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Falls Injury Prevention ForumHealthy at Home Programme

Prepared byJacqueline Greenham

Programme Co-ordinatorNovember 2007

Revised : March 2008

OverviewBackground

Flags

Client story – processes– Intake

– Assessment

– Referrals

– Outcomes

How to refer

Brief background - HAHPiloted project 2006-07 SAFTE– 4 sites– Situated within existing services– Retrospective study– Aging population

Age and geographical criteria– 65 years >– Newcastle and Lake Macquarie LGAs

Early intervention through early case finding– Community service providers– Flags

Brief background - HAH

Health / community service partnership– CAPAC and COPs

6 week programme

Central intake (RIC)

CHIME

ONI

Holistic and comprehensive

HAH clients

Average age 83 years

Females 67%

66% + indicated to having fallen in the past 6 months

HAH health team - CAPACCommunity Acute Post Acute Care– Newcastle Community Health Centre– 7day service– 08.00hr - 18.30hr– 24 hour “on-call”– Medical, nursing, physio and occupational therapy– Hospital avoidance / substitution model

• “Hospital in the Home” service• Transitional Aged Care Programme

HAH service team - COPsCommunity Options

Brokerage service

– Case management

– “Compacks”

– Specific programmes (eg DemCop, NESB)

– Also manage CCRC and Carelink

HAH - Flags

•Increasing tiredness•Taking to bed during the day•Sleep disturbance or night time wandering

Sleep Patterns

•Worsening memory; forgetting to do things etc•Getting lost outside•Confused

Change in Memory

•Lack of interest in normal activities•Social isolation and reduced communication skills•Lack of motivation

Emotional Change

•Difficulty getting to the dining room •Increasing difficulty rising from a chair/toilet•Problems getting in and out of bed•Becoming unsteady on their feet•Furniture walking to get around environment•Need for extra care or assistance•Falls or stumbles•Need for walking aid or wheelchair

Activities of Daily Living / Mobility Problems

•Lack of interest in food, loss of appetite•Weight loss•Aspiration (choking on food/drink)•Needing assistance with eating

Weight and Nutrition

•Dishevelled appearance•Not changing out of night wear or wearing slippers outside•Staining from urine/bowels or food •No longer making an effort with make-up or shaving•Increasing tiredness and weakness •Increasing ‘frailty’

Change in Physical Appearance and Activity

DescriptionFLAGS

Referral to HAH - 24/10/2007

HNE GNC Standard Intake Protocol

TYPE OF SERVICE REQUIRED: HEALTHY AT HOME - SAFTE ASSESSMENT

NAME OF PERSON GIVING CONSENT:CLIENT

GP AWARE OF REFERRAL:NO

PRESENTING ISSUE:AMBULANCE CALLED TO CLIENT THIS AM, CLIENT HAD FALLEN OVERNIGHT AND SPENT THE NIGHT ON THE FLOOR. NOT MANAGING AT HOME, NEEDS DOMESTIC ASSISTANCE ETC. REFERRER STATED THAT HOUSE WAS UNKEPT. CLIENT WAS RELUCTANT WHEN HAH SUGGESTED BY AMBULANCE OFFICERS BUT DID AGREE THAT IT WOULD BE BENEFICIAL TO HER IN THE LONG RUN.

HOSPITAL ADMISSION DETAILS:N/A

RELEVANT MEDICAL HISTORY:HYPERTENSION, INCONTINENCE

CURRENT SERVICES:NONE

FAMILY/SOCIAL SUPPORT:FAMILY LIVE IN SYDNEY, HAS SUPPORTIVE FRIEND, KELLIE GALLAGHER, ADAMSTOWN BUT CONTACT NUMBER CLIENT HAS, IS INCORRECT. KELLIE SHOPS FOR CLIENT ONCE A WEEK.

LIVING ARRANGEMENTS:LIVES BY SELF

DO THEY NEED TRANSPORT?YES

MOBILITY ISSUES:AMBULATES WITH A WALKING STICK

FALLS HISTORY:HISTORY OF FALLS IN THE PAST, FELL OVER NIGHT

EQUIPMENT IN USE:WALKING STICK AND VITAL CALL SYSTEM

COGNITION/MEMORY ISSUES:ALERT

BEHAVIOURAL ISSUES:N/A

ADDITIONAL INFORMATION:CLIENT HAS SECURE BOX AT FRONT OF HOUSE FOR SCREEN DOOR KEY BUT AMBULANCE

OFFICERS HAD TROUBLE ACCESSING THIS WHEN THERE THIS AM.

Next stepService request to CAPAC via CHIME

Service request emailed to COPs

GP contacted to – inform him / her of referral– request health summary and medication list

Client / NOK contacted– home safety check attended– appointment arranged

Sometimes dual health / service visit

HAH Nursing assessment – 25/10/2007

PRESENTING ISSUE

Fall night 23/10/07, client spent night on fall. Ambulance called. Client not managing at home, needs domestic assistance, house very unkempt. Friend helps with shopping each week and some chores. HAH home visit for home assessment. Client's friend Kerrie answered door on nurse arrival. House has very strong smell of urine and very unkempt.

Medical Hx: HT, incontinence.

Observations: BP 110/60, T38.2, RR 18, P59, Sa02 95% RA.

MEDICATION ASSESSMENT– Forgets to take medications regularly

PAIN ASSESSMENT– Denied any pain

SELF CARE/CARER ASSESSMENT– Dressed in underwear only– Not showering regularly, difficulty accessing bath / shower

ELIMINATION ASSESSMENT– Bladder incontinence.

SKIN INTEGRITY ASSESSMENT– No wounds, rashes, skin intact

HOME MANAGEMENT ASSESSMENT– Home unkempt, unable to attend to domestic chores

MOBILITY/EQUIPMENT ASSESSMENT– Ambulant with walking stick, unsteady on feet – Client needs home modifications and equipment.– Client needs muscle strengthening exercise education.

COGNITIVE ASSESSMENT– Alert and orientated to time, place and person. MMSE 21/30

NUTRITIONAL ASSESSMENT– well nourished, appetite fair

HAH Nursing assessmentEXISTING REFERRALS

CURRENT SERVICE– Friend helps with shopping / banking

PLAN

COPS for major house clean, personal care assistance, meal preparation, medication supervision and domestic services.

OT for home modifications and equipment assessment.

Physio for assessment re mobility aid and exercise programme.

Referral to continence clinic.

Blister pack medication delivery

Fax assessment to G.P.

Liaise with HAH / CAPAC registrar re fever / fall

HAH nurse home visit daily for review medications, observations.

Follow-up with COPS.

ONI - standardised assessmentCore profile - demographics, issues, current services, plan (from profiles)

Health behaviours profile - alcohol and smoking, nutrition, physical activity / fitness

Health conditions profile - overall, vision and hearing, falls, feet, continence, medications, speech swallowing, listed medications and medication management, client health concerns, medical diagnosis

Functional profile - ability to attend various activities eg housework, showering, shopping, finances, mobility

Carer profiles – identifies need for carer, carer details and any threats to carerarrangements

Living arrangements profile – home situation, type of residence, employment status, decision making responsibility, financial decisions

Psycho-social profile - not usually attended, use MMSE and GDS

Every client receives……

Health assessment

Keeping active

Medications

Eyesight

Footwear

Environment (inside and out)

lighting

slipping

tripping

Alternately …..

COPs Care Plan and Schedule Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Early AM

<Other> vital call Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 9:30am to 10:00am hah$

<Other> vital call Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 9:30am to 10:00am hah$

<Other> vital call Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 9:30am to 10:00am hah$

<Other> vital call <Other> Kerry visits and does shopping and banking Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 9:30am to 10:00am hah$

<Other> vital call Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 9:30am to 10:00am hah$

<Other> vital call Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 9:30am to 10:00am hah$

<Other>

vital call Personal Care Grade 2 carer

1/2 hour Extracare Home Services Pty

Ltd 9:30am to 10:00am

hah$

Morning

Domestic Cleaning Extracare Home Services Pty Ltd 10:00am to 11:30am HaH$

Lunch

A’noon

Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 4:30pm to 5:00pm hah$

Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 4:30pm to 5:00pm hah$

Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 4:30pm to 5:00pm hah$

Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 4:30pm to 5:00pm hah$

Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 4:30pm to 5:00pm hah$

Personal Care Grade 2 carer 1/2 hour Extracare Home Services Pty Ltd 4:30pm to 5:00pm hah$

Personal Care Grade 2 carer 1/2 hour

Extracare Home Services Pty Ltd

4:30pm to 5:00pm hah$

Current Goals: • Personal care to maintain good hygiene.

• Cleaning of dwelling to promote safety and maximise mobility in moving around unit.

Special Notes: Care Manager: Wendy Yuide Tel: 49246099, AH: , Newcastle/Lake Macquarie Community Options, COP Tel : 02 4924 6099, AH: Key Contacts: GP: Dr Andrew McDonald 4929 2718, Ms Kerrie Gallagher (02) 4961 3396, Extracare Home Services Pty Ltd

Copies to: Mrs Dorothy Thorpe, Ms Kerrie Gallagher, Dr Andrew McDonald, Extracare Home Services Pty Ltd

Medical reviewThis client has had a recent fall in her home which resulted in R sided chest wall injuries. Although her pain is only mild and with movement she has developed a temperature over the last couple of days and she feels that her breathing is not as good as usual. She has really only been taking occasional panadol for her pain. An MSU was unremarkable.

She has never smoked. has no significant heart disease and lives alone.

Today she was bright and cheery with the occasional pang of sharp pain with some movements. Deep breathing was actually pretty good. She has not had any significant expectoration but she feels as if she could.

On exam she has decreased air entry at the base of her right lung with some crackles. There are also some crackles at her R base. She has a normal l.o.c and normal thought content.

Most likely she has a R sided LRTI secondary to sputum retention after a chest wall injury. The plan is to start empirical anti biotic treatment, regular pain relief, medication supervision, some personal care and probably physio review. Her fall sounds like misadventure but I don`t think she uses her frame consistently. I will review her condition next week.

HAH OT assessment Present on visit: Client, OT, OT student

1 Diagnosis and Medical History: Fall 23/10/07, HT, incontinence, falls Hx – poor history.

2 Medications: See Nursing Assessment

3 Pain managements: See Nursing Assessment

4 Bowel Management: Nil concerns

5 Bladder Management: Incontinent

6 Anti-embolic stockings (TEDS): N/A

7 Wound Management N/A

8 Current Services: Via HAH

9 Follow-up appointments:

1 Personal Hygiene/ Self-care: Client is presently receiving assistance showering from Extracare (HAH).

1 Social Issues/ Domestic Support Client reports that she has a brother and SIL in Sydney.

• Meals Client’s “friend” Kerrie buys frozen meals.

• Housework Client is presently receiving assistance with housework Extracare (HAH). Clutter noted.

• Laundry N/A

• Shopping Client reports friend Kerrie attends to shopping. Client reports accompanying Kerrie occasionally.

• Finances Independent – pension (? self funded).

• Transport Client travels in taxis or with Kerrie and/or Kerrie’s husband.

1 Mobility:

• Indoors: Independent with an A-frame walker

• Outdoors: Not assessed by OT

• Steps: Not assessed by OT

HAH OT assessment – cont.1 Transfers

Chair: Independent with effort with use of chair arms

Bed: Independent with bed stick

Toilet: Independent with RTS

Car: Not assessed by OT

Floor: Not assessed by OT

Home Environment

Type of Accommodation: Single level unit

Ownership: Owned by client

Layout: Level throughout with 1 x threshold step at front access, nil rails.

Access

Front: 1 x step and high latched gate to access front yard from sidewalk. 1 x threshold step, nil rails.

Back: N/A

Internal: Level throughout

Floor Coverings: Tiles – bathroom, hallway, kitchen, toilet; carpet – living areas, bedroom.

Outside (path/driveway): Level concrete path in good condition.

Bedroom

Bed size: Single Height: Appropriate for client

Equipment: Nil – recommend bed stick

Possible space for commode: Yes

Access by patient: Accessed from hallway or bathroom. Clutter noted.

Telephone/Alarm: Vital call insitu

General Comments: Light switch is awkward to access as it is located behind a wardrobe. Bed stick to be provided.

OT assessment - cont.Bathroom

Door Swings : Inward (from bedroom access), sliding door from hallway access Width: Bedroom access: 800mm

Hallway access: 710mm Lip: Bedroom access: 20mm

Hallway access: 20mm

Shower Set-up: Separate recess, HHSH, outward swinging screen door

Hob Height:

Bath: Yes – not used by client

Equipment: Shower chair fitted (00733) – client was previously using a plastic outdoor chair to shower on. OT provided shower chair. Slip resistant mats outside and inside shower recess.

Comments: Client reports that the tiles in the bathroom are quite slippery when wet, recommended patient use non-slip mats. OT to provide information on non-slip solution for floor. Recommended that grab rail be installed in shower recess.

Toilet

Location: In bathroom

Rails: Nil

Equipment: Nil – RTS to be provided.

Kitchen

Layout: Good circulation space

Cupboard/ bench height: Appropriate for client

Stove: Gas, microwave

General Comments: Fridge, freezer and pantry all well stocked with food. Clutter noted.

Lounge Room

Chair: Single dining chair Height: Appropriate for client Armrests: Yes

General Comments: Lounge room contains a lot of clutter, client reports spending most of her time sitting in lounge room.

Equipment:

Ownership: Shower chair, A-frame walker

Loan expires on:

General (mats/telephone/alarm/lighting): Vital call, night-light in bathroom, mats throughout house.

OT assessment - planPlan / Recommendations:

• Complete home modification plans for installation of grab rail in shower recess.

• Complete home modification plans for installation of wedge ramps at bathroom and toilet access.

• To provide bed-stick and OTA

• Concerns re: Cognition - liaise with medical registrar for assessment

HAH physio assessmentHAH PHYSIOTHERAPY INITIAL ASSESSMENT

PRESENTING PROBLEM: Fell on floor on 23/10/07. Client reports the floor was very cluttered and slipped on something; she crawled to a chair to get a cushion and used vital call for ambulance. Was on floor for 4 hours. Reports no #’s but has had ongoing right side LBP since, aggravated by movement.

MEDICAL HISTORY: Client reports high blood pressure and incontinence.

Vision: Short sighted, not wearing glasses at time of visit but reports she wears glasses.

Hearing: No problems

Medications: Client reports using Tenormin for BP, Natrilix as a diuretic and Solprin for pain

FALLS HISTORY: Reports having 2-3 falls in the last few years. Previous fall to this tripped in the bathroom and was on floor for a few days.

SOCIAL HISTORY:

Lives with: alone

Shopping: friend Kerrie does her shopping or takes her to the shops

Transport: taxi

Meals: heats her own frozen dinners

Current services: assistance with cleaning, showering (Extracare organised by HAH) and mowing the lawns

Leisure/hobbies: gardening, reading and ABC radio

Mobility status: mobilising with walking stick

Activity level: currently mostly mobilises around the home, when going to the shops sometimes walks, other times borrows a w/c

Footwear: none at time of Ax

Current equipment: w/s, shower chair, HHSH

Physio assessment - cont.Objective Assessment:

General: Client alert and happy to receive treatment

Bed Mobility: Independent and able to manage well.

Transfers: STS- able to complete, a little slow but does not look unsteady

Toilet- currently pushing through towel rail to pull self up, able to complete independently. Would have difficulty completing without rail.

Gait: Slow with short step length, leaning slightly to right side, looks slightly unsteady. Using w/s appropriately

Outdoor mobility: Ax with push down brake walker, safe and steady. No problems noted.

Stairs: 1 step at front, able to negotiate safely with walker.

Strength/ROM: N/A

Environmental:

External Access

Front

1 small step into house rail: nil Client safe to access: Yes

Rear

N/A

Yard/paths: Paved level courtyard to gate. Cement path beyond.

Internal access One story level home.

Internal: 0 steps

Bedroom Cluttered bedroom, large pile of clothes on ground to be washed by friend

Bed size: Single

Requires bed blocks: no Client safe with transfers: Yes

Physio assessment - cont.Bathroom Door swings: in

Bath: no

Shower: Over bath Recess with hob and HHS

Screen Type: OT to ax

Frame access: yes no

Grab rails: yes no Client safe with transfers: Yes No

Toilet In Bathroom and separate (only uses bathroom toilet)

Frame access: yes Door swings: in

Grab rails: no, shower rail on left Client safe with transfers: No

Summary:1 Problems: Slight unsteadiness when mobilizing with w/s2 Some problems transferring off of toilet, requiring shower rail to assist

1 Treatment: Issued a push down brake walker to use outside and in lounge room of house. Taught to use appropriately and practiced in and outdoors.2 Advised on Rankin Park falls prevention programme.

1 Plan: OT to issue RTS today to assist with toilet transfers.2 Mail information on falls program to decide next week if she wants to participate, if not ?HEP3 r/v 1/52, Ax effectiveness of walker over past week.

How was she 19/11/2007Home environment and personal hygiene much improved – home cleaner and less cluttered, more space

OT review - equipment in place – safe transfer of toilet and out of bed. Plans completed for bathroom/ toilet wedge, PADP application for equipment

Physio review - mobilising with walking frame. No further falls. Declined RPDH falls clinic, has home exercise programme (strength and balance)

Medical review – improved, no further input

Improved cognition - MMSE 29/30

Weekly nurse, physio and COPs review

Client happy with services

Plan for discharge 5th December 2007

Where is she after HAHCOPs case management

– Domestic assistance

– Personal care

– Meal preparation

ACAT assessed – high level care – waiting EACH

Hospital admission for AMI

NO FURTHER FALLS reported

Without HAHClient gets transported to ED by ambulance or left alone with no follow-up

If ED– long waits, focus on presenting issues

– will be assessed and if not injured may be sent home, with or without follow-up (depending on EDACC nurse)

– may be admitted and later sent home with or without services (depending upon day of week and access to social work)

– is at risk of longer LOS and more adverse events

How to refer

Healthy at Home

(formerly SAFTE Care)

Support for care of frail, elderly people

1800 152 149

Thank you