cedar court healthsouth rehabilitation hospital “safe walkers” outpatient falls prevention and...
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Cedar Court Healthsouth Rehabilitation Hospital
“SAFE WALKERS” Outpatient falls prevention and
balance programEryn Wait (Occupational Therapist)
Tiana Wong (Physiotherapist)
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Cedar Court: overview
• CCHS started out as a small hospital in the 1930’s, therapy services introduced in 1980
• Purchased by Healthsouth, USA in 1997
• Present day, 80 bed inpatient capacity with orthopaedic/musculoskeltal unit, neurology unit, cardiac-respiratory unit, ABI unit and sleep study unit
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Outpatient programs
• Large outpatient program scope:
• Neurological
(stroke, parkinson’s/movement disorders, MS, neuropathies & myopathies)
• Vestibular
(dizziness/vertigo, balance and mobility problems leading to falls)
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Outpatient programs
• Acquired Brain Injury
(Traumatic head injury)
• Orthopaedic rehabilitation
(post-joint replacement or reconstruction surgery, fractures, spinal surgery or multi-trauma)
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Outpatient programs
• Musculo-skeletal rehabilitation
(arthritis, fibromyalgia, or back pain)
• Pain management
(chronic pain)
• Cardiac rehabilitation
(AMI, CABG’s, cardiomypopathies, stents, pacemaker, other acute events)
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Outpatient programs
• Respiratory rehabilitation
(emphysema, chronic bronchitis, thoracic surgery or pneumonia)
• Sleep disorder
(Ax and Rx of breathing problems during sleep, insomnia or excessive sleepiness)
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“SAFE WALKERS”Description and aims
Run under Neurology outpatient streamA comprehensive team approach for the assessment and
treatment of people who suffer from recurrent falls or poor balance affecting mobility and safety.
Aims to remediate and improve strength, fittness, balance, as well as retrain balance skills.
Educate and provide problem-solving sessions to minimise falls.
Use of safety strategies in various environments and situations.
Promote confidence and independence.
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Rehabilitation Team
Safe Walkers treating team
Rehabilitation consultant
Physiotherapist Occupational Therapist
Dietician
PsychologistAllied Health Assistant
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Referral sources & procedure
Referral sources GP’s Inpatient referrals
(Internal and other Acute private hospitals)
Specialist medical consultants
Community organisations
Referral procedure Referral from GP or
medical specialist required in writing
Health fund check Assessment by OT/PT Entry to program
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Admission criteria
TARGET GROUPS
• History of falls
• General physical
deconditioning
• Reduced ability to cope
functionally
• Emotional/psychosocial
difficulties
• Fear of falling
NON-TARGET GROUPS
• Medically unstable
• Acute vestibular dysfunction
• Individuals with significant cognitive/memory deficits
• Inability to cope in a group setting
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Assessment 1 ½ hour subjective/objective
assessment with physiotherapist and occupational therapist
Outcome measures (refer to table) Provision of information
/education booklet Home visit booked Scheduled to start program
MEDICAL REVIEW Consultants review half way
through program Team meeting with Consultant
and therapists fortnightly
Occupational
Therapist
Physiotherapist
Modified fear of falling scale
Smart balance master
Folstein mini mental
Timed up and go
Barthel ADL index
Step test
Goals 10 metre walk test
Home Assessment (as needed)
Functional reach
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Balance Master
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Group structure & content
Monday Tuesday Wednesday Thursday
9.30-10.30
OT Patient Assessment
OT Patient Assessment
10.00-10.45
PT Strength PT Strength PT Strength PT Strength
10.45-11.00
Morning tea
PT Patient
Assessment
Morning tea Morning tea
PT Patient
Assessment
Morning tea
11.00-11.45
Education Education Education Education
11.45-12.30
PT Balance
Exercises
PT Balance
Exercises
PT Balance
Exercises
PT Balance
Exercises
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Treatment 6/52 program, twice a week sessions for 2 ½ hours Mondays/Wednesdays or Tuesdays/Thursdays (4/52 program for DVA)
• Balance retraining• Strengthening and stretching• General conditioning• Outdoor and community mobility retraining• Assessment and provision of appropriate gait aids• Education on falls prevention• Functional retraining: ADL• Home visit• Psychology assessment• Referral for community services
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Balance exercises
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Occupational Therapy: ADL training
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EducationTOPICSBalanceCauses of fallsCommunity safetyHome safetyEnergy conservationWhat to do if you fallHome practicalWellbeingManaging fear of falling: RelaxationPutting changes in to practiceNutritionPreparation for outdoor walking* Outdoor walk & public transport access is conducted every 6/52, or 1:1
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Outdoor mobility and public transport access
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Evaluation
• On the patient’s final session the outcome measures are taken again
• Goals reviewed• Referral to a community exercise program
is arranged as appropriate• A 3 month review appointment is given• Discharge summary sent to GP and/or
referring specialist
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Future direction with data collection• Recent development of new database 2005• Collecting following data using excel spreadsheet format:
Gender Step test (ADM,D/C,RV)
DOB Functional reach (ADM,D/C,RV)
Reason for referral Sit to stand (ADM,D/C,RV)
Primary presenting condition Fear of falling scale (ADM,D/C,RV)
Timed up and go (ADM,D/C,RV) Mini mental (ADM, D/C)
Functional reach (ADM, D/C,RV) Falls 3/12 prior to the program Smart balance master (ADM,.D/C, RV)Private rehab post program
10 metre walk (ADM,D/C, RV) Falls during program (+ 3/12 RV)
Psychology referral Community referral
Barthel ADL index (ADM,D/C)
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Project Aims
to compare the efficacy of 4 week v 6 week program to evaluate the demographics of the patients referred to
the program, thus establishing target groups to assess the long term effectiveness of the program (3
month review) to identify and track the primary referral sources to increase suitability of referrals to determine the effectiveness of Cedar Court’s falls
and balance program both qualitatively and quantitatively
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Project aims
Evaluating compliance by determining the percentage of patients completing the program
Look at trends with outcomes for different patient groups (considering diagnoses, age, gender, supports in place)
Provide insurance providers with evidence of program effectiveness (justification of program length, and disciplines needed)
Implementation of suggestions from patient feedback surveys
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Methodology
Step 1- Identification of aims Step 2- Entering of data collected from the
past 6 months (n=50) Step 3- Evaluation and analysis of data Step 4- Presentation of data internally and
externally (Falls Clinic Coalition) Step 5- Implementation of findings
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Limitations
No control groupIncomplete data e.g patient unable to do balance master
Extraneous variables e.g patient wearing different shoes on admission and discharge thus reducing reliability
Multifactorial problems
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References
• Cockrell JR & Folstein (1988). Mini Mental Status Examination, Psychopharmacology, 24: 689-692
• Cole,B., Finch,E., Gowland,C., Mayo,N. Physical Rehabilitation outcome measures. Toronto: Canadian Physiotherapy Association, 1994
• Duncan,P., Weiner,K., Chandler,J. et al: Functional Reach: A new clinical measure of balance. Journal of Gerontology 1990; 45: M192-97
• Hill,K., Bernhardt,J., McGann,A. et al: A new test of dynamic standing balance for stroke patients: Reliability, validity, and comparison with healthy elderly. Physiotherapy Canada 1996; 257-62
• Mahoney FI, Barthel,D. “Functional evaluation: the Barthel Index” Maryland State Medical Journal 1965; 14: 56-61
• Podsiadlo,D., Richardson,S: The “timed up and go test”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society 1998;46: 758-61
• Tinetti,M., Richman, D., Powell,L. Falls efficacy as a measure of fear of falling. J Gerontology 1990; 45: P239-43