _____No

Comments:

Is this assistive device appropriate for patient?

Was assistance recommended for this activity?

How does patient call caregiver for assistance? _____ Verbal _____ Call button _____ Other:

Was the patient wearing hip protectors at time of fall? Yes/No/Declined

Protectors were issued to patient? _____Yes _____No

Protective measures in

Low bed Safety belt Non‐skid footwear Call bell within reach

Floor mat

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effect at time of fall (choose all that apply)

Frequent observation

Hip protectors Bedrails (#) Chair alarm Bed alarm

Other:

Environmental conditions at time of fall

Lighting: Adequate/Non‐ adequate

Flooring (Carpet, hard surface, rugs

Non‐skid footwear Call bell within reach

Floor mat

Furniture type (choose from list)

Rocker Recliner Chair with wheels

No arms

No back Low seat to floor height

High seat to floor height

Soft/plush furniture

Equipment failure? Specify:

Other:

Was education provided? _____Yes _____No

Does patient follow recommendations? _____Yes _____No

How many falls in the last 6 months? (Including current fall)

Recommendations: (Add comments)

MAHC‐10/Missouri Alliance Home Care Fall Risk Assessment

List of recommendations (Add comments)

Therapist will provide education/recommendations

Equipment ordered

========================================================================

c. Fall Assessment Template Samples

TemplateforIDTuseforOptimizingHomeSafetyo EducatecaregiverandpatientaboutfallsandanyKTspecific

homesafetyrecommendationso Userecommendedaidsandsupervisiono Nightlightsorleavinghallorbathroomlightsonovernighto Grabbarsinstalledinsideandoutsidethetuborshowero Grabbarsnexttothetoileto Removetrippinghazardssuchasarearugs,cords,clutter,and

cleanspillsimmediatelyo Useramps,non‐skidreflectivetape,andgrabbarsforstepso Considerhipprotectors

IssueNCPSFallToolkitFallPreventionatHomeBrochureorCDCHomeSafetyChecklist

=============================================================================

RN Fall Assessment Template Sample: Brief outline (See page 39 for detailed sample)

FRAScreeningTooloptions(Chooseone)

_____MAHC‐10

_____mJH‐FRAT

_____CDCSTEADI

OrthostaticBloodPressureandHeartRate(basedonpatient’sabilities):

_____5‐minuteslying

_____1‐minutestanding

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_____3‐minutesstanding

VisualAcuity(canusepocketeyechart,<or=20/30)

_____YES/Intact _____NO/Impaired

Reviewandcompletehomeassessmentlist(Ex:CDC“Homesafetychecklist”)

Functional Gait/Balance Assessment: (Choose one or more. Refer to CDC STEADI website for testing instruction).

TimedUpandGo(>12secondsisatincreasedriskforfalls) FourStageBalanceTest(4subtests.Eachtimedforamaximumof10secs)

o Feettogether:_____/10seco Feetin‐step:_____/10seco Feetinfulltandem:_____/10seco Uni‐pedalstance(preferredfoot):_____/10sec

30‐secondchairraisetest

• Numberoffalls• Fall‐relatedinjuries• Fallhistory/SPLATT(Symptoms,Priorfalls,Activity,Location,Trauma,

Timing)• Whydoesthepatient/caregiverthinkthefalloccurred?• DietaryhistoryandAlcohol• Depressionscreen• Cognitivescreen

RiskFactorIdentificationandtriggeredinterventions:(CanuseeitherIntrinsic/ExtrinsicRisksorHELPpreventfalls.SeeFlowchartComponentC.2)

=========================================================

RN Fall Assessment Template: Same with detailed instructional inserts

FallScreen:MAHC‐1‐,mJHFRAT,STEADI3orStayIndependent

Fallshistory:SPLATT(symptoms,priorfalls,activity,timing,trauma)

Whydoesthepatientorcaregiverfeelthefallsoccurred?

PHQ‐2 or VA Clinical Reminder

Overthepasttwoweeks,howoftenhaveyoubeenbotheredbyanyofthefollowingproblems?

Littleinterestorpleasureindoingthings?_______o 0=Notatallo 1=Severaldayso 2=Morethanhalfthedayso 3=Nearlyeveryday

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Feelingdown,depressed,orhopeless?________o 0=Notatallo 1=Severaldayso 2=Morethanhalfthedayso 3=Nearlyeveryday

Totalpointscore:___________

Orthostatic vitals:

5minlyingBP: HR= 1minstandingBP: HR= 3minstandingBP: HR=

Corrected Visual Acuity:_____(worsethan20/30riskfactorforfalls)

Pain:_____(0‐10scale)

Cognitive Screening:Recall_____of3

Functional testing: (Choose one or more. Refer to CDC STEADI website for testing instruction).

4StageBalanceTest:(Hold4differentpedalpositionsfor10secondseach)

o Feettogether:_____/10secs(Standwithfeetsidebyside).

o Feetin‐step:_____/10secs(Placeinstepononefootsoitistouchingthebigtoeoftheotherfoot).

o Feetinfulltandem:_____/10secs(Placeonefootinfrontoftheother,heeltouchingtoe).

o Uni‐pedalstance(preferredfoot):_____/10secs(Standononefoot).

BalanceImpaired:Y/N

TUG:_____seconds(TimedUpandGoTestforwalking10feetandback.>11secissignificantforimpairedmobilityand>13.5issignificantforincreasedriskoffalling)SignificantforGaitMobilityImpairment:Y/N

SignificantforincreasedriskofFalls:Y/N

30‐SecChairStand:Agenormativevalues

Age Men Women

60‐64 <14 <12

65‐69 <12 <11

70‐74 <12 <10

75‐79 <11 <10

80‐84 <10 <9

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85‐89 <8 <8

90‐94 <7 <4

Deconditioned:Y/N

INTRINSIC FALL RISK FACTORS:

Advancedage:_____(Yes/No) Fearoffalling:_____(Yes/No) Previousfalls:_____(Yes/No) Poorvision:_____(Yes/No) Posturalhypotension:_____(Yes/No) Muscleweakness:_____(Yes/No)(Abnormal30‐SecChairStandoruseofarmto

arisefromchair) Gait&balanceproblems:_____(Yes/No)(AbnormalTUGor4StageBalanceTest)

EXTRINSIC FALL RISK FACTORS:

HomeEnvironment:

Lackofstairhandrails:_____(Yes/No) Poorstairdesign:_____(Yes/No) Lackofbathroomgrabbars:_____(Yes/No) Dimlightingorglare:_____(Yes/No) Obstacles&trippinghazards:_____(Yes/No) Slipperyorunevensurfaces:_____(Yes/No) Idealfootweareducation Ambulatoryassistdeviceassessmentandeducation Petsafetyeducation Prostheticdevicesevaluation

OR

HELPpreventfalls

H‐HomeEnvironment:

Lackofstairhandrails:_____(Yes/No) Poorstairdesign:_____(Yes/No) Lackofbathroomgrabbars:_____(Yes/No) Dimlightingorglare:_____(Yes/No) Obstacles&trippinghazards:_____(Yes/No) Slipperyorunevensurfaces:_____(Yes/No) Footweareducation Ambulatoryassistdeviceassessmentandeducation Petsafetyeducation Prostheticdevicesevaluation

E‐ExerciseorActivity.SeeFunctionalAssessmentresults:

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PT/OT,TaiChi,Rehab,WalkingProgram,Activityincreased,Chair‐standfromSTEADIexercisehandout.Focusonincreasinglegstrength,flexibilityandimprovingbalance,andthattheygetmorechallengingovertime.

L‐LimitComorbidity‐Maximizecurrenttreatment:

Reviewfallriskscreenpositivefindingsandaddress Visioncheckandophthalmologyconsult OrthostaticAssessment:NotifyPCPandissueCDCBrochure:ChangePositions

Slowly:Standingupslowlyafterlyingorsitting. Fearoffallingandhistoryoffalls,Depression:Considercognitivebehavior

therapy,MentalHealthconsult,MotivationalInterviewing,PTconsult. AdditionalComorbidityconsiderations:VitaminDdeficiency;Hearingloss;Pain;

Incontinence;Cardiovasculardiseaseincludingarrhythmia,CAD,Syncope,hypotension;Pulmonarydiseaseincludinghypoxia,COPD;Neurologicdiseaseincludingstroke,syncope,Parkinson’sdisease,vertigo,neuropathy,vestibularchanges;DJDandpedalissues,DiabetesMellitus,Thyroiddisease,Anticoagulation,Osteoporosisassessifadditionalinterventionneeded

P‐Pharmacyconsultedfor:

MedicationsthatincreaseriskofFALLING MedicationsthatincreaseriskofINJURY ConsiderVitaminD/Calciumsupplementation

========================================================================

PCP Fall Multifactorial Fall Assessment Template Sample:

FRA:MAHC‐10,mJHFRAT,orCDCSTEADI

PositivefindingsontheFRAaboveinclude:

FallsHistory:o PHQscore:_____o Cognitivescreenscore:_____

Orthostaticvitals:o OrthostaticBP:_____/lying5minutes,_____/standing1min,

_____/standing3mino OrthostaticPulse:_____Sitting,_____lying,_____standing

EXAM:o Constitutional:Includingmobilityaidso HEENT:VisualAcuity:+/‐Glasseso CV,RESPIRATORY,GI,etc.o NEUROLOGIC:A&OX3,recall/3,Clock,CNII‐XIIgrosslyintact,Tone,

Cogwheeling,Sensation,Proprioception,Reflexeso MUSCULOSKELETAL:Strength,Laxityandsynovitiso EXT:Edema,FeetandFootwear

GAIT,STRENGTH&BALANCEASSESSMENT:(Completedbynurse)

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o TUGforGait:_____secImpairedMobilityvs.IncreasedriskofFallo 30SecChairStandforStrengtho 4StageBalanceTesto 30SecChairStandforStrengtho 4StageBalanceTest

ASSESSMENT:Thepatientisatriskforfallsduetothefollowingextrinsic

andintrinsicfactors:EXTRINSICFALLRISKFACTORS:

o Homeenvironmento Medicationso Assistivedeviceuseo Lackofstairhandrailso Poorstairdesigno Lackofbathroomgrabbarso Dimlightingorglareo Obstacles&trippinghazardso Slipperyorunevensurfaceso Psychoactivemedicationso Anticholinergicmedicationso SedatingOTCmedicationso Improperuseofassistivedevice

INTRINSICFALLRISKFACTORS:

o Advancedageo Muscleweaknesso Gait&balanceproblemso Poorvisiono Posturalhypotensiono Fearoffallingo Chronicconditions(Diabetes,DJDincludingfootproblems,CVA,

Parkinson's,incontinence,dementia,depression,cardiacarrhythmias,etc...)

FALL INTERVENTIONS:To reduce the risk of falling, the following fall interventions are recommended (include all which are applicable):

1.Optimizemedicationso Manageandmonitorhypotensiono Givebrochure:PosturalHypotension,WhatItIsandHowtoManage

It.o Usenon‐pharmacologicoptionssuchasdrinkadequateamountsof

fluidsanddoanklepumpsandhandclenchesforaminutebeforestanding

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o Discontinueordecreasepsychoactivemedications,sedatingmedications,andanticholinergicmedications

2.Enhancestrengthandbalanceo ChairRiseExerciseHandouto Refertoanexercise,fitness,orfallpreventionprogramtooptimize

legstrengthandbalance(goalis1‐hour3xweekforminimumof4monthsor1hour

o 2xweekforminimumof6months)o Consider800IUormoreofVitaminDsupplementtooptimizemuscle

strength3.Improvefunctionalmobility

o Considermentalhealthconsultifdepressionpresentorfearoffallingo AdviseonproperuseofmobilityaideswithconsulttoPTo Addressfootproblemsorrefertopodiatryo Considerneuropathyworkupwithneurologyandlabs

4.ManageOsteoporosisriskso ConsiderCalciumandVitaminDdailyo ConsiderDEXAScan

5.Optimizevisiono Referraltoanophthalmologisto Suggestsinglelensdistanceglassesforwalkingoutside

6.Optimizehomesafetyo ConsiderhomePTconsultfora1timehomesafetyevaluation.o Nightlightsorleavinghallorbathroomlightsonovernighto Grabbarsinstalledinsideandoutsidethetuborshowero Grabbarsnexttothetoileto Removetrippinghazardssuchasarearugs,andcluttero Userampsforstepso Considerhipprotectors

7.Educatepatiento Use"StagesofChange"motivationalinterviewingmodelo Emphasizethatafallisnotsimply"badluck"o Emphasizethatmanyfallscanbepreventedo Donotwalkifdizzyo Issuebrochure:CDC'sWhatYouCanDotoPreventFallsandCheck

forSafety

ORusetheHELPPreventFallspneumonictooldescribedbelow

HELP Prevent Falls

WhentheAssessmentindicatesthepatientisatinincreasedriskoffalls,

UsetheH‐E‐L‐Ptoolbelowtodeterminewhatspecificinterventionsmaybeneededtoaddressidentifiedrisks:

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H‐Homeenvironmentalhazards:(Extrinsicrisk)

Forpatientswithidentifiedissueswithenvironment,clothes,pets,ambulatoryassistdevices:

Interventionsmayinclude,butnotlimitedto:

Footweareducation AmbulatoryassisteducationandMotivationalInterviewing Lowbed Peteducation Floormats Hipprotectors Helmet Removeclutter

Provideroom‐by‐roomsafetyassessmentandinterventions(SomeHBPCusetheSTEADIhomeevaluationchecklist).

Performmobilityassistivedeviceassessment&interventions,usemotivationalinterviewing

ConsiderHISAGrantformodifications

E‐ExerciseandActivity:(Intrinsicrisk)

Forpatientswithissuesrelatedtomobility,weakness,orgaitandbalance:

Interventionsmayinclude:

PT/OT TaiChi Rehab Walkingprogram Activityincreasedprescription(MonitorheartrateperAmericanHeart

AssociationTargetHeartRateRanges) Communityexerciseprogram Chair‐standfromSTEADI

L‐LimitComorbidity:(Intrinsicrisk)

1.Reviewandaddressfindingsonvalidatedfallrisksscreeningtoolforinterventions:

(Ex:Muscleweakness,Gait/Balance,Visionloss,Historyoffall,#Comorbidconditions,Incontinence,Pain,CognitiveImpairment)

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2.Maximizeimportantcomorbiditytreatmentsandconsiderconsultationsespeciallyfor:

Hearingloss Depression Cardiovasculardisease(CAD,Syncope,Arrhythmia,Hypotension/Orthostatic) Pulmonarydisease(COPD,Asthma,Pulmonaryhypertension) Neurologicdisorders(Dementia,CVA,Seizure,Parkinson’sDisease, Parkinson’sPlusDisorders,vertigo,neuropathy) ArthriticdiseasesandPedalproblems DiabetesMellitus Thyroiddisorders

3. AssessforInjuryrisk:

Osteoporosisriskfactors Ageover60 Familyhistoryofosteoporosisorhip,wrist,orvertebralfractures Dietaryrisks:lowcalciumintake,anorexia,bypassessurgery Lifestylechoices:sedentary,excessivealcoholconsumption,tobaccouse Medications(steroids,antidepressants,antiepileptic,anti‐refluxmedications) Diseasestates(Menopause,cancer,depression) WHOFractureRiskAssessmentTool(FRAX)*NoteAgelimitation

https://www.sheffield.ac.uk/FRAX/tool.jsp Percent(%)riskofmajorfractureinthenext10years Percent(%)riskofhipfractureinthenext10yearsInterventionmayinclude:

Reducemodifiableinjuryriskfactorssuchasactivity,smoking,limitingmedicationslikePPIandsteroids

Assessforbisphosphonates,vitaminD,andcalciumtreatments

Assessmedicationsforhighinjuryrisk:seebelowP‐Pharmacy)

P‐Pharmacy/Pills:(Extrinsicrisk)

Medicationsthatincreaseriskoffalling(Psychoactivemedications,antihistamines,Benzodiazepine,anti‐convulsantagents,Antidepressants,musclerelaxers,hypertensives,anti‐Parkinsonagents,analgesic,antineoplastic,hypoglycemicagents)

Medicationsthatincreaseriskofinjury(Anticoagulation,diabetichypoglycemicagents,Adrenalglucocorticoids,Anticoagulants,PPIs,Anti‐androgens,psychotropicdrugs)

ConsiderVitaminD/Ca+2supplementation

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Additional Sample Post Fall Assessment Templates Ifpreviousfallinsamequarter,useclinicaljudgementiftotallynewevaluationneeded.ConductaFallRiskScreenwithin4weeksoffallbyKT/OT/PTorPrimaryCareProvider(usingMAHC‐10,STEADI,ormJHFRATtools)

IfMAHC‐10:

CoreElements Yes

Age65yearsandolder

Diagnosis(3ormoreco‐existing)Includesonlydocumentedmedicaldiagnosis

Priorhistoryoffallswithin3months(Anunintentionalchangeinpositionresultingincomingtorestonthegroundoratalowerlevel)

Incontinence(InabilitytomakeittothebathroomorcommodeintimelymannerIncludesfrequency,urgency,and/ornocturia).

Visualimpairment(Includesbutnotlimitedto,maculardegeneration,diabeticretinopathies,visualfieldloss,agerelatedchanges,declineinvisualacuity,accommodation,glaretolerance,depthperception,nightvision,ornotwearingprescribedglassesorhavingthecorrectprescription).

Impairedfunctionalmobility(MayincludepatientswhoneedhelpwithIADLSorADLSorhavegaitortransferproblems,arthritis,pain,fearoffalling,footproblems,impairedsensation,impairedcoordinationorimproperuseofassistivedevices).

Environmentalhazards(Mayincludebutnotlimitedto,poorillumination,equipmenttubing,inappropriatefootwear,pets,hardtoreachitems,floorsurfacesthatareunevenorcluttered,oroutdoorentryandexits).

PolyPharmacy(4ormoreprescriptions–anytype)AllPRESCRIPTIONSincludingprescriptionsforOTCmeds.Drugshighlyassociatedwithfallriskincludebutnotlimitedto,sedatives,anti‐depressants,tranquilizers,narcotics,anti‐hypertensives,cardiacmeds,corticosteroids,anti‐anxietydrugs,anticholinergicdrugs,andhypoglycemicdrugs.

Painaffectingleveloffunction(Painoftenaffectsanindividual’sdesireorabilitytomoveorpaincanbeafactorindepressionorcompliancewithsafetyrecommendations).

Cognitiveimpairment(Couldincludepatientswithdementia,Alzheimer’sorstrokepatientsorpatientswhoareconfused,usepoorjudgment,havedecreasedcomprehension,impulsivity,memorydeficits.Considerpatientsabilitytoadheretotheplanofcare).

Totalpoints:

Ascoreof4ormoreisconsideredatriskforfalling

Ifindicated:Homeevaluationwithin4weeksoffall(byKT/OT/PT).Canbebrief,andindicateonlychangesfrompreviousvisit.

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o Include:poorillumination,equipmentandtubing,inappropriatefootwear,pets,hardtoreachitems,floorsurfacesthatareunevenorcluttered,bathroomsafety,andoutdoorentryandexits.FunctionalityinHomeenvironmentsettingandneededequipmentandadaptiveequipment.

Medicationevaluationwithin1week(bypharmacist)o Highfallriskmedications‐sedatives,anti‐depressants,tranquilizers,

narcotics,anti‐hypertensives,cardiacmeds,corticosteroids,anti‐anxietydrugs,anticholinergicdrugs,hypoglycemicdrugs,etc.

o Highinjuryriskmedications(Steroids,anti‐coagulates,PPI,chemo‐tx.espanti‐androgens,Dilantin,Phenobarbital,Lithium,Heparin,Methotrexate,SSRI,Tamoxifen,ExcessThyroidhormone)

o Roleofnewmedications,addedinthepast3months,infall?Y/N PMHofhigh‐riskdiagnosis(CVA,DM,Neuropathy,Neuromusculardisease,

Parkinson’sDisease,Dementia,Seizures,CAD,DJD,Depression) Eyeexamdate(vision<or=to20/30)‐andhearingassessmentifneeded. Cognitionscreendateandresults(SLUMS,MMSE,etc.) Depressionscreendateandresults(PHQ‐2or9) Osteoporosisevaluation(Riskfactors:ageover50,female,menopause,FMHOP,low

BMI,h/ofractureorheightloss,toandalcoholuse,lowcalciumintake,lowVitaminD,inactivelifestyle,diseasessuchasRA,IBDandDM,medications,Dexascan,FRAXscore,labs)

Nocturiaevaluation CardiologyROSandexam(Especiallyfororthostaticvitals,syncopeandarrhythmia) Painevaluation(Painscale) Neurologicalevaluation(includingposturalinstability,bruit,CNII‐X,weakness,

proprioception,sensation) Muscular‐SkeletalandGaitandBalanceEvaluation(TUG:12secondcutoff,4stage

balance,30secchairstands,assistivedeviceevaluation,jointlimitations) Assessment:

o H/oFalldueto(IntrinsicandExtrinsicriskfactorsorHELP) Interventions:

o Homeevaluationo Exerciserecommendationso LimitComorbidityimpacto Applicablecomponentsoffallassessmentandinitialpostfallnotification

noteo Comorbidityburdentreatmentmaximization(Example:Assistivedeviceuse,

Footwearadvice,EyeClinicconsult,Alcoholconsumptiono PharmacyMedicationassessmentforfallriskandinjuryrisk(Medication

safety/anticoagulation)o Education:CosignMentalHealthifneeded,suchasOsteoporosiseducation,

Exercisehandoutslikesittostand,Safefallrecovery,PosturalHypotensioninformation(drinkfluids,anklepumps/handclenchesforaminutepriortostanding,donotwalkifdizzy)

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o UseMotivationInterviewingandStagesofChangeModel(ProchaskaAmJHealthPromot1997;12(1):38‐48. Pre‐contemplativeStage(Downplayspersonalsusceptibility) ContemplativeStage(Weighsbenefitsvs.costsofbehaviorchange) PreparationStage(Experimentswithsmallchanges) ActionStage(Takesdefinitiveactiontochange) MaintenanceStage(Maintainsnewbehaviorovertime)

Reporting:o AddHistoryofFalltoproblemlisto ReporteachfallindividuallyonthePostFallNotificationTemplateand

cosigntoteammembersandfallcoordinator.

4.ReferencesandWebsitesforfurtherinformationThe American Geriatrics Society/British Geriatrics Society. (2010) AGS/BGS clinical practice guideline:

Prevention of falls in older persons. Retrieved from:

www.americangeriatrics.org/education/prevention _of_falls.shtml

Calys, M, Gagnon K, Jernigan S. (2012). A validation study of the Missouri alliance for homecare fall risk

assessment tool. Home Practice Care Management. doi: 10.1177/1084822312457942.

Centers for Disease Control. (2017). CDC STEADI Program for Falls Prevention. Atlanta, GA: Author.

Retrieved from: http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

Chandler J, Duncan P, Weiner D, Studenski S. (2001). Special feature: The Home Assessment Profile‐A

reliable and valid assessment tool. Topics in Geriatric Rehabilitation. 16(3):77–88.

Cooper B, Letts L, Rigby P, Stewart D, Strong S (2005). Measuring environmental factors. In M. Law, C

Baum & W Dunn (Eds.), measuring occupational performance: Supporting best practice in

occupational therapy (2nd ed., pp. 326–327). Thorofare, NJ: Slack.

Cumming, R. G., Thomas, M., Szonyi, G., Frampton, G., Salkeld, G., & Clemson, L. (2001). Adherence to

occupational therapist recommendations for home modifications for fall prevention. American

Journal of Occupational Therapy, 55(6), 641–648.

Cwikel, JG, Fried V, Biderman A, Galinsky D. (1988). Validation of a fall‐risk screening test, the Elderly Fall

Screening Test (EFST) for community‐dwelling elderly. Disabil Rehabil, 20(5): 161–167.

Flemming, P. (2006). Utilization of a Screening Tool to Identify Homebound Older Adults at Risk for Falls:

Validity and Reliability. Home Health Care Services Quarterly, Vol. 25(3/4).

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Flores, E. Falls Risk Assessment and Modification. Home Health Care Management & Practice 24(4),

198–204. 2012 Sage Publications.

Gillespie, L.D., Robertson, M.C.,W.J., Sherington, C., Gates, S., Clemson, L.M., & Lamb, S. E. (2012).

Interventions for preventing falls in older people living in the community. Cochrane Database of

Systematic Review, 9, CD007146. doi:10.1002/14651858.CD007146.pub3

Hnizdo S., Archuleta RA., Taylor B., Kim SC. (2013). Validity and Reliability of the Modified John Hopkins

Fall Risk Assessment Tool for elderly patients in home health care. Geriatr Nurs 34(5):423‐7.

doi:10.1016/j.gerinurse.2013.05.011.

Johnson M, Cusick A, Chang S (2001). Home‐screen: A short scale to measure fall risk in the home. Public

Health Nursing, 18(3), 169–177.

Mackenzie L, Byles J, Higginbotham N (2002). Reliability of the Home Falls and Accidents Screening Tool

(HOME FAST) for identifying older people at increased risk of falls. Disability & Rehabilitation 24(5);

266–274.

Minnesota Safety Council. Fall Prevention Checklist‐Personal Risk Factors.

http://www.fallpreventiontaskforce.org/documents/PersonalRiskFactorsChecklist.pdf

Moyer, V. A. (2012). Prevention of falls in community‐dwelling older adults: U.S Preventive Services.

Annals of Internal Medicine, 157, 815–825.

Tromp M, Pluijm S, Smit J, Deeg D, Bouter L, Lips P (2001). Fall‐risk screening test: A prospective study

on predictors for falls in community‐dwelling elderly. Journal of Clinical Epidemiology, 54, 837–844.

Websites for further information:

National Patient Safety Goal #9

www.jointcommission.org/standards_information/npsgs/aspx

Implementation Guide for Fall Injury Reduction

VA National Center for Patient Safety: Reducing Preventable Falls and Fall‐Related Injuries (2015). Neily,

J., Quigley, P.A., Essen, K.

https://www.patientsafety.va.gov/docs/fallstoolkit14/falls_implementation_%20guide%20_02_2015.pd

f

AGS/BGS 2010 Clinical Practice Guideline

https://www.aafp.org/afp/2010/0701/p81.pdf

http://www.alabmed.com/uploadfile/2014/0504/20140504033204923.pdf

CDC STEADI

https://www.cdc.gov/steadi/

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• Timed Up and Go (recommended) https://www.cdc.gov/steadi/pdf/STEADI‐Assessment‐TUG‐

508.pdf

• 30 sec Chair stand test (optional) https://www.cdc.gov/steadi/pdf/STEADI‐Assessment‐30Sec‐

508.pdf

• 4 stage Balance Test (optional) https://www.cdc.gov/steadi/pdf/STEADI‐Assessment‐4Stage‐

508.pdf

• Data sheets and instruction for performance of orthostatic

https://www.cdc.gov/steadi/pdf/STEADI‐Assessment‐MeasuringBP‐508.pdf

• Data sheets and instruction for performance of functional measures

https://www.cdc.gov/steadi/materials.html

• Integrating fall prevention practice handout that links specific risk factor

assessment to targeted intervention https://www.cdc.gov/steadi/pdf/STEADI‐Algorithm‐508.pdf

• Handouts pertaining to fall risk factors and medications https://www.cdc.gov/steadi/materials.html

CDC Checklist

https://www.cdc.gov/steadi/pdf/STEADI‐Form‐RiskFactorsCk‐508.pdf

Home safety

https://www.cdc.gov/steadi/pdf/check_for_safety_brochure‐a.pdf

Personal Risk Factors Fall Prevention Checklist

CDC Checklist: https://www.cdc.gov/steadi/pdf/STEADI‐Form‐RiskFactorsCk‐508.pdf

WHO Fracture Risk Assessment Tool (FRAX)

https://www.sheffield.ac.uk/FRAX/tool.jsp

ABCS Injury Risk (validated for hospitals)

www.hret‐hiin.org/resources/display/abcs‐injury‐risk‐assessment

Motivational Interviewing

www.motivationalinterviewing.org

MotivationInterviewingandStagesofChangeModel(Prochaska)AmJHealthPromot1997;12(1):38‐48.

Minnesota Safety Council. Fall Prevention Checklist‐Personal Risk Factors

http://www.minnesotasafetycouncil.org/seniorsafe/falls/

http://www.fallpreventiontaskforce.org/documents/PersonalRiskFactorsChecklist.pdf

Pighills, A. C., Torgerson, D.J., Sheldon, T.A., Drummond, A. E., Bland, J.M. (2011). Environmental

Assessment and Modification to Prevent Falls in Older People. Journal of the American Geriatrics

Society, 59(1),26‐33. https://doi.org/10.1111/j.1532‐5415.2010.03221.x

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Standardized and Validated Multi‐Factorial Fall Risk Assessment Screening Tools for Home Bound

Patients

MAHC‐10: Missouri Alliance for HomeCare Fall Risk Assessment

https://www.homecaremissouri.org/projects/falls/documents/Oct2012FINALValidatedFallriskassessme

nttool.pdf

Calys, M, Gagnon K, Jernigan S. (2012). A validation study of the Missouri alliance for homecare fall risk

assessment tool. Home Practice Care Management. doi: 10.1177/1084822312457942.

Johns Hopkins Fall Risk Assessment Tool (not Modified)

https://www.hopkinsmedicine.org/institute_nursing/models_tools/JHFRAT_acute%20care%20original_

6_22_17.pdf

EFST‐Elderly Falls Screening Test

https://www.tandfonline.com/doi/pdf/10.3109/09638289809166077

Cwikel, JG, Fried V, Biderman A, Galinsky D. (1988). Validation of a fall‐risk screening test, the Elderly Fall

Screening Test (EFST) for community‐dwelling elderly. Disabil Rehabil, 20(5): 161‐167.

Comprehensive Falls Risk Screening Instrument

https://www.researchgate.net/publication/228789786_Development_and_Validation_of_the_Compreh

ensive_Falls_Risk_Screening_Instrument

Fabre J, Elli R, Kosma M, Moore D, McCarter K, Wood R. (2010). Development and Validation of the

Comprehensive Falls Risk Screening Instrument. Physical and Occupational Therapy in Geriatrics, 28(2):

181‐194.

Fall‐Risk Screening Test

https://ac.els‐cdn.com/S0895435601003493/1‐s2.0‐S0895435601003493‐main.pdf?_tid=247df818‐

4c28‐4c7d‐9072‐ec7f9c2d920b&acdnat=1532542590_4c7bf5b419a1ebcc715834c5bba35688

Tromp M, Pluijm S, Smit J, Deeg D, Bouter L, Lips P (2001). Fall‐risk screening test: A prospective study

on predictors for falls in community‐dwelling elderly. Journal of Clinical Epidemiology, 54, 837‐844.

Home Assessments

Home Assessment Profile (HAP)

Chandler J, Duncan P, Weiner D, Studenski S. (2001). Special feature: The Home Assessment Profile‐A

reliable and valid assessment tool. Topics in Geriatric Rehabilitation. 16(3):77‐88.

HOME FAST

Mackenzie L, Byles J, Higginbotham N (2002). Reliability of the Home Falls and Accidents Screening Tool

(HOME FAST) for identifying older people at increased risk of falls. Disability & Rehabilitation 24(5); 266‐

274.

Home‐screen Scale

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Johnson M, Cusick A, Chang S (2001). Home‐screen: A short scale to measure fall risk in the home. Public

Health Nursing. 18(3), 169‐177.

Westmead Home Safety Assessment

Cooper B, Letts L, Rigby P, Stewart D, Strong S (2005). Measuring environmental factors. In M. Law, C

Baum & W Dunn (Eds.), measuring occupational performance: Supporting best practice in occupational

therapy (2nd ed., pp. 326‐327). Thorofare, NJ: Slack.

The National Quality Forum “Falls: Screening, Risk‐Assessment, and Plan of Care to Prevent Future

Falls”. STEWARD: National Committee for Quality Assurance. This was originally endorsed in 2009 by

NQF and re‐endorsed in 2012, and is currently updating it as of August 14, 2018, specific for patients 65

and older. Website link: https://www.qualityforum.org/Home.aspx

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