Strategies and Actions
for Independent
Living©
Training Manual for CHW/HHPs
Lead author: Vicky Scott, PhD, RN
SEPTEMBER 2012
GUIDE TO
TAB DIVIDERS
Introduction
Lesson 1:
Scope and Nature of the Problem
Lesson 2:
Fall Risk Factors
Lesson 3:
Best Practices for Prevention
Lesson 4:
Putting It All Together:
4 (a) The Role of the CHW
4 (b) The Role of the HHP
Glossary
References
Appendices
July 2012
Strategies and Actions for Independent Living©
LIST OF APPENDICES
starting page 117
Appendix A:
FALL REPORT AND CALENDAR
Appendix B:
CHECKLIST AND ACTION PLAN
Appendix C:
SAIL HOME ACTIVITY PROGRAM (HAP)
Appendix D:
STEPS FOR IMPLEMENTING SAIL FOR THE CHW
How to introduce the SAIL
Package to Your Client
Appendix E: SAIL FALL PREVENTION
GUIDELINES FOR HHP
Steps for the HHP on Developing, Implementing
& Evaluating Individualized Fall Prevention Plans
Appendix F: PRINTABLE SAIL TOOLS
Fall Report, Calendar, Checklist and Action Plan,
SAIL HAP Program (Moving, Standing, Sitting),
HAP Tracker
2
INTRODUCTION
COURSE OVERVIEW
WELCOME to a unique course designed for community health workers
and home health professionals designed to help prevent falls among
seniors and persons with disabilities who live in their own homes and
receive home support services.
The information in this reference manual will build on your previous
training, skills and experience in caring for clients in the community.
The intent is to integrate this new learning about fall prevention into
regular, ongoing care for clients. The course promotes a team
approach and emphasizes your ability to communicate effectively with
your clients, caregivers and other team members.
LEARNING OBJECTIVES
Course Goals
The goal of this course is to increase your skills in understanding why
some people are at greater risk for falls than others and ways to
reduce the risk of falls and fall-related injuries among your clients.
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Strategies and Actions for Independent Living©
4
ACKNOWLEDGEMENTS
Lead author: Vicky Scott, PhD, RN (PI)
Senior Advisor on Falls & Injury Prevention, BCIRPU
With thanks to the following for their assistance:
Bonnie Fiala for her work on the data, charts and editing,
Yasmin Yassin for her work on the formatting and
editing, Kate Milne for her work on the integration of
new material, Lynnda Swan and Anne Higginson for
their work on clinical expert content and synthesis of
feedback from their respective clinical advisory groups.
Thanks also to those who worked on the earlier version of
the SAIL manual, including Hansdeep Bawa, Kristine
Votova, Elaine Gallagher and Bronwen Duncan and
the SAIL review team from across the five B.C. health
authorities.
Funding for the development of the new SAIL program
was provide by the Ministry of Health and the Centre of
Excellence in Mobility, Fall Prevention and Injury in
Aging .
Recommended citation:
Scott, V. (2012). Strategies and Actions for Independent
Living (SAIL) Manual. Vancouver, BC: BC Injury
Research and Prevention Unit.
5
Strategies and Actions for Independent Living©
Copyright
These materials are copyright protected and cannot be used within
British Columbia (B.C.), Canada, without written permission from
the SAIL Project Manager at the B.C. Injury Research and
Prevention Unit at www.injuryresearch.bc.ca. Use of these
materials outside of B.C. requires the written permission of the lead
author, Vicky Scott, PhD, RN., at: [email protected] or
[email protected].
Limitation of Liability
In no event shall the authors, the British Columbia Injury Research
and Prevention Unit, its partners, directors, employees, agents or
licensors be liable for damages of any kind arising from the use of
the information in the manual.
Disclaimer of Warranties
Information and content are provided “as is.” While we endeavour
to provide content that is correct, accurate and timely, we can not
guarantee applicability in all cases. By using the manual, the user
acknowledges and agrees that he or she is using the manual at their
own risk and liability.
For More Information
Contact the Strategies and Actions for Independent Living©
coordinator through the British Columbia Injury and Research
Prevention Unit:
Phone: 604 875-3776
Email: [email protected]
Website: www.injuryresearch.bc.ca
6
TABLE OF CONTENTS
INTRODUCTION
Course Objectives
SAIL Background
SAIL 2 Findings
SAIL Components
LESSON 1: SCOPE & NATURE OF THE PROBLEM
Defining a Fall
Fall Facts
The Impact of Population Trends
The Cost of Falls
LESSON 2: FALL RISK FACTORS
Biological Fall Risk Factors
Behavioural Fall Risk Factors
Socioeconomic Fall Risk Factors
Environmental Fall Risk Factors
LESSON 3: BEST PRACTICES FOR PREVENTION
Current Research Findings
A Comprehensive Fall Prevention Model
Behavior Change
Education
Equipment
Environment
Activity—Physical and Social
Clothing and Footwear
Health Management
LESSON 4: PUTTING IT ALL TOGETHER
The CHW Role
The HHP Role
Role of Regional Protocols
Conclusion
GLOSSARY
REFERENCES
APPENDICES (see listing on next page)
7
7
8
11
16
19
20
20
21
25
27
30
37
41
45
51
53
54
55
64
65
70
74
77
78
87
87
99
108
109
111
113
117
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Strategies and Actions for Independent Living©
INTRODUCTION
COURSE OBJECTIVES
There are three key learning objectives for this course
1. To learn more about why people fall
2. To learn more about what can be done to
prevent falls and fall-related injuries
3. To learn more about your role in preventing falls
and injuries with your clients
8
Introduction—SAIL Background
SAIL BACKGROUND
Strategies and Actions for Independent Living (SAIL) is designed to
promote the safety and independence of older people or adults with
disabilities living in the community receiving home support services.
Services are provided through a team approach between home health
professionals and community health workers in the identification and
reduction of risks that contribute to falls and related injuries.
This is a new approach to fall prevention that actively involves the
home health professional, the community health worker and the client
as partners in the fall prevention process. The content and tools of
the SAIL program were developed over a number of years with the
help of many people in B.C. who receive home support and who
provide home support services. This program is designed by them to
be integrated into normal service delivery with the goal of enhancing
the quality of care and is endorsed by the Home and Community Care
Directors of B.C. (Dec. 15, 2006).
SAIL Phase 1 – Pilot
Study
Phase 1 of the SAIL program began in 2004 with a pilot study
involving 70 clients who were free of cognitive problems and were
receiving publicly funded home support services in three communities
in B.C. (Victoria, 100 Mile House and Castlegar). Findings showed
that, compared to the six months prior to the intervention, there was
a three per cent reduction in the number of falls and a 44 per cent
reduction in the number of clients who fell once or more (Scott,
Votova & Gallagher, 2006).
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Strategies and Actions for Independent Living©
SAIL Phase 2 –
Controlled Trial
Phase 2 of SAIL consisted of a controlled trial over six months in
2005 with over 200 clients, including those with cognitive
limitations, at two health units in the Central Okanagan. One site
was the control site (where staff had training in using the Fall Report
form, but no specific fall prevention training), and the other site was
the intervention site (where staff received SAIL fall prevention
training and implemented prevention protocols such as the Checklist
and Action Plan as well as the Fall Report form).
SAIL Phase 3 Provincial
Collaboration
SAIL 3 involved a collaborative effort by the B.C. Injury Research
and Prevention Unit research team and partners in each of the B.C.
Regional Health Authorities. This phase focused on applying the
learning from SAIL 1 and 2, selecting core components for
application across B.C. and to adapt aspects that are unique to
specific regions. This manual reflects the results of this work.
SAIL Phase 4 Provincial
Dissemination
Phase 4 took place between October 2007 and September 2008. It
involved a detailed analysis and recommendations based on learning
from SAIL 3, followed by an implementation phase to roll out SAIL
across all health regions in British Columbia.
As of January 2012, the SAIL program has been successfully
implemented in all of the regional health authorities and each region
has implemented the program and its core components to differing
degrees. A provincial evaluation plan has been proposed to
determine how best to foster widespread implementation.
10
Introduction—SAIL 2 Findings
SAIL 2 FINDINGS
The following are highlights from the findings of the SAIL 2 study
and how they relate to the final SAIL program. A full report of the
SAIL 2 findings can be accessed by contacting the B.C. Injury
Research and Prevention Unit.
Descriptive Findings
•
A total of 220 clients across two sites participated in the SAIL
study
•
A total of 85 clients (39 per cent) clients had a one or more falls.
Of these, 59 clients fell once and 26 clients had a recurrent fall.
•
Over the course of the SAIL study, there were a total of 142
falls. Of these falls, a total of 110 (77 per cent) resulted in some
injury to the client. Thirty-six falls (25 per cent) resulted in a
severe injury leading to a visit to a doctor or emergency
department.
•
78 per cent of all falls were unobserved.
Location of fall: As shown in Figure 1, 82 per cent of the falls
occurred inside the client’s home. The highest proportion of the
falls inside the home occurred in client’s bedroom (32 per cent),
followed by living room (15 per cent), and bathroom (13 per cent).
11
Strategies and Actions for Independent Living©
Figure 1
Time of fall: As shown in Figure 2 below, 37 per cent (N=52) of falls occurred in the morning
between 7 am and noon, 28 per cent (N=39) in the afternoon between noon and 5 pm, 27 per cent
(N=37) in the evening between 5 pm and 10 pm, and 11 per cent (N=11) at night between 10 pm
and 7 am.
Figure 2
12
Introduction—SAIL 2 Findings
Fall-related injuries: As shown in Figure 3 below, 77 per cent of all falls resulted in an
injury. The top three reported injuries due to falls were bruises/abrasion, cuts/scrapes, and
sprain/strain dislocation.
Figure 3
Intervention
Findings
Following the six-months of interventions, findings of the SAIL 2
study showed a downward trend in falls, fall-related injuries and fall
risk factors among clients in the intervention group compared to the
control group. Among the intervention group, there was a statistically
significant 42 per cent decrease in the rate of falls from the first three
months of the study compared to the second three months in the
intervention group and a non-significant decline of 3 per cent in the
control group.
Over the six month intervention, control clients showed significant
declines in mobility and function compared to the intervention group.
This was shown by increased Timed Up and Go assessment scores,
and the need for assistance with a number of activities of daily living
and instrumental activities of daily living functions, including dressing,
personal hygiene, bathing, meal preparation, housework, managing
finances, managing medications, shopping and transportation.
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Strategies and Actions for Independent Living©
Community health workers (CHWs) reported greater job
satisfaction and an increased sense of being a part of a team due to
the development of new skills which help make a difference in a
client’s health and wellbeing. In addition, home health professionals
reported an increased appreciation for CHWs as vital members of
the team.
Focus Group
Findings
What CHWs have to say about SAIL:
“I liked the wellness approach. Not just focusing on taking
care of people because they were sick. “
“It is great to being able to help prevent falls and assist our
clients.”
“We are better aware of all the situations in a home that
may cause a fall.”
What home health professionals have to say about SAIL:
“The CHWs felt more important, more empowered. We
have not used them enough. This really showed they
are capable of doing a lot more than we gave them
credit for.”
“My clients have really benefited from the SAIL project –
the extra teaching and support and the
recommendations. “
What clients have to say about SAIL:
“I have learned to stop and think before I take action. “
“I now attend exercise classes. The whole concept seems
to be an excellent one.”
“Because of this program, I had a couple of poles installed,
one by the bed and one in the bathroom. Before that, I
fell getting out of bed. They have been very
successful.”
14
Introduction—SAIL 2 Findings
Implications
Implications of these findings are that falls are a common occurrence
among home support clients, and that the majority of falls result in
some type of injury. The fact that most falls were found to be
unobserved, points to the importance of interviewing clients about
the details of each fall to help determine the contributing causes.
Using the SAIL Fall Report to capture such details, we know that the
most common location for falls in the home is the bedroom and the
most common time of day is the morning. Knowing these, and the
many other facts captured by the Fall Report, helps to tailor
interventions to the specific contributing factors. For example, SAIL
2 findings also show that of those clients who had a fall, 30 per cent
had multiple falls. Details of these findings provide valuable
information necessary to implementing tailored prevention plans for
these individuals.
SAIL Pilot Study
The SAIL intervention findings show that the SAIL program was
successful in reducing falls, injuries and in helping to maintain clients’
mobility and physical well-being. SAIL 2 findings demonstrate that
SAIL interventions work, that staff job satisfaction increases, and that
clients benefit. The essential components of these interventions are
the SAIL staff training and use of the SAIL Fall Report, client
calendar, Checklist and Action Plan and the SAIL Home Activity
Program.
15
Strategies and Actions for Independent Living©
SAIL COMPONENTS
The SAIL program consists of the following key components:
1. Staff Training ‒ Includes use of an online course, this
reference manual and power-point presentations for:
•
community health workers
•
home health professionals
A facilitator’s manual is also provided
2. Client Calendar (see Appendix A)
3. Fall Report Form & Database (see Appendix A)
4. Checklist and Action Plan (see Appendix B)
5. SAIL Home Activity Program ‒ For eligible clients
(see Appendix C)
The SAIL program is implemented and evaluated through regional
protocols.
16
Introduction—SAIL Components
SAIL Program
Participants
This manual is designed for community health workers (CHWs),
who are defined here as unregulated care providers who provide
services such as personal care assistance, mobility assistance and
assistance with meal preparation through publicly funded home
support agencies or services; and home health professionals
(HHPs), defined here as nurses, physiotherapists and occupational
therapists who work in home and community care programs such as
home care nursing, long term care case management, and
community rehabilitation services. It also includes home support
administrators such as managers, supervisors and coordinators.
There may be different titles in different health regions to describe
HHPs.
Home support clients are defined here as those who receive
publicly funded home support services on a routine basis through
the case management program.
SAIL Participant Roles
Community health workers: Roles are crucial day-to-day client
interaction and observation, with ongoing team communication and
reporting.
Home health professionals: Roles include screening and followup for all clients, with focus on high risk fallers. Case manager also
provides leadership and coordination of the team.
SAIL clients: Roles include recording and reporting falls,
interacting with staff to identify fall risk, and choosing actions to
reduce risk.
17
Strategies and Actions for Independent Living©
18
LESSON 1 SCOPE & NATURE OF THE PROBLEM
Learning Objectives for Lesson 1
To increase your understanding of the scope
and nature of the problem of falls among
older persons in B.C., including:
1. Defining a fall
2. Facts on falling
3. The impact of population trends
4. The cost of falls
19
Strategies and Actions for Independent Living©
DEFINING A FALL
When discussing falls, it is important to have a common
understanding as to what constitutes a fall. The definition applied
here comes from an internationally accepted definition of a fall as
"unintentionally coming to rest on the ground, floor or other lower
level, whether or not the faller is injured."
FALL FACTS
•
•
•
A fall is
defined as
unintentionally
coming to rest
on the ground,
floor or other
lower level,
whether or not
the faller is
injured.
20
•
•
•
•
•
Falls account for more than half of all injuries
resulting in hospitalization and are the leading cause
of injury among seniors (65+) in British Columbia.
Almost half of those who fall experience a minor
injury and between 5 and 25 per cent suffer from
more serious injury, such as a fracture or a sprain.
Fall-related injury rates are nine times higher among
those aged 65 years and older compared to those
less than 65 years of age.
Falls cause more than 95 per cent of hip fractures
among persons aged 65 years and older and
20 per cent die within a year of their fracture.
Families of older persons are often unable to
provide the care needed after a fall, and 40 per cent
of nursing home admissions are due to a fall.
Even without an injury, a fall can cause a loss in
confidence and a curtailment of activities, which can
lead to a decline in health and function and
contribute to future falls with more serious
outcomes.
40 per cent of long-term care admissions are fall-related.
Most falls occur in seniors’ own homes, while
doing normal daily activities. Falls usually happen
due to the combined effects of multiple factors.
Lesson 1: Scope and Nature of the Problem—Impact of Population Trends
IMPACT OF POPULATION TRENDS
Figure 4 shows the rapid increase of people in B.C. aged 65 years and older by age group,
with the greatest change occurring among those aged 85 years and older. This is of particular
concern as this age group has the highest incidence of falls and injuries from falls.
Figure 4
21
Strategies and Actions for Independent Living©
To understand how big the problem is, it is important to know how
many older people fall, and how many are injured or die from a fall.
However, it is often difficult to get this information. Our best
sources are from hospital admissions and death records. What is
missing is data on the number of people who get treatment for
injuries from falls at emergency departments, doctors offices, clinics,
or the number who are treated at home or not treated. We do know
that the majority of falls and fall related injuries are treated at home
or not treated at all, as shown in Figure 5. We also know that for
every death that results from a fall for persons aged 65 years and
older, there are approximately 34 hospital admissions and 56
emergency visits for people treated and released (Scott, Peck &
Kendall, 2004).
In 2009 alone, 950 British Columbian seniors died either directly or
indirectly from a fall, with the highest direct death rates among those
aged 85 years and older. There has been a significant decrease in the
rate of deaths due to falls over the past ten years, which coincides
with the increase in fall prevention programming in B.C., as
demonstrated through a recent scan by the Public Health Agency of
Canada (Scott et al., 2011) that reports an increase of 150 per cent in
the number of fall prevention programs between 2001 and 2010.
Figure 5
FALL INJURY PYRAMID
DEATHS
DEATHS
HOSPITALIZATIONS
HOSPITALIZATIONS
TREATED IN EMERGENCY
TREATED
IN DOCTORS
’ OFFICES OR CLINICS
TREATED
IN DOCTORS’
TREATED
AT AT
HOME
OROR
NOT
TREATED
TREATED
HOME
NOT
TREATED
22
Lesson 1: Scope and Nature of the Problem
Death rates also differ among B.C. health authorities as shown in Figure 6, with the highest
rates occurring in Northern Health and the lowest in Vancouver Coastal Health.
Figure 6
Falls were either the primary cause or a secondary contributing cause for 12,006 hospital
separations (cases) in 2009/2010 for seniors (65+) in British Columbia. This number has been
steadily increasing over the past decade – from 9395 cases recorded in 2000/2001 (see Figure 7),
and likely reflects the increasing number of seniors in the province. Hip fractures account for
approximately 40 per cent of fall-related hospital cases in British Columbia. The good news is
the rate of fall related hip fractures among seniors has significantly decreased over the nine year
period between 2001/02 and 2009/10. This may reflect the increase and effectiveness of the fall
prevention programs in this province.
23
Strategies and Actions for Independent Living©
Figure 7
The proportion of seniors (per 1,000 population) who are hospitalized for falls in B.C. differs
considerably by regional health authorities and local health service delivery area. As shown in
Figure 8, Northern Health has the highest rates, with Fraser Health, Vancouver Island Health
Authority and Vancouver Coastal Health showing the lowest rates.
Figure 8
24
Lesson 1: Scope and Nature of the Problem
THE COST OF FALLS
Over 195 million dollars in direct health care costs were spent in 2009/10 in B.C. related to medical
treatment, hospital stay and rehabilitation for fall-related injuries among seniors aged 65 and over.
This amount is increasing annually. Fall-related injuries account for 85 per cent of the total costs
for all causes of injury among seniors. (Smartrisk, 2001).
Figure 9
25
Strategies and Actions for Independent Living©
Other Costs Associated
With Falls
26
There are other costs that result from falls and fall-related injuries
among the older people that are more important than the direct
financial costs to the health care system. These include:
√
Pain and suffering for the person who fell.
√
Permanent disability or death.
√
Fear of falling and a lack of confidence.
√
Greater dependence on others for assistance in daily
activities.
√
Reduced quality of life.
√
Increased burden of care-giving for family and other
caregivers.
√
Loss or limitation of relationships for extended family and
friends (grandchild loses a grandparent, daughter loses a
mom, wife loses her spouse).
√
Loss of work time and/or decreased productivity at work
for the informal caregiver.
√
Increased workloads and costs related to treating
musculoskeletal injuries to health care providers caring for
injured seniors.
LESSON 2
FALL RISK FACTORS
Learning Objectives for Lesson 2
To understand why some older people fall
and others do not for the following groups
of factors:
· Biological
· Behavioural
· Socioeconomic
· Environmental
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Strategies and Actions for Independent Living©
Most falls are both predicable and preventable. This section covers
reasons why people fall. The term risk factor is used to describe
something that has been shown through research to be associated
with an event, such as falling. Older people who have fallen recently
are likely to fall again. Therefore, having a fall is a risk factor for
having another fall.
Some risk factors cannot be changed – such as one’s age or gender.
However, other risk factors, such as having poor balance or muscle
weakness, have been shown to be changeable through exercise
programs. In many cases, these changes have resulted in significant
reductions in falls.
Not all risk factors apply to all clients, nor will they apply in the
same way. The combination of factors will differ between
individuals because each person has a different life circumstance.
We know that when clients have more than one risk factor their risk
for falling increases.
Having two risk
factors does not
just double the
risk—it can
increase the risk
by four times or
more.
Risk factors for falls and fall-related injuries among older persons
and seniors can be grouped into the following four categories (also
shortened to BBSE):
BIOLOGICAL
BEHAVIOURAL
SOCIOECONOMIC
ENVIRONMENTAL
28
Lesson 2: Fall Risk Factors—Biological
BIOLOGICAL RISK FACTORS
The biological risk factors include those factors that have to do with
the human body and are related to the natural aging process as well
as the effects of chronic (long term) and acute (short term) or
palliative (end of life) health conditions.
It is important to remember that seniors with multiple health
problems are at greater risk of falling and having an injury. And, it is
most often the combination of biological risk factors together with
behavioral, socioeconomic and environmental risk factors that result
in a fall.
29
Strategies and Actions for Independent Living©
BIOLOGICAL FALL RISK
FACTORS
•
FEMALE GENDER
•
ADVANCED AGE
•
CHRONIC ILLNESS/DISABILITY
•
•
•
•
•
•
COGNITIVE IMPAIRMENT
•
SIDE EFFECTS OF MEDICATIONS
•
DIZZINESS
•
BOWEL/BLADDER PROBLEMS
•
ACUTE ILLNESS OR PAIN
•
NEURO-MUSCULAR CHANGES
•
•
•
•
•
Gait disorders
Poor balance
Diminished muscle strength
Limited range of motion of joint(s) of lower
extremity, esp. the ankle
Spinal deformities, e.g., kyphosis, scoliosis
•
MULTIPLE FOOT DISORDERS – ULCERS,
BUNIONS, INGROWN TOENAILS, ETC.
•
SENSORY CHANGES
•
•
•
•
30
Stroke
Parkinson’s disease
Cardiovascular disease
Osteoporosis
Arthritis
Visual impairment
Reduced hearing
Diminished touch sensation
Poor proprioception
Lesson 2: Fall Risk Factors—Biological
Female Gender
More women than men fall and are injured as a result of a fall (Scott,
Peck & Kendall, 2004). However, men tend to have more serious
injuries, likely because they are more likely to take part in high risk
behaviours, such as climbing ladders.
Advanced age
On average, one in every three seniors will fall at least once each year.
This number increases to one in every two seniors for those who are
80 years or older (Tinetti et al., 1997). As we age there are many
changes that we all go through that increase our risk of falling. These
include reduced vision, decreased sensation in our feet to detect
uneven surfaces, reduced hearing, loss of muscle mass and slower
reaction times. Cognitive changes found among many older persons
further compromise balance by interfering with the ability to respond
quickly to changes in the environment. These changes are found in
approximately 50 per cent of those over the age of 80 years and affect
an older persons ability to anticipate and adapt to changes in their
environment that involve movement (Rose, 2003).
Chronic Illness/
Disability
With advanced age also comes an increase in risk for chronic illness
and disability, such as heart problems or osteoporosis (weak bones).
Having a chronic disease increases the risk of falling and this risk
increases with each additional chronic disease the senior may have
(Fortin et al., 1998; Winslow & Jacobson, 1998).
Stroke: Approximately 40 per cent of those who have a stroke fall
within the first year (Jørgensen, Engstad et al., 2002). Falls among
people who have had a stroke typically occur towards their weaker
side, and those who have had a stroke are up to four times more
likely to fracture a hip when they fall (Lamb et al., 2003).
31
Strategies and Actions for Independent Living©
Parkinson’s disease: People with Parkinson’s disease have an
increased risk for falls due to problems with walking, such as
“freezing” and being unsteady on their feet. They are also almost
twice as likely suffer a fracture during a fall compared to other
seniors. Two studies found over 60 per cent of people with
Parkinson’s disease fell within a one-year period (Wood et al., 2002;
Ashburn et al., 2001). Also, the risk of a fracture from a fall when
the person has Parkinson’s disease is about twice that of other
seniors who don’t have Parkinson’s disease (Genever, 2005).
Cardiovascular disease: Cardiovascular diseases (heart and blood
pressure problems) are often associated with dizziness and a higher
risk of falling (Crilley et al., 1997; Dey, Stout & Kenny, 1997). This
usually happens when a person with low blood pressure stands
quickly, causing a temporary reduction in blood supply to the brain
and lack of oxygen that is carried by the blood. This leads to a
feeling of being ‘light-headed’ or dizzy. Other disorders which cause
irregular or brief stoppages in the beating of the heart (e.g., cardiac
arrhythmias) also contribute to fall risk. People who fall due to
cardiovascular disease are more likely to die from the fall than those
who fall from other causes (Carey et al., 2001). This may be due to
the suddenness of the fall, resulting in serious injury.
Osteoporosis (poor bone strength): People with osteoporosis are
at greater risk for fracturing a bone due to a fall. A Canadian study
found that a year after sustaining a low trauma fracture, less than 20
per cent of these people had been diagnosed or treated for
osteoporosis (Lord et al., 2003). As more older women have
osteoporosis than men, women tend to break bones more often.
Anyone who has had a fracture from a fall that did not involve
falling from a height (e.g., fell while getting out of a chair or
standing on ground level) should be assessed and treated for
osteoporosis.
32
Lesson 2: Fall Risk Factors—Biological
Arthritis: People with arthritis in their legs have been shown to
have an increased risk for falling and being injured from a fall
(Sturnieks et al 2004). People with arthritis are also at greater risk for
loosing their balance with trying to open doors that are heavy or
difficult to open.
Cognitive Impairment
The risk of falling and sustaining a fall injury is almost twice as high
among individuals with dementia or other cognitive disorders,
compared to seniors without cognitive disorders (American
Geriatrics Society et al., 2001). People with dementia also have
slower reactions to regain balance and prevent a fall (Hauer et al.,
2003).
Side Effects of
Medications
These symptoms may be made worse by the side effects of
medications taken to manage behaviour problems that accompany
many dementias. Taking four or more prescription medications
significantly increases the risk of falling and this risk increases even
more if the person is taking medications such as sleeping pills,
tranquilizers or sedatives (Monane et al., 1996).
Dizziness
Approximately one third of falls among older persons and seniors
are related to some form of dizziness (Dewane, 1995). In addition to
dizziness from cardiovascular disease, there are a number of other
causes of dizziness, including dehydration and the side effects from
medications.
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Strategies and Actions for Independent Living©
Bowel & Bladder
Problems
Acute Illness or Pain
Neuro-Muscular
Changes
34
Bladder and bowel problems include incontinence (inability to
control the bladder), urgency (the urge to void quickly), frequency
(the need to void often), and infections such as urinary tract
infections (Tromp, 2001). These conditions can lead to a person
falling when rushing to the bathroom or when getting up frequently
at night when not fully awake or when the lights are not on. Urine
on the floor can also create a slip hazard. People with bladder or
bowel problems often do not drink enough fluids and so are at
increased risk for dehydration. The risk of falling is increased
whenever someone becomes dehydrated.
When people are ill or in pain they often reduce their activity, spend
long periods of time in bed, and take medications that impair clear
decision making. All these changes increase their risk of falling, and
pain which interferes with daily activities significantly increases risk
of multiple falls (Blyth, Cumming, Mitchell & Wang, 2007).
Sometimes the illnesses itself can lead to weakness and poor decision
making. This is particularly hazardous if the person does not know
they are ill, such as with some types of pneumonia or urinary tract
infections. Older persons discharged from hospital after an acute
medical illness are likely to fall, particularly in the first two weeks
after returning home (Mahoney et al., 2000).
Problems with balance, gait and muscle strength are known to be
some of the leading causes of falling among older people and those
with disabilities (American Geriatrics Society et al., 2001). There are
many risk factors that contribute to these conditions, including
chronic disabilities, taking medications, acute illness and an inactive
life style.
Lesson 2: Fall Risk Factors—Biological
Gait disorders: Almost half of older people have some difficulty
walking. Some have serious mobility issues such as weak muscles,
foot disorders, disabilities or from normal changes that come with
aging. These disorders become a problem when the person can no
longer cope safely in their environment. It is estimated that between
40 to 50 per cent of those aged 85 years and older have identifiable
gait problems and that half of these are severe (Rubenstein, 2006).
Poor Balance: Poor balance or postural sway can result from the
normal process of aging, and can affect the neuromuscular and
sensory systems. Postural sway is defined as the inability of an
individual to keep the body in one position (Lord, Sherrington &
Menz, 2001). A small amount of sway is normal but excessive sway
can cause the person to move outside of their center of balance and
lead to a fall.
Diminished muscle strength: This is a normal part of aging but
can be made worse due to a diet low in protein, lack of exercise, and
from illness or disease. For those with muscle weakness, falls often
occur when the person puts all their weight on one leg, such as
when going up or down stairs (Lord, Sherrington & Menz, 2001).
Limited range of motion: This typically affects the joints of the
lower body, particularly the ankle. A fall may result because the
person is unable to pick up their feet to avoid an obstacle or
because their reaction times are slowed due to stiffness in their
joints, and they may be unable to move quickly enough to brace
themselves to avoid a fall.
Spinal deformities: People with kyphosis (spine curved forward)
have increased postural sway and impaired balance reactions, which
increase their risk of falling (Lynn et al., 1997).
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Strategies and Actions for Independent Living©
For behaviour change strategies to be successful, it is important to
actively engage clients in the change process through:
A. COLLABORATING FOR MUTUAL
UNDERSTANDING OF SELF
IDENTIFIED GOALS
B. APPLYING GOOD COMMUNICATION
AND MOTIVATIONAL INTERVIEWING
SKILLS
C. FACILITATING READINESS FOR
CHANGE
D. IDENTIFYING AND EMPHASIZING THE
POSITIVE BENEFITS OF CHANGE
36
Lesson 3: Best Practices for Fall Prevention—Behavior Change
A. Collaborating For
Mutual
Understanding
The key to understanding your client’s perceptions of the importance
of the problem and their confidence to change lies in collaborating for
mutual understanding, rather than lecturing or advising. The following
table demonstrates the difference between a lecturing versus a
collaborative approach to understanding (Johnston et al., 2002).
LECTURING
COLLABORATING
Asks only for facts
about the quantity or
frequency of the behaviour
Aims to understand
the client’s view of
the behaviour and
their experience
Tells client why
he/she should
change
Shares information;
acknowledges and
empathizes with
challenges or barriers
Tells client what
actions to take
Creatively explores
possibilities for change
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Strategies and Actions for Independent Living©
Foot Disorders
—Ulcers, Bunions,
Ingrown Toenails,
Etc.
Sensory Changes
People with multiple foot disorders such as hammer toes, corns and
bunions are at increased risk for falling due to pain when walking or
inability to walk properly (Menz et al., 2001).
We mainly rely on three of our sensory systems for balance. These
are the visual, vestibular (in our inner ear) and somatosensory (the
sensation of touch and pressure) systems.
Visual impairment: Fall risk is increased for those with reduced
ability to see clearly and for those with impaired depth perception
(Lord, Sherrington & Menz, 2001; Harwood, 2001). This is most likely
due to an increased risk of tripping or bumping into obstacles or not
noticing changes in height such as stairs and curbs.
Reduced hearing: Reduced hearing increases the risk of falling by
limiting sounds that alert a person to potential hazards. An example
might be an elderly person losing their balance when startled by the
approach of a person from behind that they did not hear coming.
People with hearing loss are often further at risk due to damage to
sensors that control balance that are found in the ear.
Diminished touch sensation: A reduced sense of touch is a normal
outcome of the aging process. The risk of falling increases when the
touch sensors in the feet become reduced to the point that someone
can no longer detect changes in the surface they are walking on. This
can lead to trips, slips and falls due to unevenness in the flooring and/
or ground. Footwear with thick soles can make this problem even
worse.
Poor proprioception: Proprioception is the ability to sense the
position and movement of body parts without using vision. People
with chronic health problems, such as a stroke or diabetes, often have
impaired proprioception and sensation. Poor proprioception is a
significant fall risk factor (Lord et al., 1996).
38
Lesson 2: Fall Risk Factors—Behavioural
BEHAVIOURAL FALL RISK FACTORS
Behavioural risk factors refer to risks associated with human
actions, emotions or choices.
BEHAVIOURAL FALL RISK
FACTORS
•
HISTORY OF FALLS
•
LACK OF EXERCISE
•
REDUCED ACTIVITY DUE TO FEAR OF
FALLING
•
MEDICATIONS
•
•
•
Taking multiple medications (especially 4 or
more prescription meds)
Taking tranquilizers; sleeping pills;
antidepressants
Not taking bone enhancing medications when
indicated
•
ALCOHOL OR OTHER SUBSTANCE ABUSE
•
DEHYDRATION/MALNUTRITION
•
INAPPROPRIATE CLOTHING
•
INAPPROPRIATE FOOTWEAR
•
NOT USING / INAPPROPRIATE USE, OF
EQUIPMENT AND MOBILITY AIDS
•
RISK-TAKING (E.G., STANDING ON
CHAIRS) USING LADDERS, OR CARRYING
THINGS WHILE USING STAIRS
•
HURRYING / NOT PAYING ATTENTION
•
POOR SLEEP HABITS
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Strategies and Actions for Independent Living©
History of Falls
A fall within the last year significantly increases the risk of another
fall. This can only be determined if older people are asked on a
regular basis whether or not they have fallen.
Lack of Exercise
Lack of exercise leads to weak muscles, loss of bone strength, general
weakness, poor health and increases risk for many chronic diseases,
as well as falls. For the older or frail population physical activity also
minimizes the biological changes from aging, increases functional
levels, reduces the chance of isolation and acts as a protective agent
against depressive symptoms (B.C. Ministry of Health Services,
2005).
Reduced Activity Due
to Fear of Falling
Seniors who have had a prior fall are often fearful of falling again and
may (sometimes from the advice of their families) reduce their
activity because they wrongly believe that it will reduce their chances
of falling again. In fact, the opposite is true– a lack of activity leads to
weak muscles, which increases the risk of falling (Fletcher et al.,
2004).
Medications
Studies have shown that there is a much greater risk of falling among
people who take certain medications – particularly medications such
as sleeping pills, anti-anxiety medications, muscle relaxants and
medications for high blood pressure. For some of these drugs, it is
the side effects that create the risk; for others it is a combination of
the side effects and the health condition (Campbell et al., 1999;
Monane et al., 1996).
40
Alcohol or Other
Substance Abuse
Excess alcohol use causes impaired balance, judgment and slower
reaction times. Alcohol can also interact with other drugs and cause
changes in awareness, balance, and gait.
Dehydration/
Malnutrition
Dehydration (lack of fluids in diet) and/or malnutrition (poor diet)
can cause generalized weakness. Dehydration and malnutrition can
also cause an electrolyte imbalance that may trigger acute delirium.
Lesson 2: Fall Risk Factors—Behavioural
Inappropriate
Clothing
Aging causes a loss of height and posture may become more stooped.
Trip hazards can be created by clothing such as pants, nightgowns or
housecoats that may be too long due to a reduction in height or
stooping that occurs among many people as they age. This is
particularly a problem when climbing stairs. Another problem posed
by clothing results from fabric that is too slippery, such as satin, silk
and rayon. This can lead to older people sliding off the edge of their
bed or off a sofa or chair. Bedding made of slippery fabric can further
compound the problem.
Inappropriate
Footwear
Shoes with high, narrow heels are particularly dangerous when it
comes to increased fall risk among older adults (Tencer et al., 2004).
Another problem results when seniors retain fluid in their ankles and
feet. Shoes may become too tight or too loose as the fluid retention
changes. Loose shoelaces create another fall risk. Seniors who
typically wear socks or go barefoot in the house should be
encouraged to wear shoes whenever possible.
Shoes with soles
that are too thick,
a tread that is too
smooth and shoes
with heels that are
too high or too
narrow are
common fall
hazards.
Not Using/
Inappropriate Use of
Equipment and
Mobility Aids
There is also a common misconception that a thick sole with a dense
tread is a safe design for seniors' shoes. In fact, a thinner sole with a
good tread is better, as a senior is more likely to feel objects beneath
their feet that they might trip over, and are less likely to slip on wet
surfaces.
Many seniors may be using the wrong equipment for their needs or
using it incorrectly. As you have probably noticed in your work, many
seniors believe that using equipment, such as a walker, means a loss
of independence, disability and inevitable decline (Gallagher, Scott,
Thomas & Hughes, 2002). Seniors indicated that the look and
appearance of some of the devices contribute to this negative
perception.
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Strategies and Actions for Independent Living©
Risk-Taking
Hurrying/Not
Paying Attention
Poor Sleep Habits
42
Not only do seniors who engage in risk taking behaviour have an
increased risk of falling (compared to doing the same activity when
younger), but the risk for significant injury and chronic disability is
much greater. An example is the increase in hospital admissions
due to falls among older men during November and December as
a result of putting up seasonal decorations (Stevens, 2004).
Seniors often say they fell because they were hurrying or were not
paying attention. However, younger people sometimes hurry and
don’t always pay attention, but they don’t usually fall. The
difference may be explained by the increase in frailty among older
persons and seniors – as we age our bodies change and we are not
able to react to changes in our environment as quickly as we did
before.
Poor sleep habits can contribute to the risk of falling due to
reduced energy and poor judgment caused by lack of sleep. Fall risk
can also be increased due to frequent trips to the bathroom during
the night brought on by drinking caffeinated beverages or alcohol
before bedtime.
Lesson 2: Fall Risk Factors—Socioeconomic
SOCIOECONOMIC FALL RISK
FACTORS
Socioeconomic risk factors are related to the social and economic
status and functioning of the individual and the impact of those
factors on their health and risk of falling. Older people with low
income and lack of social support tend to have poorer health, and
this increases their risk of falling.
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Strategies and Actions for Independent Living©
SOCIOECONOMIC FALL RISK
FACTORS
Low Income
44
•
LOW INCOME
•
INADEQUATE HOUSING
•
LACK OF ACCESS TO HEALTH SERVICES
•
LACK OF AFFORDABLE TRANSPORTATION
•
LANGUAGE BARRIERS
•
CULTURE
•
LIMITED READING OR WRITING SKILLS
•
LIVING ALONE AND/OR LACK OF
CARING RELATIONSHIPS
•
LIMITED PERSONAL HEALTH PRACTICES
AND COPING SKILLS
Low income is one of the most important socioeconomic risk factors
for poor health and increased risk of chronic illness and injury.
People with low income may be unable to buy enough food for a
healthy diet or basic medical equipment such as a walker or bath stool.
A recent report found that low income was a key risk factor for falls
(Public Health Agency of Canada, 2005).
Lesson 2: Fall Risk Factors—Socioeconomic
Inadequate Housing
Inadequate housing includes an increased number of environmental
risks such as poor lighting, clutter due to limited space, as well as
poor design and condition of stairs and entrance ways.
Lack of Access to
Health Services
People who live in areas with limited health services, those who live
in rural, isolated areas, and those who lack affordable transportation
are all at greater risk for falls. This is thought to be due to being
unable to access health services in a timely and thorough manner,
which contributes to delayed diagnosis and lack of treatment. As
well, delay in treatment of injuries after a fall can result in
complications and a longer recovery period which increases the risk
of disability or even death.
Lack of Affordable
Transportation
A lack of affordable transportation deprives many older people of
access to health services and opportunities for physical and social
activities. Lack of transportation may also result in a person walking
over unsafe ground, or carrying heavy items like groceries, that may
increase the risk of falling.
Language Barriers
An inability to speak or understand the local language may create
challenges in terms of developing supportive relationships with
neighbours or friends. Language barriers also reduce the chance of
understanding patient educational resources, such as materials on
how to reduce the risk of falling.
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Strategies and Actions for Independent Living©
Culture
Most cultures have common values, beliefs and experiences. Some
values and beliefs may contribute to increased falls risk, such as a
belief that seniors should be cared for by others and not be expected
to maintain their independence or a healthy level of activity. Cultural
differences also influence the way older persons and seniors access
health information and participate in health promotion activities
(Stone, 1992).
Limited Reading or
Writing Skills
Lack of access to health information may also be caused by problems
with reading or writing. Some older adults are unable to understand
basic numbers or written materials (Marcus, 2006).
Living Alone and/or
Lack of Caring
People who live alone are more at risk for falling, likely due to a lack
of social supports, caring relationships, and reduced access to
informal assistance for help with household and personal tasks. Social
isolation is also related to increased risk for depression and inactivity,
which are both highly associated with an increased risk for falls.
Limited Personal
Health Practices &
Coping Skills
46
People with a lack of experience in successfully overcoming past
difficulties are less likely to take action to recognize and reduce their
risk of falling. Poor coping skills are often linked to depression and
fewer supportive relationships.
Lesson 2: Fall Risk Factors—Environmental
ENVIRONMENTAL FALL RISK
FACTORS
Environmental risk factors are those factors associated with the
physical environment such as the design of a building, entrances and
outdoor spaces and the type of furniture and other objects in the
rooms. More than ever before, increasing numbers of older people
with chronic health problems are choosing to continue to live in their
own homes. Unfortunately, the design of buildings, equipment and
furniture has not changed to meet the needs of people with health
problems and disabilities.
For someone with poor balance or weak muscles, chairs without
armrests, chairs that move, such as rocker, swivel or glide chairs, or
beds that are too high, become potentially hazardous. For someone
with low vision, clutter in hallways or uneven walkways can be
dangerous.
47
Strategies and Actions for Independent Living©
ENVIRONMENTAL FALL RISK FACTORS
48
•
BUILDINGS THAT DO NOT MEET CODE
REQUIREMENTS OR ARE POORLY
MAINTAINED
•
UNSAFE TRANSITION AREAS AND CHANGES
IN ELEVATION
•
UNSAFE STAIRS
•
LACK OF: HANDRAILS, REST AREAS, GRAB
BARS WHEN NEEDED
•
POOR LIGHTING OR GLARE
•
SLIPPERY OR UNEVEN SURFACES
•
OBSTACLES: SCATTER RUGS, ELECTRIC
CORDS, PETS, CLUTTER, OXYGEN TUBING
•
HAZARDOUS MOBILITY AIDS
•
DESIGN OF SOME FURNITURE
•
NEW SURROUNDINGS
•
COMMUNITY HAZARDS
Lesson 2: Fall Risk Factors—Environmental
Buildings that do not
Meet Code
Requirements or are
Poorly Maintained
Existing building codes are often inadequate for the safety needs of
older persons and seniors. Buildings that are constructed below the
minimum requirements, or that are poorly maintained, can lead to
frequent falls and severe injuries. Examples are narrow doorways
that don’t allow a walker to pass through, door sills that create a
tripping hazard, inadequate lighting in entrances or along walkways,
washrooms that are difficult to access, and ramps that are too steep
or stairs that are hazardous.
Unsafe Transition
Areas and Changes in
Elevation
Transition area hazards include places where there is a change in the
flooring or a change in elevation between one room and the next.
An example is at outside entrance doors where there may be a three
or four inch change in elevation between the inside and outside of
the home. Other transition area hazards include doors that are too
heavy to open or that have strong resistance due to the closure
mechanism, or changes in the type of flooring surface from one area
to another.
Unsafe Stairs
Stair use for able-bodied persons is encouraged as part of an active
lifestyle. However, unsafe stairs are one of the most dangerous
locations for falls, and contribute to more injuries per hour of use
than motor vehicles (Pauls, 2002). Also, injuries occurring on stairs
tend to be more serious than injuries occurring elsewhere in the
seniors’ environment. In 2002, over 6,200 Canadians were
hospitalized due to injuries from falls on stairs (Canadian Mortgage
and Housing , 2011).
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Strategies and Actions for Independent Living©
Lack of Hand Rails,
Rest Areas, Grab Bars
when Needed
Risk factors associated with stairs:
•
stairs that are difficult to see (may be due to poor lighting
or visually distracting patterns on the treads)
•
stairs that are too high or too narrow
•
uneven stairs – when height of step or the depth of the step
changes from one step to another
•
winding or curved stairs – due to different depths of the
steps
•
treads that are slippery or in poor condition
•
loose rugs on stairs or positioned at the top or bottom of
the stairs
•
missing, loose, or broken handrails or handrails that are not
continuous from the top to the bottom on both sides of the
stairs, or do not extend past the first or last step
For older persons and seniors with poor balance, falls often occur
due to a lack of handrails along walk ways and hallways, or due to a
lack of rest areas with stable, supportive chairs. Grab bars in
strategic locations such as shower stalls and poles or bars next to the
bed can reduce the fall risk.
Poor Lighting or Glare
Slippery or Uneven
50
The eyes of a senior do not adjust or handle glare or poor lighting as
well as a younger person.
Liquid on the floor, bath oil in the tub or shower, and ice or snow
outside are all fall hazards.
Lesson 2: Fall Risk Factors—Environmental
Obstacles: Scatter
Rugs, Pets, Electric
Cords, Clutter, Oxygen
Any obstacle that interferes with free easy movement or is a
possible slipping/tripping hazard is a potential fall risk. Pets can
become a trip hazard, particularly for persons with low vision.
Hazardous Mobility
Mobility aides that are in need of repair or maintenance can be a
significant hazard. This includes four-wheeled walkers with brakes
that are not holding, equipment with cracked frames, rubber tips on
canes that are worn and need replacing etc.
Design of Some
Furniture
Examples of furniture which create a fall hazard are soft, low chairs,
sofas or beds; and chairs that move, such as rockers, swivel chairs or
glide chairs.
New Surroundings
Community Hazards
A recent move to different surroundings (including to hospital or a
respite bed), or placing furniture in a new arrangement can increase
fall risk.
Cracks in sidewalks, tree roots on paths, slippery floors in stores,
and heavy store doors are examples of community hazards that
contribute to falls.
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Strategies and Actions for Independent Living©
52
LESSON 3
BEST PRACTICES FOR FALL
PREVENTION
This section presents prevention and harm reduction strategies for
falls and fall-related injuries. Your learning about fall risk factors in
the previous lesson is needed to help understand the nature of the
problem and where to focus attention for reducing risk. Your
professional experience is also needed to judge the importance of
each risk factor for individual clients in planning for prevention.
The model for fall prevention and harm reduction presented in this
section brings your learning on fall risk factors into a plan for action
that is tailored to fit your role as a home health professional or
community health worker, the individual client and their family, and
the availability of other team members.
53
Strategies and Actions for Independent Living©
Learning Objectives for Lesson 3
1. To understand what we know works to prevent falls
2. To understand how to encourage behaviour change
that will help prevent falls
54
Lesson 3: Best Practice for Fall Prevention—Current Research Findings
CURRENT RESEARCH FINDINGS
In the last ten years there has been a dramatic increase in knowledge
about fall risk factors and successful strategies to prevent falls or
decrease the severity of injuries related to falls. We know that most
falls among seniors occur in their home while doing normal daily
activities. Because of this, home health professionals and
community health workers who visit clients in their homes are well
positioned to play a key role in helping to prevent falls for their
clients.
From Lesson 2, we know falls usually happen because of the
combination of a number of factors. In the same way, prevention is
most effective when it combines the following approaches:
• Addresses all risk factors and their combined effects;
• Focuses on individualized prevention plans tailored to risk
factors;
• Reflects current evidence and staff expertise; and
• Involves a team approach.
The following section builds on these approaches and provides
details of the most effective strategies and how to put them into
practice.
55
Strategies and Actions for Independent Living©
A COMPREHENSIVE FALL
PREVENTION MODEL
The SAIL model for prevention is based on current evidence and
effective interventions. In this model, some of the possible actions
to help your clients reduce risk may be outside of your role as
community health workers – these actions will need to be referred
to a home health professional. Lesson 4 covers your role in detail.
The SAIL model for prevention covers the following categories,
represented by the abbreviation BEEEACH:
BEHAVIOIUR CHANGE: of clients, caregivers, health care
providers and others
EDUCATION: of clients, caregivers and health care staff
EQUIPMENT: appropriate use of mobility aids and safety
equipment
ENVIRONMENT: in the home and public places
ACTIVITY: physical and social
CLOTHING AND FOOTWEAR: appropriate for risk reduction
HEALTH MANAGEMENT:
• Annual medical assessment
• Annual medication review and modification
• Annual vision test
• Referral to appropriate specialists or other health care
professionals
• Bone health and fracture risk reduction
• Good sleep habits
• Healthy nutrition and hydration
• Chronic disease self management
56
Lesson 3: Best Practice for Fall Prevention—A Comprehensive Falls Prevention Model
SAIL FALL PREVENTION MODEL
Education
Health
Management
Clothing and
Footwear
Equipment
BEHAVIOUR
CHANGE
Environment
Activity
BEHAVIOUR CHANGE
As shown in the model above, behaviour change is the common goal for all of these
strategies. In most cases the client will be the one whose behaviour is expected to change to
reduce risk. However, there are a number of prevention actions that involve a change in
behaviour by others responsible for an older person’s safety – this may include health care
providers, emergency services, transportation providers, building inspectors, building
managers, and family members.
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Strategies and Actions for Independent Living©
B. Applying Good
Communication and
Motivational
Interviewing Skills
Keys to good communication skills include active listening,
reflecting and summarizing. These skills can help clients think
about change more positively. The following tips build on skills that
you already use as part of the regular care you give your clients.
Active listening:
Involves encouraging your client to share their story with you by
asking ‘open-ended’ questions – this is a question to which they
cannot answer only ‘yes’ or ‘no’.
For fall prevention, you could ask:
• “What is your understanding of why older people fall?”
• “Can you tell me more about that?”.
• “What do you think might be helpful?”
• “What would you like to do first?”
Active listening also involves good ‘body language’, including
appropriate facial expressions, nodding, facing the person and
making eye contact – preferably being on the same level as the
person.
Reflecting:
Involves making empathetic responses – this means that you
reflect not only the content of what they are saying but how
they are saying it.
For example, if your client who lives in a supportive housing
complex tells you that she is having her dinners sent up to her
room because she fell going into the dining room last week, you
might respond by saying: “It sounds like you are afraid that you will
fall again if go down for your meals” Other examples of reflecting
phases include:
• “Let me see if I have this right…”
• “What I hear you saying is…..”
• “So, if I am hearing you right…”
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Lesson 3: Best Practices for Fall Prevention—Behavior Change
Summarizing:
Includes reviewing the important points to show your understanding;
bringing closure to the discussion; or in some cases, helping your client
move toward taking action to find a solution.
C. Facilitating
Readiness for Change
If your client does not seem ready to offer ideas for a solution, you
might want to bring closure to the discussion by saying:
•
•
“Let’s talk about this again the next time I am here to see
how you are feeling about it”, or
“I have to go now, but what I understand that we have
agreed on is….”.
Readiness for
behaviour
change is
determined by
how important
the problem is
perceived by the
person and by
the amount of
confidence they
have in their
ability to make
the needed
change.
For each fall risk identified with your
client, it is helpful to understand how
important your client thinks the risk
factor is and how confident they are that
they can make a change. You will then
begin to have a better understanding of
how ready they are to move toward
action.
IMPORTANCE
Sometimes, just being understood is enough. However, at some point it
is important to know if your client is ready to take action – this is
covered below.
R
ES
N
I
D
EA
S
CONFIDENCE
This figure represents a model for exploring readiness for change by
understanding where your client is on the continuum of change, and
then targeting interventions to help them move further along the path
of change.
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Strategies and Actions for Independent Living©
It is important to understand that moving through the continuum
often takes time and is not always a smooth process. Understanding
the stages of change will allow you to tailor your support to the
client’s stage of readiness.
Based on the work of Prochaska and Norcross (2001), these stages
of change are as follows:
precontemplation (not really ready to change)
contemplation (getting serious about changing)
preparation (making a plan for change),
action (doing the plan)
maintenance (doing the plan long term)
termination (completion of change)
In the precontemplation stage the client expresses no wish to
change and does not see that they have a problem.
A typical statement by the client might be that they do not wish to
do any increased physical activity. The role of the community health
worker at this stage might be to ask the client about whether it is
important to them to be able to stay in their own home as long as
possible and be somewhat independent. If the client does indeed
express this desire and value, then the community health worker can
help the client understand that increasing their physical activity will
make it more likely that they will be able to stay in their own home
longer and can help to improve or maintain health.
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Lesson 3: Best Practices for Fall Prevention—Behavior Change
Contemplation is the stage where the client states that they are
aware they have a problem but have not yet made a commitment to
overcoming it. They may be fearful of failure or not have
confidence that they are capable of taking the necessary actions.
A typical statement regarding physical activity might be that they
know physical activity will help but don’t know if they can do it.
This is an opportunity to explore options based on realistic goals
and help the client to visualize a plan that would suit them. Help
your client to remember situations in which they coped successfully
with change in the past. It may also be helpful to connect the client
with a peer who has made changes successfully and who can be a
role model and offer support.
The preparation stage comes once the client can visualize
themselves making the change and are ready to start putting plans in
place to take action but don’t know where to start. This is the stage
when the client needs specific information on how to get started.
In the example related to physical activity, the community health
worker could facilitate change by providing information about the
SAIL home activity program and encouraging client to contact their
home health professional to see if home activity program would be
appropriate.
Goals for change should be realistic, clearly defined, short-term and
not overly ambitious.
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Strategies and Actions for Independent Living©
In the action stage the client commits to change and takes the
necessary steps to bring this about.
The community health worker’s role at this stage is to work with the
client to make sure they have the information and resources
necessary to get started. This stage is the most intensive in terms
of client’s time and energy. A good deal of positive reinforcement is
needed to make this stage a success.
The maintenance stage is where the client needs to work to build
on gains that they have made and to prevent relapse. This stage is
only reached when the person has made a continuous and sustained
commitment to the change.
In the example of increased physical activity, this could mean a
commitment to the plan for a period of six months or more.
Support is needed to help your client celebrate the improvements
they have made and to realize the benefits from their efforts.
Establishing measures to demonstrate improvement can be helpful,
such as a diary of time spent exercising and a record of
improvements in health and function that have resulted from the
activity program over time.
The termination stage is reached when the problem is overcome
and the person no longer relies on outside support to maintain the
change. It is defined by total self-confidence across all situations
that there is zero temptation to relapse (Prochaska & Norcross,
2001).
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Lesson 3: Best Practices for Fall Prevention—Behavior Change
D. Identifying and
Emphasizing the
Positive Benefits of
Change
Both you and your client’s attitude are also important for change to
occur. In order for the wish to change to move from a place of low
importance and/or low confidence to a place of high importance
and/or high confidence, it is helpful for your client to identify and
desire the positive benefits to be gained by the change.
Examples of questions to help a client explore change more
positively are :
•
•
“If you did decide to ..(exercise each day), what do you think the
benefits might be?” or
“If you decide to get a personal alarm, what advantages do you
think there might be?”
The following “Keys to Change” (Johnston et al., 2002) may help
clarify this process.
Keys to Change:
1. Change is likely if your client sees more pros than cons
for change.
2. Change is likely when it is realistic and approached one
step at a time.
3. If you argue strongly for change, your client will likely
argue strongly against change.
4. Confronting and arguing for change increases
resistance to change.
5. Trying to listen and understand the feelings and
priorities of your client increases their openness to
consider change.
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Strategies and Actions for Independent Living©
EDUCATION: STAFF, CLIENTS &
FAMILY
Education is a key component of most fall prevention programs.
The purpose of education for fall prevention is to:
• increase awareness about the nature and importance of
the issue,
• to increase understanding that prevention is possible, and
• to promote learning about effective strategies.
Balance knowledge of risk with increasing fear of falling:
Education Tips
It is helpful for clients to be aware of the risks that increase the
chances of falling but it is not helpful for a client to become so
afraid of falling that he/she starts to limit activities that are
important for healthy living, social interactions, and quality of life.
Respect client’s right to choose to live at risk: Based on what
we know from evidence, it is appropriate to inform persons about
their risk and how to reduce it, but we need to respect the right to
choose to live at risk once they are aware of the options and
consequences.
Recognize tendency for self blame: Many older persons blame
themselves for their falls, saying "I fell because I was rushing", or
"because I was not paying attention." However, in reality most falls
occur due to the compounding effect of multiple factors, many of
which are unrelated to the older person’s behaviour.
Older persons need to be made aware of the multiple contributors
to falls, including age-related changes, muscle weakness,
environmental hazards, side effects of some medications, risk
taking, etc. and that there are many people besides themselves that
need to take action to reduce risk.
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Lesson 3: Best Practices for Fall Prevention—Education/Equipment
EQUIPMENT
A troubling aspect of fall prevention is the degree to which seniors
either choose not to use equipment that could reduce their risk of
falls and injuries, or in some cases, use equipment inappropriately.
Indications are that many seniors may be using the wrong equipment
for their intended purpose, using it incorrectly, or using equipment
that is not in safe working order.
We know from the SAIL 2 study findings that 41 per cent of those
who fell were not using any assistive devices at the time of their fall
(Scott et al., 2006). We also know that of those who fell, 29 per cent
were using a walker at the time of their fall. The implications of
these findings are that some clients may be at risk because they don’t
have appropriate assistive devices or are not using them when they
should. Also, for those who are using walkers, these devices may not
be enough to prevent falling or may even be contributing to their
risk if they are faulty or not being used correctly.
Barriers to use
Looking "old" or disabled: Some seniors feel using a walker
makes them look old or disabled.
Unattractive equipment: Some equipment looks very institutional.
Feeling of dependence: Some seniors say using an assistive device
makes them feel dependent.
Cost: Cost for equipment is an issue for many seniors. Some clients
may be eligible for funding through third party funders such as Blue
Cross, Veterans Affairs, Ministry of Employment and Income
Assistance, Red Cross, Legion, or the MS Society. A social worker,
physiotherapist or occupational therapist may be able to help access
this funding.
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Strategies and Actions for Independent Living©
Findings of one study showed that the following points were
important in enhancing the use and acceptance of assistive devices
by older persons and seniors (Gallagher, Scott, Thomas & Hughes,
2002).
√ Timing: Realization of the need to use an assistive device
tended to happen following a crisis event such as a fall,
rather than before the event.
√ Personal contact: Older people strongly preferred to get
recommendations and information about assistive devices
through personal contact, particularly from a physician or
other health professional.
√ Assessment and training: Seniors value the services of
occupational therapists and physiotherapists for
assessment and training on the use of assistive devices.
√ Fit with lifestyle: The best way to help seniors use
devices was to understand the person’s lifestyle and
identify the activities most important for that person.
Community health workers have an important role in the safe use of
equipment by their clients. You may be the only person that some
clients see on a regular basis and are often the first to notice changes
in their abilities or condition of their equipment. Information about
changes is important to pass along to a supervisor or other home
health professional. Because you see clients frequently, you are also
in a good position to encourage the correct use of the equipment
that has been provided.
Report problems with client equipment related to:
Set up: look for walker or bath stool legs that may not be adjusted
to correct height.
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Lesson 3: Best Practices for Fall Prevention—Equipment
Appropriateness for assessed need: look for a fit between the
equipment and the client’s strength, balance, and mobility and
understanding of the correct use of the equipment.
Working order: report equipment that appears in need of repair,
such as a walker frame that is cracked, canes with rubber tips that
have lost their tread.
Used as directed for intended purpose: e.g. 4 wheeled walker used
for walking, not for being pushed while sitting on the seat (ask your
supervisor for handouts on equipment use).
EQUIPMENT HELPFUL IN
PREVENTING FALLS:
•
PERSONAL ELECTRONIC ALARMS AND ID
BRACELETS
•
MOBILITY AIDES – CANE, WALKER,
WHEELCHAIR, SCOOTERS, ETC.
•
BATHROOM AIDES – RAISED TOILET SEAT,
BATH STOOL OR BENCH, NON SLIP
RUBBER MAT, HAND HELD SHOWER
•
TOILETING AIDES – URINAL, COMMODE
•
GRAB BAR
•
BED ASSIST RAIL
•
FLOOR TO CEILING POLE
•
STAIR LIFT, WHEELCHAIR LIFTS,
ELEVATORS
•
HIP PROTECTORS
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Strategies and Actions for Independent Living©
Personal Electronic
Alarms and ID
Bracelets
These devices are usually worn as a pendant around the neck or as
a bracelet on the wrist and are linked to a monitored alarm system
that activates a help response when the button is pushed (e.g.,
Lifeline 1 866 784-1992). While not preventing falls, they promote
a quick response for an injury and can decrease the seriousness of
complications such as skin breakdown or dehydration related to
being on the floor for an extended period. Bracelets worn by clients
that alert emergency personnel to call a toll-free number for
medical information, such as diagnoses or medications, can also be
very helpful (e.g., Medic Alert at 1 800 668-1507).
Bracelets with identifying information are helpful for seniors with
dementia who have a tendency to wander and become lost, and
may be at risk for falling while walking in a strange environment,
(e.g., the Alzheimer Wandering Registry at 1 800 616-8816).
Mobility Aides – Cane,
Walker, Wheelchair,
Scooters, etc.
68
These devices are often used incorrectly due to lack of knowledge
by the client. For canes and walkers, the standard height is the
height of the crease of the wrist when the arm is hanging loosely at
the side. A cane is to be used in the hand opposite the weaker or
more painful leg. When using a walker or cane, the usual pattern is
to move the walker or cane, followed by the weaker or more
painful leg, then the other leg. A consultation or referral to
community rehab services or other occupational/physiotherapy
services should be considered if the assistive device or other
equipment does not appear to be appropriate for the client.
Lesson 3: Best Practices for Fall Prevention—Equipment
Bathroom Aids—
Raised Toilet Seats,
Bath Stool or Bench,
Non-Slip Rubber Mat,
Hand Held Shower;
Toileting Aids—
Urinal, Commode;
Grab bar;
Bed Assist Rail;
Hip protectors
These are best purchased and installed with the advice of a physical
or occupational therapist. Correct installation often requires the
services of professional installers. A vertical grab bar is usually
recommended on the faucet end wall by the outer edge of the tub or
shower for increased safety when transferring in and out. Another is
often recommended on the wall beside the toilet. Floor to ceiling
poles and bed rails can be helpful for safer transfers in and out of
bed.
Hip protectors protect the hips from impact due to a fall by either
absorbing the impact (soft padded variety) or shunting the impact
away from the hip and into the soft tissue surrounding the hip
(hard shield variety).
The pads or shields are typically inserted into pockets of
undergarments that keep the protection in place over the hip. They
are a suitable fracture prevention strategy for all seniors at risk of
falling, but are most strongly recommended for persons known to
have osteoporosis, those who have had a prior low trauma fracture
(i.e., a fall from a height of less than one meter which resulted in a
fracture), and for women who have below average weight for their
height. Seniors who use hip protectors also tend to feel more
confident and therefore are more active. However, issues of
comfort, appearance, ease of use, laundry and cost make acceptance
of their use difficult for many seniors.
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Strategies and Actions for Independent Living©
ENVIRONMENT
Some environmental risk factors can be decreased or eliminated
through easily identifiable and changeable interventions such as
removing scatter rugs; other times more complex strategies such as
building a ramp or enlarging a doorway may be required.
The following areas in the home or outdoor environment should
be considered in terms of decreasing risk for falls or injury.
•
•
INDOOR
•
•
•
•
Doors: minimal resistance
Furniture: good height, stable
Walkways
Lighting
• Adequate
• Non-glare
• Easily accessible switches, touch
lights, night lights, motion detector
lights
•
Flooring
• Non-slip
• Level thresholds
STAIRS
•
•
•
•
OUTDOOR
•
•
•
Entrances well lit
Level walkways clear of obstacles or slip
hazards e.g., ice/snow
PUBLIC PLACES
•
•
70
Geometry
Visibility
Handrails
Sidewalks in good repair
Cross walks with adequate crossing time
Lesson 3: Best Practices for Fall Prevention—Environment
Indoors
Doors into suites of apartment buildings: Preferred type of
door closure is one that meets fire regulations and provides
minimum resistance during normal use.
Furniture:
Bed: Preferred height for a bed with a firm mattress is usually
20 to 22 inches. This is high enough to stand up from
independently but still manageable to get the legs up onto, and
not too high as to contribute to slipping off the side when
sitting. A bed assist rail which is secured between the box
spring and the mattress may be helpful.
Encourage
clients to start
with home
modifications
that are easy
and involve
little or no cost
Living Room Chair: A chair with solid arm rests, without a
rocker or a swivel mechanism, and with a fairly firm seat is
usually best. A rocker chair can be adapted with a piece of
wood positioned under the front of the chair to stop the chair
from rocking too far forward so that transferring in and out is
easier. To raise the height of the seat for safer and easier
transfers, using risers for each chair leg is usually preferred
rather than adding another cushion to the seat. The leg risers
consist of hollow wooden boxes with a base into which the leg
sits. Loose squares of plywood are cut to fit into the box and
the number of layers of loose plywood squares determines the
increase in height.
Walkways: Ensure walkways are clear of clutter and slip/trip
hazards and have good lighting.
Lighting: Use higher wattage non-glare bulbs if safe to do so and
glare is not increased. Push plate switches are easier to use than the
older small knobbed switches.
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Strategies and Actions for Independent Living©
Flooring: Modify uneven surfaces in thresholds, and remove
scatter rugs or area rugs if possible. Otherwise, add a non-slip
backing. One study found that clients who fell had fewer hip
fractures when there was carpeting on the floor than when there
was a hard surface such as linoleum or hardwood (Simpson et al.,
2004). Hardwood or laminate floors are more slippery than
carpet, but are much easier to move a wheeled walker or
wheelchair on.
Stairs
The most important priorities for stairs are appropriate and even
stair geometry, visibility of the steps, and functional handrails.
Geometry: Each step should have the same height and the same
depth (where you put your foot). If this is not the case, older
people should avoid using the stairs, take extra caution or, if
possible, have modifications made.
Visibility: Stairs should have good lighting and, ideally, have
contrasting color on the edge on each step. It is important to have
the edge of contrasting colour on all steps, not just the top and
bottom steps. A motion detector light may also be helpful and a
locking gate at the top of the stair may help to prevent a fall down
the stairs by someone who is unsafe on stairs.
Handrails: The best handrails are those that are circular so that
the fingers can wrap around for good grip. At least one handrail
should continue beyond the top and bottom of the stairs and then
turn down or in towards the wall. Handrails should be on both
sides of the stairs, and continuous throughout the length.
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Lesson 3: Best Practices for Fall Prevention—Environment
For more information on how to prevent falls on stairs among older
persons and seniors, see the Canadian Mortgage and Housing
handout on Falls Prevention on Stairs which is available on the
internet at www.cmhc.ca/en/co/maho/adse/adse_001.cfm.
Outdoors
Ice and snow are major hazards for falls. Canes are available
with a special tip for use in ice and snow. There are special devices
designed to fit over shoes or boots to increase traction when
walking on ice and snow. Walkways need to be shoveled regularly
or special substances to melt the snow or ice applied.
Public Spaces
Encourage your clients to report tripping and slipping hazards
in public places. This includes sidewalks and crosswalks are in poor
repair, not well lit or cluttered. Contact town, city, band or
government officials to identify unsafe areas. Discuss change their
walking route, if possible, while waiting for action.
Environmental Issues
for those with
Dementia
Environmental recommendations for clients with dementia:
•
Outside doors with sensors to indicate when opened to
reduce wandering
•
Walking routes should have good lighting and no mirrors
(mirrors can be confusing)
•
Flooring should not have busy patterns or sharp contrasts
•
Stable furniture, i.e., no swivel chairs
•
Bathroom grab bars, non-slip strips, no scatter rugs and no
items that can be knocked over
•
Provide information to caregiver about available supports
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Strategies and Actions for Independent Living©
ACTIVITY –
PHYSICAL AND SOCIAL
Physical Activity
Physical activity is associated with improved health outcomes, an
overall sense of well-being and a reduced risk of falls and fall
injuries. Programs that include strength and balance exercises have
some of the strongest evidence in decreasing fall risk. However,
older people are often more interested in hearing how exercise will
help them improve their overall health, such as reducing the risk for
heart disease, diabetes, hypertension, osteoporosis, dementia and
some types of cancer, than they are about hearing how it will reduce
their fall risk.
Activities that are most successful are those that are tailored to the
individual’s capability and interest. Increasing one’s activity level is
difficult for many seniors and should be started gradually. It is also
important that activities are similar to those that the person has
done in the past, or builds on ones that they are already doing or are
interested in trying. People who are weak and/or in poor physical
condition should start exercises over short time periods that are
done frequently throughout the day, rather than longer periods for
one time in a day. For example, it is easier to start with three five
minute walks a day, rather than doing 15 minute walk. The time can
then be slowing be increased to meet the desired goal.
Normal aging results in a loss of muscle mass and slower reaction
times. The good news is there is no upper age limit to benefit from
exercise. Many studies have found that very frail seniors in their 80s
and 90s can make significant gains in strength and function
(20 per cent or more increase) with a carefully paced strengthening
exercise program. The type of exercise should be tailored to the
individual’s ability, interest and enjoyment, and ideally should
include some resistance (strength) training, balance training and
endurance training.
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Lesson 3: Best Practices for Fall Prevention—Activity
Examples of types of physical activity recommended for older
persons and seniors include:
√
SAIL Home Activity Program
√
Community balance training, e.g., Osteofit, Tai Chi
√
Strength training – using weights or resistance
√
Walking
√
Chair exercise
√
Water fitness
√
Dancing
The SAIL Home Activity Program (Appendix C) has been designed
as a safe way for clients to improve their strength, balance and
endurance and decrease their fall risk. Each exercise is clearly
explained and includes suggestions for safe progression. Before
starting the program, each client is screened by a home health
professional to determine if they are appropriate for the program.
The community health workers then teach, encourage, and monitor
the activity program with clients who wish to participate.
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Strategies and Actions for Independent Living©
Social Activity
Being socially connected is known to improve quality of life and
health outcomes. Seniors who live alone, or have limited or no
social supports and relationships, say that they are less happy, less
well off financially and generally less satisfied with life (Chappell &
Badger, 1989). It is also well known that seniors who are socially
isolated tend to have more health problems.
The poor health outcomes that are associated with social isolation
are also associated with fall risk. To maintain good health, it is
therefore important for seniors to be socially active.
It may be difficult for many older persons and seniors who have lost
a partner to reestablish social contact as a single person. Help may
be needed to find social activities or community programs that feel
safe and comfortable to the client. Sometimes transportation to
social activities is another barrier to participation. For others, help
may be needed to reduce concerns they have about interacting
socially when they have newly acquired health problems, such as
incontinence or need to use a new mobility aid. These problems
may become less of a concern if the senior finds others in the same
situation.
It is well
known that
seniors who are
isolated have
more health
problems
76
The potential benefits of social activity are many, including a wider
social network for support and assistance, sharing of information on
health and community resources, greater exposure to opportunities
for more physical activity and just having fun.
Lesson 3: Best Practices for Fall Prevention—Clothing and Footwear
CLOTHING AND FOOTWEAR
Clothing
Clothing that is relatively loose and has large buttons or velcro
closures is easier to put on and off. Pants and housecoats need to be
a safe length. Suspenders may be helpful to keep pants from
hanging too low. Modified clothing is available from a number of
suppliers – check your local listings for contact information to pass
on to your clients. As well, many seamstresses can modify clothing
so that it is easier to manage.
Footwear
Shoes with the following features are recommended:
√ large contact surface on sole
√ closed heel (not sling backs or thongs)
√ low, wide heel or no heel
√ toe box with enough depth and width to avoid
pressure on the toes
√ a beveled heel
√ raised heel collar height
√ non-slip, textured outer sole
√ thin, firm midsole
√ midsole flare (increased surface contact area)
Safe Shoe Features1:
1Adapted
from Lord et al., 2001, page 161: “The theoretically optimal ‘safe’ shoe.
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Strategies and Actions for Independent Living©
HEALTH MANAGEMENT
As discussed under biological risk factors, many medical conditions are
known to contribute to fall risk. When properly assessed and treated,
these risks can be reduced or
eliminated.
Most of the information in this section
is related to roles for Home Health
Professionals (HHPs). However,
community health workers have an
important role in monitoring the health
of their clients and reporting changes to
their supervisor or HHP. The following
section will help you to understand the type of health-related strategies
known to reduce the risk for falling or having a fall related injury for
older persons.
•
ANNUAL MEDICAL ASSESSMENT
•
ANNUAL MEDICATION REVIEW AND
MODIFICATION
•
ANNUAL VISION TEST
•
REFERRAL TO APPROPRIATE SPECIALISTS OR
OTHER HEALTH CARE PROFESSIONALS
•
BONE HEALTH AND FRACTURE RISK
REDUCTION
78
•
GOOD SLEEP HABITS
•
HEALTHY NUTRITION AND HYDRATION
•
CHRONIC DISEASE SELF MANAGEMENT
Lesson 3: Best Practices for Fall Prevention—Health Management
Annual Medical
Assessment
Annual medical assessment by the family physician is to be
encouraged for the diagnosis and ongoing treatment of conditions
that contribute to falls and fall-related injury among seniors. In the
SAIL program, community health workers (CHWs) will assist clients
to report all of their falls and this information will be passed on to a
home health professional (HHP) through the Fall Report form (see
Appendix A). The HHP will then encourage their clients to report any
falls to their physician.
Annual Medication
Review and
Modification
Annual medication review by the family physician and/or pharmacist
is to be encouraged by HHPs. The role of the CHW is to report any
concerns about medications, such as
finding pills on the floor on a regular
basis, or changes that you notice in
your client’s health or behaviour that
may be related to new medications.
Some of the medications that are
known to increase the risk of falling
are sleeping pills, tranquilizers, muscle
relaxants and anti-depressants. These
medications can slow reaction times,
worsen the person’s ability to think
clearly and impair their balance.
Annual Vision Test
If you notice that your client has difficulty seeing, ask them if they
have had an annual vision test. If glasses are worn, check how the
glasses are cleaned each day and if they are in good repair. If your
client has not had their vision checked for more that a year and does
not know how to go about this, or if your client’s glasses are lost or
broken, notify a family member or your supervisor/HHP. The cost of
eye exams for seniors in B.C. is covered in large part by Medical
Services Plan (MSP), but there may still be a user fee.
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Strategies and Actions for Independent Living©
Referral to Appropriate
Specialists or Other
Health Care
Professionals
Bone Health and
Fracture Risk
Reduction
Referral to appropriate specialists or other health care professionals
is to be encouraged as appropriate. In particular, a full assessment
by a doctor who specializes in the care of older people can be
invaluable, especially for symptoms of unexplained loss of balance
or blackouts or a history of falls with serious injury. Community
health workers can help by observing changes in their client’s health
conditions that may be contributing to a fall risk and reporting this
to their supervisor or home health professional so that the
appropriate referrals can be made.
Strong bones are very important to reduce the risk of having a
fracture due to a fall. Osteoporosis (weak bones) affects
approximately 1.4 million Canadians, or approximately one in four
women over the age of 50, and one in eight men over age 50
(Scientific Advisory Board, 1996). Regular exercise, exposure to
sunshine and balanced diets high in calcium are the best way to
prevent bone loss.
Once diagnosed with osteoporosis, recommended fracture
prevention strategies include taking Vitamin D and calcium;
avoiding smoking and caffeinated drinks; taking bone-enhancing
medications; wearing hip protectors to reduce the risk of sustaining
a hip fracture; and engaging in specific types of exercises that
involve weight bearing, resistance, balance and graded dynamic
stresses on the bones such as those exercises included in the
Osteofit exercise program.
Your role in helping to promote strong bones would include
encouraging your client to have a regular activity program and to
spend some time each day out of doors, and when possible to spend
up to 20 minutes each day exposed to sunshine.
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Lesson 3: Best Practices for Fall Prevention—Health Management
Good Sleep Habits
You can help clients who have difficulties sleeping by giving them a
copy of a handout on good sleep habits and, if the client expresses
an interest, discussing the suggestions with your client, including the
need for the following:
• having a regular, consistent schedule of bedtimes and wakeup
times, even on weekends.
• doing physical activity that they will perform regularly in the
morning and/or afternoon, but not within four hours of
bedtime.
• getting exposure to bright light during the day and, conversely,
avoiding it at night. (If clients need to get out of bed during the
night, only the minimal amount of light required for safety
should be used.)
• avoiding heavy meals or a large amount of liquid within three
hours of bedtime, especially for patients with nocturia (frequent
need to urinate during the night) or heartburn (indigestion or
acid reflux).
• avoiding caffeine and nicotine. Both are stimulants and can
disrupt sleep.
• avoiding alcohol. (Although a “nightcap” is sometimes used to
help hasten sleep onset, as alcohol is metabolized it causes sleep
fragmentation and can increase nocturia.)
• creating a relaxing sleep environment by reducing noise (or use
white noise, such as a fan, to block out noises), turning off
lights, and considering a relaxing bedtime routine, such as a
warm bath or relaxing music.
If you notice that your client is drowsy most of the time or
complains of not getting enough sleep most nights, then notify your
supervisor or home health professional for follow -up.
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Strategies and Actions for Independent Living©
Healthy Nutrition and
Hydration
Vitamin D and calcium: Elemental calcium (1200 mg/day) and
vitamin D (800 to 1000 IU/day) are recommended for most
seniors as a preventive measure for bone loss and as a means of
enhancing bone and muscle strength. Studies have shown that
taking the combination of calcium and Vitamin D supplementation
were more effective in reducing the number of falls and improving
muscle function than calcium taken alone (REF). If your client’s
diet does not include milk, other dairy sources or fortified/
enriched non-dairy sources of calcium, they will need additional
supplementation. If this is the case, recommend to your client that
they talk with their doctor or home health professional about
Vitamin D and calcium supplements.
Adequate nutrition and fluids are to be encouraged. Poor diets and
missed meals will lead to dizziness and weakened muscles. Lots of
fluids are particularly important for the elderly during the summer
months when temperatures are high. It is important to encourage
six or more glasses of non-caffeinated fluids each day.
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Chronic Disease Self
Management
The free chronic disease self management program
(phone 1 866 902-3767) is an excellent program offered in many
parts of the province. Information about specific diseases including
disease specific provincial and national organizations, information
regarding symptom management, and information regarding risk
factors for specific diseases and strategies to decrease risk can be
very helpful.
Postural
Hypotension
Postural hypotension occurs when there is a significant drop in
blood pressure with a change in position, such as moving from
lying to sitting, or from sitting to standing. When this happens, the
brain temporarily lacks oxygen and dizziness results. Community
health workers can help prevent a fall due to postural hypotension
with reminders to: move the legs a bit before changing position
and to change position slowly.
Lesson 3: Best Practices for Fall Prevention—Health Management
Possible Interventions for Specific Chronic Diseases/Health
Issues:
Bowel and Bladder Function: A number of equipment or
environmental adaptations including a urinal, commode,
nightlight(s) on the route to the bathroom, a grab bar near the
toilet, raised toilet seat, and non-skid strips on the floor in front
of the toilet can reduce the fall risk due to incontinence.
Products that are inserted in the toilet tank that colour the toilet
water are also found to improve the ‘aim’ of men using the toilet.
Emphasize the need for keeping up their fluid intake with
beverages that are non-caffeinated, such as water and juice.
If your client has on-going bladder or bowel problems,
recommend that they contact their doctor or a home health
professional (HHP).
Remember:
Most Falls are
both
predictable and
preventable
Cognitive disorders: For clients with dementia, helpful
interventions for falls prevention that fit with the role of a
community health worker include encouraging physical activity,
maintaining familiar routines, minimizing changes to the physical
environment, eliminating clutter, promoting meaningful activities
and relationships.
Diminished touch sensation and/or proprioception (ability
to sense the position and movement of body parts): When touch
or proprioception is impaired, it is helpful to learn to use other
senses to compensate. Vision is particularly helpful. Train the
person to use their eyes to be aware of where and how they are
stepping.
Regularly check the condition of the feet and toenails for any
redness or signs of irritation and report serious foot problems to
your supervisor/HHP.
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Strategies and Actions for Independent Living©
Implementation Plan
for
Higher Risk Clients
Your role is to implement the care plan, using the BEEACH
model, ensuring ongoing good communication and team work
between all team members, including the community health
workers.
BEEEACH MODEL:
BEHAVIOUR CHANGE
EDUCATION
EQUIPMENT
ENVIRONMENT
ACTIVITY
CLOTHING & FOOTWEAR
HEALTH MANAGEMENT
Monitoring Client and
Outcomes
Monitor the outcome of interventions and overall health status.
Monitor the outcome of the team interventions and the overall
health status of the client. Monitoring can be done directly with
home visits, repeat TUGs, the annual InterRAI-MDS-HC and Falls
CAP, and phone calls; or indirectly through team communication,
Fall Reports, and the Checklist and Action Plan. Revise the plan as
needed, especially considering the involvement of a geriatric
medical specialist if the client has several unexplained falls.
SAIL Falls Prevention
Guidelines for Home
Health Professionals
The SAIL Falls Prevention Guidelines for Home Health
Professionals summarizes the above steps in a one page flow-chart
(see Appendix E).
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Lesson 4: Putting It All Together
ROLE OF REGIONAL PROTOCOLS
All SAIL components and roles are supported by regional
protocols (organization and/or agency) which are essential to
ensure clear and consistent practices and processes for effective
falls prevention. These may vary by health region in B.C. and are
designed to reflect regional practices in home care delivery.
It is recommended that each home care delivery organization/
agency offering SAIL appoint a facilitator /coordinator to manage
the program. This person would be the one to go to for
information on your regional protocols.
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Strategies and Actions for Independent Living©
86
LESSON 4(A)
PUTTING IT ALL TOGETHER:
THE CHW ROLE
Learning Objectives for Lesson 4
1. To understand the key components of the SAIL
program
2. To understand the roles of the team members and
the importance of team work in implementing the
SAIL program
3. To understand the role of the community health
worker (CHW) and home health professional in
implementing the SAIL program, specifically:
- The CHW role in reporting falls
- The CHW role in promoting fall prevention
4. To understand the role of regional protocols
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Strategies and Actions for Independent Living©
INTRODUCTION
Working with your clients and colleagues to help prevent falls is a
gradual process. Change usually does not happen at once. The
process will take time and commitment and relies on your
knowledge, skills, collaborative efforts and relationship with your
team members and clients to build appropriate action and positive
change.
Clients usually see their community health workers (CHWs) more
often than any other health care provider. This frequent contact
provides an opportunity for building trusting and caring
relationships. CHWs are also in an ideal position to observe
changes in health and behaviour that may increase falls risk. This
unique role of the CHW is ideal for helping to bring about
gradual, positive change over time. For this reason, CHWs are
seen as a vital component of falls prevention for the home
support client.
This lesson provides step-by-step instructions for implementing
the SAIL falls prevention program for CHWs.
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Lesson 4: Putting It All Together
KEY COMPONENTS OF THE SAIL
PROGRAM
The SAIL program consists of the following key
components:
1. Staff Training – Includes use of participant
training manuals and power-point presentations for:
•
community health workers (CHW)
•
home health professionals (HHP)
A facilitator’s manual is also provided
2. Fall Report Form & Database (see Appendix A)
3. Client Calendar (see Appendix A)
4. Checklist and Action Plan (see Appendix B)
5. SAIL Home Activity Program – For eligible
clients
(see Appendix C)
The SAIL program is implemented and evaluated through
regional protocols.
A description of each follows on the next page.
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Strategies and Actions for Independent Living©
Training of HHPs and
CHWs
Calendar,
Fall Report Form and
Database
Checklist and
Action Plan
SAIL Home Activity
Program
The SAIL training for community health workers (CHWs) and
home health professionals (HHPs) consists of online training and
power point presentations. The in-person HHP training session is
designed to be offered over two to three hours. The HHP training
emphasizes the role of the HHP in preventing falls, including
providing direction and support to the CHW.
The Fall Report form is designed to track individual client falls,
provide information about client-specific risks and prevention
strategies. Fall Report forms are kept in client’s homes and are
completed for every fall, whether or not there is an injury or if the
fall was unwitnessed. A standardized, excel data entry program is
also available to the community care office to track patterns or
trends of all falls over time.
The Checklist and Action Plan is an interactive tool to record clientidentified risks for falling, record client plans for action, monitor
change over time, and help communication between the client,
family, CHWs and HHPs on fall risk reduction.
The SAIL Home Activity Program is designed to maintain or
improve strength, balance and endurance. The HHP does the
screening to ensure client suitability, and the activities are taught,
encouraged and monitored by the CHWs.
During the SAIL CHW training session, you will be given training
on your role with each of the key SAIL components by working on
case studies and exercises provided by your facilitator or as
demonstrated in the online course.
Instructions for the use of the Fall Report and Checklist &
Action Plan are found in Appendices A and B.
Instructions for your role in the SAIL Home Activity Program
are found in Appendix C.
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Lesson 4: Putting It All Together
ROLES OF CHWS, HHPS & CLIENTS IN
IMPLEMENTING SAIL
The following roles apply to the key components of SAIL.
Roles of CHWs
Fall Report Form:
Review client’s Calendar
for falls
Ensure Fall Report
completed for every
fall and review
portions completed by
client and/or family
Deliver the completed
Fall Report to the
Community Care
Office
Checklist and Action Plan
Use the content of the
Checklist & Action
Plan to talk with
clients about fall risks
Sign and date each section
when completed
Review on regular basis
SAIL Home Activity
Program
Teach, encourage and
monitor on ongoing
basis
Assist in completion of
tracking form as
needed
Observe and report changes
in health and risks to
HHP
Roles of HHPs
Fall Report Form:
Review Fall Reports to help
identify fall risks and
tailor strategies for
prevention
Contact client/family as
appropriate
Communicate with CHWs
to work as a team to
prevent future falls
Check Fall Report dates
when completing fall
history question on
InterRAI-MDS-HC
Complete Fall Report if you
are the first staff person
to hear about a fall
Checklist and Action Plan:
During clients visits, review
Checklist and Action
Plan and complete parts
with clients as
appropriate
Encourage client to use the
Plan to keep track of
actions they plan to do
SAIL Home Activity
Program:
Screen for appropriateness
Follow regional protocols
Roles of Clients
Fall Report Form:
Mark their Calendar with a √
for every day that do
NOT have a fall, and
with an X for every day
that do have a fall
Complete as much of the
Fall Report as they can
immediately after the fall
Checklist and Action Plan:
Complete as much of the
Checklist & Action Plan
as they can
Participate in conversations
about fall risk and
prevention
Choose and take actions to
reduce risk
SAIL Home Activity Program
Read client materials and
advise CHW or HHP
desire to participate
Follow instructions and
complete of tracking
form
Promote changes to
decrease fall risk (may be
gradual over time)
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Strategies and Actions for Independent Living©
ROLES OF CHWS IN PROMOTING
FALL PREVENTION
Reporting Falls
With each Fall Report that you complete, talk with your client about
why they think the fall happened and discuss mutual ideas that you
both have for preventing similar falls. Use the Checklist and Action
Plan to see if there are recommendations for reducing risk related to
this fall.
Remember, SAIL is a team effort. The diagram on the following
page shows the range of possible team members in a client centered
approach to fall prevention.
In Lesson 3, the BEEEACH model for comprehensive falls
prevention was presented—based on this model, the following are
highlights of some actions that you are encouraged to take within
your role as a community health worker (CHW):
Promoting Falls
Prevention
Behaviour Change: CHWs can promote small changes over time
which can result in big changes (e.g. helping to move a small
amount of clutter each visit will soon lead to a clear walkway).
Education: CHWs see the client more often than home health
professionals, and so may find more “teachable moments” when the
client is really interested in finding out more about a particular
concern. An example could be when a CHW hears client describe
how she almost fell while sitting on the edge of the bed trying to
put socks on. This is a good opportunity to suggest sitting on a firm
chair instead of the edge of the bed when dressing the lower body.
92
CLIENT CENTERED FALLS PREVENTION MODEL
Home Care Nurses
(HHP1)
Health Maintenance /
Medications/ Education /
Referral
Community Health
Worker
Direct Personal Care /Health
Monitoring
and Support
Nurse
Practitioner
Primary Care
CLIENT
MD
Health Assessment &
Treatment/ Referral
Optician /
Audiologist
Vision / Hearing
Assessment / Treatment
Home Support Manager/
Supervisor/Coordinator
(HHP)
CHW Education & Supervision /
Client Health Monitoring
Physiotherapist/
Occupational Therapist
(HHP)
Functional Assessment/
Exercise/ Assistive Devices/
Education
Social Worker (HHP)
Patient & Family
Counseling / Financial
issues
Case Managers (HHP)
Case Management / LongTerm Care
Dietitian
(HHP)
Assessment /
Education
1HHP:
Pharmacist
(HHP)
Medication
Review/
Education
Home Health Professional
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Strategies and Actions for Independent Living©
Equipment: Community health workers (CHWs) may be the first
to notice things such as brakes that are no longer working or
increasing client weakness which can trigger a suggestion to contact
the home health professional. CHWs are often the ones to hear
first hand accounts of problems and therefore have greater
opportunity to talk about the benefits of repairing or getting new
equipment.
Environment: CHWs may observe a client doing every day
activities such as reaching high or low to get something so that they
are at risk for losing their balance. The CHW can suggest moving
the item to a place that is easier and safer to access and problem
solve together where that place might be.
A CHW might also observe a client stumble due to clutter on
walking routes in their home, and then talk about the pros and
cons of removing the clutter.
Focus on those
areas where your
client spends
most of their
time
Clutter in the kitchen is a trip hazard.
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Lesson 4: Putting It All Together
Activity: Physical and Social: It takes time to build new habits but
every bit of increased physical activity is helpful. Community health
workers are essential for encouraging and reminding clients to
increase their activity on an ongoing basis. Suggestions include
encouraging clients to stand and stretch when commercials come on
TV, to walk down the hallway every hour or two, or to join an
exercise program in their apartment building. Clients on the SAIL
Home Activity Program benefit from ongoing encouragement and
reminders to do the activities regularly.
For more active clients who want to start an exercise program away
from home, encourage and support them to make phone calls for
information about locations and schedules. Bring brochures or
handouts that may be helpful.
Social activity is an important part of falls prevention and healthy
aging. If your client states that they wish to increase their social
activity. You can suggest the following:
√ Encourage/assist your client to list the telephone numbers
of family and friends and place this in a handy location near
the telephone.
√ Encourage/assist your client to list the addresses of family
and friends who are out of town in a handy location.
Encourage your client to write letters regularly to these
people.
√ Assist your client to explore options for new social
opportunities, e.g. church, meal programs, seniors centers,
and clubs.
√ If transportation is a problem, provide a brochure on
seniors transportation options if available. If transportation
is an issue, suggest they talk with their home health
professional.
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Strategies and Actions for Independent Living©
Clothing/Footwear: Work with your client to
√ Help them identify clothing that may be a trip or slip
hazard.
√ Help them to understand why some shoes or other
clothing items are better than others for reducing their risk
of slipping, tripping or falling.
√ Show sensitivity to reluctance to give up footwear or
clothing.
Each client has a right to live at risk and make
choices about their own life. Our job is to provide
helpful information, so the client can make
informed choices.
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Lesson 4: Putting It All Together
Health Management: Community health workers role in helping
clients to prioritize reducing risks related to the management of
their health could include the following:
√ For clients who have obvious changes in their health
condition that affects their muscle strength, balance or gait
e.g. complaints of dizziness, light-headedness, recent weight
loss, pain when walking or muscle weakness – particularly
after extended bed rest or hospitalization – observe
carefully and provide objective feedback about these
changes to your supervisor/home health professional.
√ Promote appropriate use of medications by reporting
concerns to your supervisor/home health professional (e.g.,
if you find loose pills on the floor or if a client who has
been managing their pills independently now seems
confused with what they should be taking or how often).
√ Promote good vision by making sure that eye glasses are
clean and in good repair. For clients with hearing aids,
make sure that they are working and that your client is
using them. Remind/assist the client to replace the batteries
on a regular basis.
√ For those clients with questions about health problems or
medications, suggest that they call their home health
professional or physician. As well, HealthLink a 24-hour
toll free line by dialing 811 – is available. This service is free
of charge for residents of B.C. with a B.C. Health Care
Card and can be provided in most languages.
97
Strategies and Actions for Independent Living©
Please read through the Appendices following the glossary (page 116
on) to get more detailed information on the use of the SAIL tools.
98
LESSON 4(B)
PUTTING IT ALL TOGETHER: THE
HHP ROLE
Learning Objectives for Lesson 4
1. To understand the key components of the SAIL
program.
2. To understand the interconnected roles of home health
professionals (HHPs), community health workers and
clients in implementing the SAIL program.
3. To understand the role of the HHP in implementing the
SAIL program, specifically:
· The HHP role in fall risk screening for all clients
· The HHP role in assessing, planning, implementing and
monitoring falls prevention for high risk clients
4. To understand the role of regional protocols.
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Strategies and Actions for Independent Living©
INTRODUCTION
The focus of this section is to integrate research evidence presented
in the previous sections with your clinical expertise. The goal is to
apply best practices with each client in a way that reflects that
their values, preferences and personalities.
"External clinical evidence can inform, but
never replace, individual clinical expertise.
Any external guideline must be integrated
with individual clinical expertise in deciding
whether and how it matches the patient's clinical
state, predicament, and preferences, and thus
whether (and how) it should be applied"
(Sackett et al., 1996)
Working with your clients and colleagues to help prevent falls is a
gradual process. It will not happen all at once. The process will take
time and commitment and relies on your knowledge, skills,
collaborative efforts and relationship with your team members and
clients to build appropriate action and positive change. A
multifactorial, multidisciplinary approach is the most effective
approach in fall prevention.
The SAIL program is unique in that it involves team collaboration
(particularly home health professionals and community health
workers) utilizing falls prevention tools specifically designed for
clients receiving home support services. These tools and processes
are integrated into regular, ongoing care.
100
Lesson 4: Putting It All Together
KEY COMPONENTS OF THE SAIL
PROGRAM
The SAIL program consists of the following key
components:
1. Staff Training – Includes use of participant training
manuals and power-point presentations for:
•
community health workers (CHW)
•
home health professionals (HHP)
A facilitator’s manual is also provided
2. Client Calendar (see Appendix A)
3. Fall Report Form & Database (see Appendix A)
4. Checklist and Action Plan (see Appendix B)
5. SAIL Home Activity Program – For eligible clients
(see Appendix C)
6. High Risk Faller Prevention Plan – To be used by
home health professionals
The SAIL program is implemented and evaluated through
regional protocols.
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Strategies and Actions for Independent Living©
Training of HHPs and
CHWs
The SAIL training for community health workers (CHWs) and
home health professionals (HHPs) consists of online training and
power point presentations. The in-person HHP training session is
designed to be offered over two to three hours. The HHP training
emphasizes the role of the HHP in preventing falls, including
providing direction and support to the CHW.
Calendar,
Fall Report Form and
Database
The Fall Report form is designed to track individual client falls,
provide information about client-specific risks and prevention
strategies. Fall Report forms are kept in client’s homes and are
completed for every fall, whether or not there is an injury or if the
fall was unwitnessed. A standardized, excel data entry program is
also available to the community care office to track patterns or
trends of all falls over time.
Checklist and
Action Plan
SAIL Home Activity
Program
The Checklist and Action Plan is an interactive tool to record clientidentified risks for falling, record client plans for action, monitor
change over time, and help communication between the client,
family, CHWs and HHPs on fall risk reduction.
The SAIL Home Activity Program is designed to maintain or
improve strength, balance and endurance. The HHP does the
screening to ensure client suitability, and the activities are taught,
encouraged and monitored by the CHWs.
During the SAIL CHW training session, you will be given training
on your role with each of the key SAIL components by working on
case studies and exercises provided by your facilitator or as
demonstrated in the online course.
Instructions for the use of the Fall Report and Checklist &
Action Plan are found in Appendices A and B.
Instructions for your role in the SAIL Home Activity Program
are found in Appendix C.
102
Lesson 4: Putting It All Together
ROLES OF CHWS, HHPS & CLIENTS IN
IMPLEMENTING SAIL
The following roles apply to the key components of SAIL.
Roles of CHWs
Fall Report Form:
Review client’s Calendar
for falls
Ensure Fall Report
completed for every
fall and review
portions completed by
client and/or family
Deliver the completed Fall
Report to the
Community Care
Office
Checklist and Action Plan
Use the content of the
Checklist & Action
Plan to talk with
clients about fall risks
Sign and date each section
when completed
Review on regular basis
SAIL Home Activity
Program
Teach, encourage and
monitor on ongoing
basis
Assist in completion of
tracking form as
needed
Observe and report changes
in health and risks to
HHP
Roles of HHPs
Fall Report Form:
Review Fall Reports to help
identify fall risks and
tailor strategies for
prevention
Contact client/family as
appropriate
Communicate with CHWs
to work as a team to
prevent future falls
Check Fall Report dates
when completing fall
history question on
InterRAI-MDS-HC
Complete Fall Report if you
are the first staff person
to hear about a fall
Checklist and Action Plan:
During clients visits, review
Checklist and Action
Plan and complete parts
with clients as
appropriate
Encourage client to use the
Plan to keep track of
actions they plan to do
SAIL Home Activity
Program:
Screen for appropriateness
Follow regional protocols
Roles of Clients
Fall Report Form:
Mark their Calendar with a √
for every day that do
NOT have a fall, and
with an X for every day
that do have a fall
Complete as much of the
Fall Report as they can
immediately after the fall
Checklist and Action Plan:
Complete as much of the
Checklist & Action Plan
as they can
Participate in conversations
about fall risk and
prevention
Choose and take actions to
reduce risk
SAIL Home Activity Program
Read client materials and
advise CHW or HHP
desire to participate
Follow instructions and
complete of tracking
form
Promote changes to
decrease fall risk (may be
gradual over time)
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Strategies and Actions for Independent Living©
HHP STEPS FOR IDENTIFYING LEVEL
OF FALL RISK
In addition to the home health professional (HHP) role in
implementing the key tools of the SAIL program, the unique role
of the HHP in SAIL is to identify the level of fall risk for all
clients and to tailor prevention strategies to individual risk
profiles. The following outlines the steps for doing this. A
condensed version of the following is provided in Appendix E in
the form of:
√ SAIL Falls Prevention Guidelines for the Home
Health Professionals. This one page guideline
summarizes the role of the HHP in screening for risk,
assessing, planning, implementing and monitoring
high-risk clients.
√ STEPS For the Home Health Professional on
developing, implementing and evaluating
individualized falls prevention plans.
Please use these handouts for easy reference.
Role of the HHPs include:
104
•
screening for risk
•
assessing, care planning, implementing and monitoring
high risk clients
Screening of all clients on admission and annually by the home
health professionals (HHPs) consists of:
√ History of Falls: Ask "Please tell me about any falls you have
had in the last 12 months." Also check for any completed Fall
Report forms over that same time period.
Indicator is two or more falls in the past 12 months
√ Timed Up and Go Test: See Appendix D.
Indicator is a TUG score of 15 seconds or more
√ InterRAI-MDS-HC Falls CAP (case managers):
Indicator is a Falls CAP is triggered
√ Clinical Judgment:
Indicator is when the HHP’s clinical judgment suggests a
client is at high risk for falling
Lower Risk Clients: Clients who do not have any of the screening
risk indicators.
Actions:
•
Continue routine falls prevention practices including
Checklist & Action Plan
•
Continue monitoring falls and related injuries with Fall
Report
Higher Risk Clients: Clients who have one or more of the
screening risk indicators. These high risk clients require more
detailed assessment, planning, implementation of interventions and
monitoring by the HHP.
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Strategies and Actions for Independent Living©
Assessing Higher Risk
Clients
Identify the unique combination of fall risk factors with each high
risk client and tailor the prevention plan according to the individual
risk profile.
•
"BBSE" risk factors: Risks identified by biological,
behavioral, socioeconomic and environmental groupings.
Note the relative number and type of risks in each grouping.
For example, one client may have a high number of
environmental risks, whereas another client may have more
biological risks.
•
SAIL Fall Report Form: Risks identified by circumstances
of fall
•
Checklist & Action Plan: Risks identified by client
•
Care team consultation: Risks identified by other team
members
Care Planning for
Higher Risk Clients
•
InterRAI-MDS-HC: Risks identified by Falls CAP
•
Reliable and valid standardized tools: Risks identified
by standardized tools (e.g., BERG Balance Scale or MiniMental State Examination). Please see Appendix F (p. 138)
for information on choosing a falls risk assessment tool.
Based on risk assessment findings, the next step is to prioritize and
plan interventions. Consider what risk factors are most important and
what risk factors are more easily addressed. Develop an individualized
falls prevention plan in collaboration with the client and according to
regional protocols. Involve other team members as appropriate given
the available resources.
The following diagram shows the range of possible team members in
a client centered approach to falls prevention.
106
CLIENT CENTERED FALLS PREVENTION MODEL
Home Care Nurses
(HHP1)
Health Maintenance /
Medications/ Education /
Referral
Community Health
Worker
Direct Personal Care /Health
Monitoring
and Support
Nurse
Practitioner
Primary Care
CLIENT
MD
Health Assessment &
Treatment/ Referral
Optician /
Audiologist
Vision / Hearing
Assessment / Treatment
Home Support Manager/
Supervisor/Coordinator
(HHP)
CHW Education & Supervision /
Client Health Monitoring
Physiotherapist/
Occupational Therapist
(HHP)
Functional Assessment/
Exercise/ Assistive Devices/
Education
Social Worker (HHP)
Patient & Family
Counseling / Financial
issues
Case Managers (HHP)
Case Management / LongTerm Care
Dietitian
(HHP)
Assessment /
Education
1HHP:
Pharmacist
(HHP)
Medication
Review/
Education
Home Health Professional
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Strategies and Actions for Independent Living©
The Appendices following the glossary (page 116) provide more
detailed information on the use of the SAIL tools. To learn more
about how to develop a plan for high-risk clients or to read more
about choosing an appropriate assessment tool, please refer to the
Appendices E and F.
108
GLOSSARY
ADL (Activities of Daily Living) include self care activities such as
getting dressed and undressed, showering, eating, using the toilet,
combing ones hair, shaving, putting on makeup.
Alzheimer’s disease is the most common cause of dementia. It is
usually diagnosed when there is no other reason for the dementia.
After death, on autopsy the brain is found to be full of tangles and
plaques.
Blood pressure is the measurement of the force or pressure of the
blood against the walls of the arteries. Untreated high blood
pressure can result in a heart attack, stroke, kidney disease or eye
problems.
Bunion is the large, thick area at the joint of the big toe when the
big toe bends inward.
Cardiac arrhythmias are uneven heart beats.
Cardiovascular disease is disease of the heart or the blood vessels
of the body.
Cognitive impairment is problems with the brain in thinking and
remembering.
Corns are pea sized, thick spots on the foot over a bony area.
Dehydration occurs when the body doesn’t have enough fluid. It
can result in confusion and damage to the kidneys and eventually
shock and even death. Dehydration can come from not drinking
enough fluid, or losing large amounts of fluids from diarrhea.
vomiting or excess sweating.
Dementia is a gradual loss of thinking skills with poor memory,
confusion, difficulty reasoning and making decisions, problems
understanding words, and in the later stages, difficulty recognizing
familiar people. Behaviour problems and personality and mood
changes may also occur. The gradual, increasing loss of abilities
usually happens in the opposite pattern to how a child develops
abilities.
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Strategies and Actions for Independent Living©
Hammer toes are toes that are permanently bent up at the middle
joint on the toe.
IADL (Instrumental Activities of Daily Living) refers to those
activities that are a part of managing a home such as meal planning,
grocery shopping, meal preparation, cleanup of dishes, laundry,
general cleaning, and managing normal personal responsibilities
such as paying bills, arranging appointments and transportation, etc.
Kyphosis describes a back which is curved forward, sometimes
called hunchback.
Neuromuscular system includes the parts of the body such as the
brain, spinal cord, nerves, muscles, tendons and bones which work
together to produce movement.
Parkinson’s disease is a disease of a part of the brain which causes
muscle rigidity (stiffness), difficulty starting movements, and often a
resting tremor (usually seen as quick shaking of the hand). The
disease usually slowly gets worse over time.
Proprioception is the ability to know the position or movement of
a part of the body without looking.
Osteoporosis is a disease of the bones that weakens them and
makes the bones more likely to break. It is most common in women
after menopause. Risk factors for osteoporosis include a family
history of osteoporosis, not enough calcium in the diet, inactivity,
being of Caucasian (white) or oriental race, underweight, certain
drugs such as steroids, early menopause, caffeine, smoking cigarettes
and alcohol.
Sensory system includes the parts of the body such as the eyes
(seeing), ears (hearing), skin (touch, temperature and pain), and joint
receptors (proprioception) which send information about the
environment to the brain.
Stroke is brain damage from lack of oxygen to the brain. It happens
when a blood vessel (artery) bringing blood to the brain becomes
blocked (by a clot) or bursts (hemorrhage). Warning signs of a
stroke include sudden changes within minutes or hours causing
weakness, trouble speaking, vision problems, severe headache, or
dizziness.
(Adapted from the BC Health Guide and The Merck Manual of Health
Information)
110
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Blyth FM, Cumming R, Mitchell P, Wang JJ (2007). “Pain and Falls in Older
People.” European Journal of Pain. 11(5): 564-71.
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“Psychotropic Medication Withdrawal and a Home-based Exercise
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Crilley JG, Khurana HB, Appleby DA, de Belder MA, Davies A, Hall JA
(1997). “Permanent Cardiac Pacing in Elderly Patients with Recurrent
Falls, Dizziness and Syncope, and a Hypersensitive Cardioinhibitory
Reflex.” Postgraduate Medical Journal. 73(861): 415-418.
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Patients: A Clinical Approach." Topics in Geriatric Rehabilitation. 11(1):
30-38.
Dey AB, Stout NR, Kenny RA (1997). “Cardiovascular Syncope is the Most
Common Cause of Drop Attacks in the Elderly.” Pacing Clinical
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Fletcher PC, Hirdes JP (2004). "Restriction in Activity Associated with Fear
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Gallagher E, Scott V, Thomas P, Hughes L (2002). “Laying the Groundwork
for Improved Knowledge and Use of Assistive Devices among Canadian
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Society, 51(11), 1638-44.
Harwood R (2001). “Visual Problems and Falls.” Age and Ageing. 30(S4): 13-18.
Johnston BD, Rivara FP, Droesch RM, Dunn C, Copass MK (2002).
“Behaviour Change Counseling in the Emergency Department to Reduce
Injury Risk: A Randomized, Controlled Trial.” Pediatrics.110: 267-274.
Jørgensen L, Engstad T, Jacobsen BK (2002). "Higher Incidence of Falls in
Long-Term Stroke Survivors Than in Population Controls." Stroke. 33: 542.
Katzmarzyk PT, Gledhill N, Shephard RJ (2000). “The Economic Burden of
Physical Inactivity in Canada.” Canadian Medical Association Journal.
163(11).
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for Falling in Home-Dwelling Older Women with Stroke.” Stroke. 34: 494501.
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Lord SR, Sherrington C, Menz HB (2001). Falls in Older People - Risk Factors
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Osteoporosis.” Archives of Physical Medicine and Rehabilitation. 78: 273277.
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“Temporal Association Between Hospitalization and Rate of Falls After
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443-448.
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242-246.
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(2004). “Physiological Risk Factors for Falls in Older People with Lower
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Tencer AF, Koepsell TD, Wolf, ME, Frankenfeld, C, Buchner D, Kukull W,
LaCroix A, Larson E, Tautvydas M (2004). “Biomechanical Properties of
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114
APPENDICES
Appendix A:
FALL REPORT AND CALENDAR
Appendix B:
CHECKLIST AND ACTION PLAN
Appendix C:
SAIL HOME ACTIVITY PROGRAM
Appendix D:
STEPS FOR CHW IN IMPLEMENTING SAIL
How to introduce the SAIL Package to Your Client
Appendix E: SAIL FALLS PREVENTION BN
GUIDELINES FOR HHP
Evaluating Individualized Falls Prevention Plans
Appendix F: COPY OF SAIL TOOLS
Fall Report, Calendar, Checklist and Action Plan,
SAIL HAP Program (Moving, Standing, Sitting),
HAP Tracker
Instructions for Using the SAIL Calendar
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Strategies and Actions for Independent Living©
116
APPENDIX A:
FALL REPORT
AND CLIENT CALENDAR
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Strategies and Actions for Independent Living©
SAIL FALL REPORT FORM:
This tool is designed to help track individual client falls, provide
helpful information about client specific risks and prevention
strategies, help identify patterns or trends that need a program or
resource shift to address the issue, and to monitor and evaluate the
effectiveness of falls prevention activities in each area. A Fall Report
form is completed on every fall, whether or not there is an injury or
the fall is witnessed. In addition to clients being asked to put an X
on the calendar every day they have a fall, community health
workers are also encouraged to frequently ask the client if they have
had a fall recently.
Who completes the Fall Report form?
The client and/or family may partially or fully complete the report
on their own
or the community health care worker (CHW) may need to assist
or fully complete the report
or the home health professional (HHP) may assist or fully
complete the form
Role of CHW with Fall Report Form:
1. Complete a Fall Report form for every fall and review portions
completed by your client or family member.
2. Make sure every fall is marked on the client’s calendar with an X
and circle and initial the X once you have completed the Fall
Report form, so that other staff members will know that this has
been done.
3. Deliver the completed Fall Report form to the community care
office.
SAIL CALENDAR:
The SAIL Calendar has one page per month. Clients are encouraged
to post the calendar on their fridge with a magnetic clip which is
provided. The calendar instructions are:
1. Mark √ every day without a fall
2. Mark X every day with a fall
3. Circle and initial the X once a Fall Report completed
4. Process with Fall Report Forms and Calendars: See
Regional Protocols
118
Role of HHP with Fall Report Form:
•
Review the form to help identify falls risks and strategies for
prevention
•
Contact or visit client/family as needed to follow-up
•
Communicate with CHWs to maximize their important role
as team members in preventing future falls
•
Implement other strategies
•
Case Managers to check the number of completed Fall
Report forms in addition to client self report when
completing the question about falls in the last 90 days on the
InterRAI-MDS-HC
•
Complete a Fall Report form when the HHP is the first staff
person to hear of a fall
119
B
Strategies and Actions for Independent Living©
120
APPENDIX B:
CHECKLIST AND ACTION
PLAN
TIPS FOR IMPLENTING THE CHECKLIST
AND ACTION PLAN
121
B
Strategies and Actions for Independent Living©
SAIL CHECKLIST AND ACTION PLAN
The Checklist and Action Pan is an interactive tool to:
•
Record client identified risks for falling
•
Record client plan for action
•
Monitor change over time
•
Help communication between client, family, CHWs and
HHPs
Who completes the Checklist and Action Plan?
Client and/or family member may partially or fully complete on
their own
CHW may assist
HHP may assist
Role of CHW:
1. Use the Checklist and Action Plan as a guide to talk with your
client about their fall risks and ways to reduce falls. Do this
while you are providing your regular care so that time is not
taken away from the care needs of the client.
2. Help your client to complete their Checklist and Action Plan
and review this on a routine basis by making sure all sections are
complete and that selected actions are being taken.
3. Sign and date each section of the Checklist and Action Plan
when a section is complete.
4. Provide ongoing support and encouragement to clients on
actions they take to reduce falls risks.
122
Role of HHP:
•
Review Checklist and Action Plan when visiting clients
•
Complete parts of the Checklist and Action Plan with
clients as appropriate
•
Encourage client to use Action Plan to keep track of
actions they plan to do
•
Checklist and Action Plan can also be given to home
care clients NOT receiving home support services.
However, remember CHWs will not be available to
assist client in completing it.
Process with Checklist and Action Plan: See Regional
Protocols
See the following page (124) for tips on using the Checklist and
Action Plan.
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Strategies and Actions for Independent Living©
TIPS FOR USING THE
CHECKLIST AND ACTION PLAN
√ Communication with other team members: The Checklist and
Action Plan can be used to help with communication between
community health workers, home health professionals (HHPs),
clients, their family members and other support people. In
addition to the responses to questions of the plan, use this
document to leave notes to others on the progress of the selected
actions and roles that others can play to help bring about change.
However, this does not replace the need for you to communicate
any urgent concerns directly to your supervisor/HHP.
√ For clients with dementia: For these clients, it may be more
helpful to work through the Checklist and Action Plan questions
with a family member or caregiver, with as much involvement
from the client as possible. Contact your supervisor/HHP if you
have any concerns about whether or not to involve the family.
√ Identifying other potential team members: The diagram on
page 93 is designed to give you a sense of potential team members
that may be involved to bring about a fall-reducing change. In
most cases your link to these team members will be through your
supervisor/HHP.
√ Look for problem areas that might not be covered in the
Checklist and Action Plan: Don’t assume that the Checklist
and Action Plan covers all of your client’s risks for falling and
what would work best to reduce them. Encourage clients to share
their ideas and suggest some of your own. Contact your
supervisor/HHP to ask questions or share new ideas.
124
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Strategies and Actions for Independent Living©
APPENDIX C:
SAIL HOME ACTIVITY
PROGRAM OVERVIEW FOR STAFF
OVERVIEW FOR CLIENTS AND THEIR
FAMILIES
SAIL HOME ACTIVITY TRACKING
FORM
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SAIL HOME ACTIVITY PROGRAM
OVERVIEW FOR STAFF
WHAT is it?
The SAIL Home Activity Program is a set of seven activities for frail
adults with limited strength and mobility who are at risk for falls and
further loss of mobility and function. The activities in the SAIL Home
Activity Program have been carefully chosen by consensus with
experienced community physiotherapists and occupational therapists
throughout British Columbia. It is adapted from the Home Support
Exercise Program developed by the Canadian Center for Activity and
Aging.
WHY was it developed?
1. Physical activity is key to maintaining and improving health:
Physical inactivity significantly increases the risk for many chronic
diseases including diabetes, heart disease, high blood pressure,
osteoporosis, dementia and cancer. For those with chronic disease,
physical inactivity results in poorer health outcomes. Physical
inactivity also leads to muscle weakness, decreased balance and
increased risk for falls.
Diabetes: Various studies have shown that changes in diet and
increasing physical activity decrease the incidence of diabetes by
40 to 60 per cent. People with diabetes who are regularly physical
active maintain more normal blood sugar levels, and significantly
decrease their rate of premature death (Roberts et al., 2005;
Warburton et al., 2006).
Heart disease and hypertension: Regular physical activity
improves the elasticity of the walls of the arteries in the body,
lowers blood pressure and increases the ability of the heart to
pump more effectively and efficiently (Taylor et al., 2004;
Warburton et al., 2006).
Osteoporosis: Physical activity (weight bearing, resistance exercises,
and exercises which put unusual stresses on the bones) is
important in preventing loss of bone density and improving bone
health (Taylor et al., 2004).
Dementia: Regular physical activity decreases the risk of cognitive
impairment or dementia. A study in the Journal of the American
Medical Association in 2004 found women who walked at least
1½ hr/week did better on mental function tests than less active
women (Weuve et al., 2004; Laurin et al., 2001).
Alzheimer’s: Exercise programs for people with Alzheimer’s
disease have been shown to improve mini-mental status exam
scores (MMSE), decrease depression, decrease agitation and
aggression and decrease falls (Heyn et al., 2004; Teri et al., 2003).
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Strategies and Actions for Independent Living©
Cancer: Up to 35 per cent of cancers are shown to be
preventable by eating well, being active, staying at a healthy
weight and not smoking. Regular physical activity results in a
significant decrease (20-40 per cent) in the risk of breast,
colon and prostate cancer (Eyre et al., 2004; Kushi et al.,
2006).
Depression: Regular exercise is associated with improved
mood in the elderly (Arent et al., 2000; Warburton, 2006))
Falls: Regular physical activity significantly reduces risk for falls
(Taylor et al.,2004; Warburton, 2006).
“The greatest health risk for older
adults is sedentary living.”
(World Health Organization, 1997)
2. This program reaches a high risk population (frail older
adults) because it:
Can be done at home: The SAIL home activity program can
be done at home, and adapted to fit within the client’s daily
routines without the barriers of transportation and efforts
needed to find programs outside of the home.
Is simple and adaptable: It can be adapted to meet the needs
and abilities of each person, and has built in progression. If
necessary, the client can start with just one exercise each
day. Additional exercises can be added as the client is able.
Every little bit of increased activity promotes health.
Requires minimal increased resource: It is designed to be
used and delivered through existing home care programs
and services and staff. It does not require a full
individualized assessment by a physiotherapist or
occupational therapist. A nurse or therapist can do the
screening, with or without a home visit, depending on the
home health professional’s knowledge of the client.
HOW does it happen?
1. Screening by home health professional: The home health
professional screens to determine the client meets the criteria
for one of the three levels of the program –Sitting, Standing, or
Moving.
128
2. Inclusion on home support care plan: The home health
professional includes the SAIL Home Activity Program on the
home support care plan as per regional or site protocols.
3. Three handouts provided to client as per regional or site
protocols: The information handout, the directions for the
seven activities, and the tracking form are provided to the client.
4. Depending on the home health care office protocols,The
community health workers:
• role may include going over each exercise – this may occur
over a number of visits (unless already done by home
health professional)
• role is to motivate client to continue with exercises,
observation that they are doing, coaching correct methods
and completing ‘HAP Tracker
PRINCIPLES in teaching the activities to the client
and/or family:
•
It is better to start slowly (i.e., with teaching and
encouraging just one or two of the exercises) initially if the
client seems hesitant or overwhelmed or tires easily.
•
Reassure the client that the first week or two or three may
be the hardest until a routine is developed and they start to
feel stronger and have more energy.
•
It may be easier for the client to do a couple of the exercises
two or three times a day rather than trying to do them all at
once.
•
If one or more of the activities seems to be particularly
difficult or to cause increased pain, the client should
discontinue that exercise for a few days. Consider
encouraging the client to try the activity just once or maybe
twice a few days later to see if it is any easier at that time. If
not, then just don’t include that particular activity in the
program.
•
Remind the client to hold on at the counter as much as is
needed to be safe, but to try gradually over time, as their
balance and strength improve, to decrease the amount of
support they get from holding on.
•
If necessary, try to encourage the client to do even a few of
the exercises while you are in the home. For example, the
client may be able to do a few of the exercises holding on at
the bathroom sink while you are preparing things for their
shower.
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Strategies and Actions for Independent Living©
References:
Arent, Shawn et al (2000). “The Effects of Exercise on Mood in Older
Adults: A Meta-analytic Review.” Journal of Aging and Physical Activity
8:407-430.
Eyre, Harmon et al. (2004). “Preventing Cancer, Cardiovascular Disease,
and Diabetes: A Common Agenda for the American Cancer Society, the
American Diabetes Association, and the American Heart Association.”
Circulation. 4(109): 3244-3255.
Heyn, Patricia et al. (2004). “The effects of Exercise Training on Elderly
Persons with Cognitive Impairment and Dementia: A Meta-Analysis.”
Archives of Physical Medicine and Rehabilitation. 85:1694-1704
Kesaniemi, Y.A. et al. (2001). “Dose-response issues concerning physical
activity and health: an evidence-based symposium.” Med. Sci. Sports
Exerc. 33(6 Suppl): S531-538.
Kushi, Lawrence et al. (2006). “American Cancer Society Guidelines on
Nutrition and Physical Activity for Cancer Prevention: Reducing the Risk
of Cancer with Healthy Food Choices and Physical Activity.” CA: A
Cancer Journal for Clinicians. 56: 254-281.
Laurin, Danielle et al. (2001). “Physical activity and risk of cognitive
impairment and dementia in elderly persons.” Arch Neurol. 58: 498-504.
Lord, S.R., Menz, H.B., & Tiedemann, H.B. (2003). A physiological
profile approach to falls risk assessment and prevention. Physical Therapy,
83(3), 237-52.
Roberts, Christian et al. (2005). “Effects of exercise and diet on chronic
disease.” Journal of Applied Physiology. 98: 3-30.
Taylor, A.H. e al. (2004). “Physical activity and older adults: a review of
health benefits and the effectiveness of interventions.” Journal of Sports
Sciences. 22: 703-725.
Teri, Linda et al. (2003). “Exercise plus Behavioral Management in Patients
with Alzheimer Disease.” Journal of the American Medical Association.
290(15): 2015-2022.
Warburton, Darren et al. (2006). “Health benefits of physical activity: the
evidence.” Canadian Medical Association Journal. 174(6): 801-809.
Weuve, J. et al. (2004). “Physical Activity, Including Walking and Cognitive
Function in Older Women.” JAMA. 292: 1454-1461.
130
APPENDIX D:
STEPS FOR CHW IN
IMPLEMENTING SAIL
HOW TO INTRODUCE THE SAIL PACKAGE TO
YOUR CLIENT
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Strategies and Actions for Independent Living©
HOW
TO INTRODUCE THE
SAIL PACKAGE
TO YOUR CLIENT
If you are the community health worker who is asked to introduce the client
package, it is important to consider how best to do this introduction.
Although one of the project objectives is to keep this process as brief as
possible, it will take a short amount of your time and your client’s time. To
save time in the client’s home, go over the instructions found in all the
resources in the SAIL package by yourself before your visit to your client.
When you are confident that you and your client are ready to start, follow
these steps:
1
Prepare yourself to briefly describe the purpose of the SAIL program,
which is to:
1) Help your client understand that most falls can be prevented;
2) Work with your client to help maintain their present level of
health and independence by reducing their risk of falling; and
3) Help your client understand how they can avoid having an
injury from a fall.
2
Try to arrange a time when your client is likely to have more energy and
when you have a few extra minutes.
3
If possible, find a location where you can sit near each other, where there
is a place to put the SAIL materials and where your client has good
lighting for reading. Make sure they have their reading glasses handy if
needed.
4
Show the client the introductory letter and let them read it. Then show
them the calendar and explain how they are to use it. Then briefly show
them the Fall Report forms and the Checklist and Action Plan. Let them
know that they can read these over in their own time. Speak clearly and do
not rush. Let your client know that the conversation can stop at any time
and be continued at a later visit.
Steps 5, 6, &7 over...
132
5
If they do not appear to understand, ask what they don’t understand and
try to clear up any misunderstandings.
6
Ask your client to put the Calendar and Fall Report form on their fridge
with the clip provided. Also let them know that the Fall Report forms and
Checklist and Action Plan are best kept with their other home support
papers in the client’s home. Encourage them to work through as much of
the plan on their own as they are able. Let the client know that the
instructions for them are at the front of the Checklist and Action Plan.
7
When you are finished, ask if there are any questions or anything that they
are not clear about. Let them know that using the Fall Reports and
Checklist and Action Plan will be a part of regular care and that their use
will become clearer as you discuss them during regular visits. Reassure
them that this will not affect their normal services and that conversations
about falls can occur while they are receiving normal care and when they
are ready.
Note:
All CHWs who are trained in the SAIL program will work with all
SAIL program clients (those with the SAIL package in their home) to
complete the Fall Report forms and Checklist and Action Plan – even
if you are not the staff member who provides the SAIL package
introduction.
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Strategies and Actions for Independent Living©
134
APPENDIX E:
SAIL FALL PREVENTION
GUIDELINES FOR HHP
STEPS FOR HHP
ON DEVELOPING, IMPLEMENTING &
EVALUATING INDIVIDUALIZED FALL
PREVENTION PLANS
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Strategies and Actions for Independent Living©
SAIL FALLS PREVENTION GUIDELINES FOR HOME HEALTH
1. Screen all clients for risk for any of:
• 2+ falls in past 12 months
• Functional mobility assessment >15 on TUG
• InterRAI-MDS-HC Falls CAP
• Clinical judgement
If lower risk:
• Continue routine falls prevention practices
including Checklist and Action plan
• Continue monitoring falls and related
2. Assess higher risk clients:
1. Refer to SAIL Manual Lesson 1 on ‘BBSE’ for potential risk factors
2. Identify contributing factors from client’s InterRAI-MDS-HC Falls CAP findings
3. Conduct additional, relevant assessments (e.g., BERG)
4. Refer to SAIL Fall Reports (Appendix A)
5. Refer to client’s Checklist & Action Plan (Appendix B)
6. Consult with care team
•
3. Plan for higher risk clients:
Complete individualized fall prevention plan using organization care plan protocols
4. Implement Multifactorial Prevention Plan
Implement a client-specific Falls Prevention Plan that reflects the
BEEEACH best practice guidelines found in Lesson 3:
• Behavior Change: client, family, health care providers &
others
• Education: clients, caregivers and staff
• Equipment: mobility aids and safety
• Environment: home and public
• Activity: physical and social
• Clothing/footwear
• Health Management: including
⋅ Medical assessment and medication review
⋅ Vision assessment
⋅ Osteoporosis risk
Team communication and make new referrals as needed
5. Monitor:
• Monitor client risk reduction through visits, phone calls, team
communication, and assessment tools such as:
InterRAI-MDS-HC including triggered CAPS
SAIL Fall Reports
SAIL C&A progress
Repeat TUG
• Modify Falls Prevention Plan as needed.
• Consider referral to geriatric specialist for further assessment,
particularly falls resulting in severe injury requiring medical treatment,
or those due to blackouts or unexplained loss of balance or weakness.
136
•
•
•
•
•
•
•
•
•
•
•
•
Possible Team
Members:
Client/family/
volunteers
Nurses
• OT / PT
• CHW
Home support
coordinator
Family GP/specialists
Social worker
Dietician
Pharmacist
Optometrist/
audiologist
Respiratory therapist
Day hospital/day
program
Podiatrist/orthotist
Community Resources
Cross-site monitoring:
Organization to review
quarterly summaries of Fall
Reports for trends and
patterns in order to
implement relevant
programs and resources.
STEPS FOR HOME HEALTH
PROFESSIONALS (HHP) ON
1
DEVELOPING, IMPLEMENTING & EVALUATING
INDIVIDUALIZED FALLS PREVENTION PLANS
Screening of all clients on admission and annually:
1) Ask client to "Please tell me about any falls you have had in the
last year or any time you unintentionally ended up on the
ground or floor."
2) Conduct Timed Up and Go Test (TUG) (appendix D).
3) Refer to completed fall reports to confirm answer to falls in last
90 days in InterRAI-MDS-HC assessment and falls in last year.
4) Clinical Judgment – client may not have fallen in the last year,
may do well on TUG, may not have had a falls CAP triggered,
& yet still be at high risk for falling. Use your clinical judgment!
2
Higher Risk Clients: Assess
3
Higher Risk Clients: Plan
1) Assess for risk factors BBSE
Higher Risk Client
from lesson 1.
Definition:
2) Identify any additional
• Two or more falls in
contributing factors from
the last year
InterRAI-MDS-HC findings.
• TUG score of 15
3) Conduct additional, relevant
seconds or more
assessments (e.g., test for
• Falls CAP triggered
postural hypotension, Berg
• Clinical judgement
Balance Test).
triggered
4) Review completed SAIL Fall
Reports (appendix A).
5) Review client’s Checklist and Action Plan .
6) Consult with care team.
1) Develop plan using organization care plan protocols.
2) Consider referrals to other disciplines or services.
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Strategies and Actions for Independent Living©
4
Higher risk clients: Implement
1) HHP to implement client specific interventions that reflects the
BEEEACH best practice guidelines found in Lesson 3.
2) Make referrals as needed.
3) Maintain good communication with team members including
CHWs in addressing relevant risks.
5
Higher risk clients: Monitor client and outcomes of interventions
1) Monitor through visits, phone calls, communication with other
team members.
2) Do annual InterRAI-MDS-HC re-assessments and compare
with previous, including any triggered CAPs.
3) Repeat TUG annually or whenever significant change in health
status.
4) Review Checklist and Action plan.
6
Respond to client fall:
1) Complete Fall Report if HHP first person to receive news.
2) Review completed fall reports completed by others.
3) Follow-up on all falls: phone call. visit, etc.
4) Consider referral to geriatric specialist for further assessment for
falls resulting in severe injury requiring medical treatment, or for
falls due to blackouts or unexplained loss of balance or
weakness.
5) Develop or review and revise as necessary client’s falls
prevention plan, and implement changes.
7
138
Support organization in effective falls reduction strategies:
1) Review organization’s progress towards falls reduction goals.
2) Identify and address challenges in existing falls prevention
activities .
3) Suggest changes in systems or processes to decrease falls and
injuries for high risk groups of clients, based on trends or
patterns or observations.
4) CELEBRATE SUCCESSES!
APPENDIX F:
HHP: HOW TO CHOOSE
A FALL RISK
ASSESSMENT TOOL
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Strategies and Actions for Independent Living©
HOW TO CHOOSE A FALLS RISK ASSESSMENT TOOL1
Of the many fall risk assessment tools and outcome measures
available to home health professionals, it is important to focus
on those that have some evidence that they actually do what
they claim to do. In other words, use tools that have some
evidence for being reliable and valid.
The best word to describe reliability is consistency – the
degree to which the information remains consistent over
repeated testing. This includes:
√
test-retest reliability: where the same tester gets
the same results when testing on two different
occasions with the same subject, and
√
inter-rater reliability: where different testers get
the same results with the same subject.
The core of validity is accuracy – the degree to which the
tool measures what it claims to measure.
The following concepts are important when considering
reliability and validity in fall risk assessment tools:
1. Sensitivity: In relationship to fall risk, sensitivity is
the percentage of fallers correctly identified as potential
fallers by the tool. A tool with good sensitivity allows
interventions to be targeted to those most at risk of
falling
2. Specificity: In relationship to falls, specificity is the
percentage of non-fallers correctly identified as
potential non-fallers by the tool. A tool with good
specificity promotes cost effective use of resources by
discouraging significant falls prevention interventions
for those who are not at high risk of falling.
3. Inter Rater Reliability: The degree of consistency
among raters who are collecting the same information
or evaluating the same client, from a score of 0, for no
agreement between different raters, to 100 per cent for
perfect agreement.
1
140
Scott et al.,
There are Two Types of Fall Risk Assessment Tools
(Scott et al, 2007):
Functional Mobility Assessments: The focus is on
functional limitations in gait, strength and balance where
clients are required to perform a physical demonstration of
ability. Most of these tools are completed by physical or
occupational therapists but may also be completed by
physicians or nurses. Examples include the Timed Up and
Go (TUG), BERG Balance Scale, and Timed chair stands.
Multifactorial Assessment Tools: These typically
consist of a checklist comprised of questions used to
screen the level of risk based on a combined score of
multiple factors known to be associated with fall-related
risk. These could include psychological status, mobility
dysfunction, elimination patterns, acute/chronic illnesses,
sensory deficits, medication use and a history of falling.
The tools may or may not include physical assessments in
addition to questions that rely on self-reporting. Some
multifactorial tools take as little as one minute to complete
and others can take over one hour. Nurses typically
administer these tools on admission to a care setting, with
regular reviews. However, physicians or therapists may
also use fall screening tools.
The type of fall risk assessment tool selected for use
should be consistent with the risk profile of the intended
population. It is well known that fall risk profiles differ
considerably among the following groups:
• healthy, active seniors living in the community,
• those who are frail and need support in the
community,
• those who are hospitalized for acute health
problems, and
• those who are residents of long-term care
facilities.
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Strategies and Actions for Independent Living©
How to Select a Falls Risk Assessment Tool: The
following recommendations apply when choosing a fall risk
assessment tool:
•
High sensitivity of 70 per cent or greater - this gives
more accuracy in predicting who will fall and help in
targeting resources to those at highest risk.
•
High specificity of 50 per cent or greater - this will
avoid focusing prevention efforts on those who are
not predicted to fall.
•
High Inter-rater reliability, above 90 per cent.
•
Has been tested and proven to be an effective
assessment tool with a similar population as the one
you are planning for your application (e.g., age,
functional level, etc.).
•
Has been tested and proven in a similar setting to your
application (e.g., community, supportive housing, acute
care or long-term care).
•
Has written procedures explicitly outlining the
appropriate use and scoring of the tool.
•
Has established cut-off scores available.
Tools with good reliability and validity that are suitable for
home support clients include:
√ Floor Transfer (Murphy et al, 2003)
√ BERG Balance (Berg, 1992)
142
√
Physiological and Clinical Predictors (Lord,
1996)
√
Functional Reach (Duncan, 1992; Murphy, 2003)
√
Five-step Test (Murphy, 2003)
√
Elderly Falls Screen (Cwikel, 1988)
√
Timed Up and Go (Rockwood et al, 2000)
Of the tests with proven predictive values, the BERG Balance
Test is one of the most commonly used by physiotherapists
and occupational therapists and the Functional Reach Test is
one that takes a small amount of time to perform but does
not provide a dynamic assessment of gait. The Timed Up and
Go (TUG) test is shown to be a time efficient and reliable test
of balance and gait, and is recommended for use in the home
setting.
Due to its ease of use and evidence to support its
effectiveness in predicting fall risk among home support
clients, this tool is recommended for use with all home and
community care clients. The TUG can be used not only to
assess falls risk, but also to monitor health status and
outcomes related to functional mobility. The TUG protocol
can be found on page 146.
In addition to the fall risk assessment tools listed above, there
are a number of other valid and reliable tools used by a variety
of health professionals to assess many of the fall and fall
injury-related risk factors already discussed, including ROM
testing, muscle strength testing, mini-mental state examination
(MMSE), 3MS (expanded version of mental status exam),
geriatric depression scale (GDS), numeric pain rating scale
(NPRS) etc. Any clients who demonstrate difficulties with any
of these tests should also be considered as being at potential
risk for falling, with tailored prevention strategies put in place
to address the specific nature of the risk.
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Strategies and Actions for Independent Living©
CONCLUSION
We have succeeded in our goal if you now feel that you are:
Knowledgeable: You know the significance of the problem and
why falls prevention is needed.
Confident: You can identify fall risk factors with your clients and
work with a multidisciplinary team to apply best practices to
reduce or eliminate those risks.
Positive: You believe falls can be prevented and that the
effectiveness of strategies to reduce falls and related injuries can
be demonstrated.
THANK YOU FOR YOUR PARTICIPATION!
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Lesson 4: Putting It All Together
145