Stand-Up for Senior Stand-Up for Senior IndependenceIndependence

(SUSI)(SUSI)

Lea Blackburn, LISW, ACSWLea Blackburn, LISW, ACSW

Riverside Methodist HospitalRiverside Methodist Hospital

John J. Gerlach Center for Senior HealthJohn J. Gerlach Center for Senior Health

614-566-4225614-566-4225

blackbl@ohiohealth.comblackbl@ohiohealth.com

SUSI Funded By:SUSI Funded By:

Ohio Department of Public SafetyOhio Department of Public Safety– Division of EMSDivision of EMS– HB 138 Special Projects HB 138 Special Projects

Columbus FoundationColumbus Foundation

Needs EvidenceNeeds Evidence

According to Columbus Fire Department According to Columbus Fire Department over 90% of the personal assist runs are over 90% of the personal assist runs are related to patient falls.related to patient falls.– During 6 month period EMS personnel have During 6 month period EMS personnel have

responded to 585 personal assist runs.responded to 585 personal assist runs.– Annual cost of $438,750Annual cost of $438,750– Takes EMS unit out of serviceTakes EMS unit out of service

Needs EvidenceNeeds Evidence

According to CDCAccording to CDC– every hour an older adult dies as the result of every hour an older adult dies as the result of

a falla fall– in 1998, more than 9,600 persons 65 and in 1998, more than 9,600 persons 65 and

older died from fall related injuries, making older died from fall related injuries, making falls the leading cause of death among this falls the leading cause of death among this age groupage group

– 60% of all deaths involve individuals over the 60% of all deaths involve individuals over the age of 75age of 75

– 30-35% of people 65+ fall each year30-35% of people 65+ fall each year– 20% of falls cause serious injury20% of falls cause serious injury

Frailty / Falls RelationshipFrailty / Falls Relationship

Frailty is defined by a constellation of Frailty is defined by a constellation of symptoms including weight loss, symptoms including weight loss, weakness, fatigue, inactivity due to food weakness, fatigue, inactivity due to food intake. An illness or trauma such as a fall intake. An illness or trauma such as a fall can trigger the acceleration of frailty.can trigger the acceleration of frailty.

Leading to loss of independent functionLeading to loss of independent function

GOALGOAL

An older adult who has experienced a fall An older adult who has experienced a fall (not resulting in a fracture) will effectively (not resulting in a fracture) will effectively implement environment modifications and implement environment modifications and individual behavior changes to prevent individual behavior changes to prevent ongoing frequent falls and thus remain ongoing frequent falls and thus remain independent.independent.

STUDY POPULATIONSTUDY POPULATION

Community-dwelling elders aged 70 or Community-dwelling elders aged 70 or greater, who have experienced 2 falls greater, who have experienced 2 falls requiring an emergency squad response requiring an emergency squad response within a 30 day period of time.within a 30 day period of time.– Changed the age criteria to 60Changed the age criteria to 60

119 initial home visits for assessment of 119 initial home visits for assessment of eligibility.eligibility.40 total subjects met the research criteria.40 total subjects met the research criteria.

Exclusion CriteriaExclusion Criteria

Fall was due to exacerbation of chronic Fall was due to exacerbation of chronic medical condition including, but not limited medical condition including, but not limited to, a spontaneous fracture due to to, a spontaneous fracture due to osteoporosis.osteoporosis.

Prior diagnosis of dementia and under Prior diagnosis of dementia and under care of physiciancare of physician

Prior diagnosis of depression and under Prior diagnosis of depression and under care of physiciancare of physician

ObjectivesObjectives

The referral program will reduce the The referral program will reduce the likelihood of falling among community-likelihood of falling among community-dwelling elders who have previously have dwelling elders who have previously have fallen at least twice within 30 days, as fallen at least twice within 30 days, as demonstrated by a fall rate which is demonstrated by a fall rate which is significantly above the baseline rate significantly above the baseline rate among this group.among this group.

Study VariablesStudy Variables

demographic demographic characteristicscharacteristics

home environment home environment and living and living arrangementsarrangements

circumstances & circumstances & location to the falllocation to the fall

baseline and follow-baseline and follow-up functional statusup functional status

co-morbidity’sco-morbidity’s

Clinical assessment Clinical assessment resultsresults– depressiondepression– dementiadementia– nutrition nutrition – home environmenthome environment– Added the CAGE Added the CAGE

(Alcohol screening)(Alcohol screening)

Study VariablesStudy Variables

follow-up after clinical follow-up after clinical recommendationsrecommendations– 1 month by phone1 month by phone– 3 months by phone3 months by phone– 6 month home visit6 month home visit

occurrence of falls occurrence of falls during study periodduring study period

hospital admissions hospital admissions during the study during the study period and reason for period and reason for admissionadmission

Collaborating PartnersCollaborating Partners

Columbus Fire DepartmentColumbus Fire Department

Community Public Health ProfessionalsCommunity Public Health Professionals

Study DesignStudy Design

This is a cohort study, which uses This is a cohort study, which uses historical data to measure the level of historical data to measure the level of success of the SUSI program.success of the SUSI program.

A randomized trial would provide the best A randomized trial would provide the best evidence for evaluating SUSI, it is not a evidence for evaluating SUSI, it is not a practical design.practical design.

Study Begins with:Study Begins with:

Referral for clinical assessment from CFD Referral for clinical assessment from CFD or Public Health Professionalor Public Health Professional

Clinical AssessmentsClinical Assessments

Depression screening - Geriatric Depression screening - Geriatric Depression Scale (GDS)Depression Scale (GDS)

Dementia Screening - Folstein 3MS Dementia Screening - Folstein 3MS Mental Status ExamMental Status Exam

Nutrition Screening - 1991 Nutrition Nutrition Screening - 1991 Nutrition Screening Initiative Level 1Screening Initiative Level 1

Home Environment ScreeningHome Environment Screening

Alcohol screening (CAGE)Alcohol screening (CAGE)

Health Status QuestionnaireHealth Status Questionnaire

Screened to Suggest RiskScreened to Suggest Risk

Educated by the Project CoordinatorEducated by the Project Coordinator

Coordinator will communicate with Primary Coordinator will communicate with Primary Physician regarding the baseline Physician regarding the baseline information.information.

Coordinator with consent (and prescription Coordinator with consent (and prescription if appropriate) from PCP will arrange PT, if appropriate) from PCP will arrange PT, OT, Dietician or Home Medical EquipmentOT, Dietician or Home Medical Equipment

Baseline Location & Reason for FallBaseline Location & Reason for FallSubject fell 2x within 30 daysSubject fell 2x within 30 days

Most Frequent Location of FallMost Frequent Location of Fall– Living Room / DenLiving Room / Den– KitchenKitchen

Qualitative reasons given:Qualitative reasons given:– Lost balance while reachingLost balance while reaching– Legs gave outLegs gave out– Turned around too quickTurned around too quick

# of Falls at 180 days# of Falls at 180 days

FALLSFALLS PERCENTAGEPERCENTAGE

00 40%40%

11 33%33%

22 10%10%

33 13%13%

4-54-5 5%5%

Results n=40Results n=4012.8% screened positive for depression12.8% screened positive for depression

57% screened positive for dementia57% screened positive for dementia

100% required home environment changes100% required home environment changes

47.5% screened positive for nutrition deficit47.5% screened positive for nutrition deficit– 32.5% required a dietician referral32.5% required a dietician referral

80% required a Physical Therapy referral80% required a Physical Therapy referral– 286 visits for 28 subjects286 visits for 28 subjects

25% required Occupational Therapy25% required Occupational Therapy– 89 visits for 1 subjects89 visits for 1 subjects

Qualitative ResultsQualitative Results““I feel like there is hope”I feel like there is hope”– Dentures were too loose, broken hearing aide, Dentures were too loose, broken hearing aide,

depressed and needs bathroom equipmentdepressed and needs bathroom equipment– referred to OSU dental clinic for denturesreferred to OSU dental clinic for dentures– referred to Cols Speech & Hearing for new aidereferred to Cols Speech & Hearing for new aide– referred to home modification company to install referred to home modification company to install

grab barsgrab bars– Ordered PT & OTOrdered PT & OT

I know why I fellI know why I fell– denying need for helpdenying need for help

Qualitative ResultsQualitative Results

““I can simply ask my doctor for an OT / PT I can simply ask my doctor for an OT / PT evaluation?”evaluation?”

““I’ll do anything to stay in my own home.”I’ll do anything to stay in my own home.”

““I’m just too old”I’m just too old”

““Therapy will come to my home?”Therapy will come to my home?”

““Medicare covers PT / OT evaluation and Medicare covers PT / OT evaluation and treatment?”treatment?”

Case ExampleCase Example

89 year old male has fallen 3x within 30 89 year old male has fallen 3x within 30 days. days.

Assessment result needs:Assessment result needs:– Depressed,Depressed,– Dietary needsDietary needs– Home ModificationsHome Modifications– dx with macular degenerationdx with macular degeneration

Case ExampleCase ExampleOutcomesOutcomes– PCP addressed overall PCP addressed overall

health including health including depressiondepression

– dieticiandietician– counselorcounselor– Home modifications - grab Home modifications - grab

bars, shower drain, bars, shower drain, removed carpetsremoved carpets

– medic alert systemmedic alert system– meals on wheelsmeals on wheels– homemaker and home homemaker and home

health aidhealth aid

– services for visually services for visually impaired came to impaired came to home and provided home and provided ‘gadgets’ to allow to ‘gadgets’ to allow to read againread again

– Physical Therapy 3x Physical Therapy 3x wk for 6 weeks wk for 6 weeks improve gait and improve gait and balance.balance.

No falls for 125 daysNo falls for 125 days

ConclusionsConclusions

Falling is not a result of a single factor it is Falling is not a result of a single factor it is a combination of some or all of the a combination of some or all of the following factors:following factors:– DementiaDementia– Over the age of 80Over the age of 80– Reaching for items in kitchen or living roomReaching for items in kitchen or living room– Currently receiving some form of caregiver Currently receiving some form of caregiver

support.support.

Variables that Directly Correlate Variables that Directly Correlate with a Decrease in Fallswith a Decrease in Falls

Improvement in DepressionImprovement in Depression– 71% improvement in GDS71% improvement in GDS

Improvement in Nutritional StatusImprovement in Nutritional Status– 55% improvement55% improvement

Home ModificationsHome Modifications– Carpets removed 45.9%Carpets removed 45.9%– Grab bars added 40.5%Grab bars added 40.5%– Home Medical Equipment 32%Home Medical Equipment 32%

Additional findingAdditional finding

There was no statistical significance There was no statistical significance between co-morbidities and falling.between co-morbidities and falling.

Qualitative Information with Qualitative Information with SignificanceSignificance

Lack of communication about falls to their Lack of communication about falls to their primary physician or family.primary physician or family.

Subjects stated they ‘knew’ why they had fallen.Subjects stated they ‘knew’ why they had fallen.

Subjects are afraid they will fall again.Subjects are afraid they will fall again.

A statistically significant number of physicians A statistically significant number of physicians were unaware that Medicare part B will cover OT were unaware that Medicare part B will cover OT or PT in the home with a prescription regarding or PT in the home with a prescription regarding fall risk.fall risk.

RecommendationsRecommendations

Education for EMS and health care Education for EMS and health care providers.providers.

Education for the older adult and their Education for the older adult and their family.family.

Riverside Hospital Gerlach Center for Riverside Hospital Gerlach Center for Senior Health developed a placemat with Senior Health developed a placemat with fall prevention strategies for EMS to take fall prevention strategies for EMS to take to older adults home or health care to older adults home or health care providers to distribute.providers to distribute.