Falls are the leading cause of preventable injury and death nationally among seniors age 65 years and older. Studies have shown that fall prevention programs emphasizing muscle strength building have been effective in reducing the number of falls in community dwelling seniors, and that exercise alone can be effective in reducing falls. To identify patients at risk for falls, consensus guidelines recommend that healthcare professionals ask about falls, with gait and balance assessment a key component for further evaluating patients at high risk (those who have fallen, or who are found to have a gait or balance problem). In late 2006, the nationwide VA External Peer Review Program (EPRP) began to conduct medical record reviews to determine how often outpatients age 75 years and older were asked about previous falls, and whether appropriate care was provided to those patients found to be at high fall risk. These data showed a wide variation in VA healthcare facilities' quality of care and significant room for improvement in national performance. Subsequently, a clinical reminder template for fall prevention was developed by a national workgroup under the auspices of the VA Office of Geriatrics and Extended Care.
To: (1) Test and refine the clinical reminder template for fall prevention to enhance its usability and allow for automated extraction of data to measure quality of care, (2) implement a care model based on the Assessing Care of Vulnerable Elders-3 (ACOVE-3) quality indicators for falls, and (3) evaluate the intervention for feasibility.
Three community-based outpatient clinics of the VAGLAHS tested the clinical reminder by screening all people age 75 years and older and subsequently managing those who screened positive using the ACOVE model. The reminder was refined based on a site visit to the clinics to determine their workflow. Subsequently, the revised reminder was presented at a second visit, coupled with education about how to perform a fall assessment.
Preliminary data indicate that between reminder activation in February 2011 and June 30, 2011, 2279 unique patients age 75 years and older visited the three pilot clinics, of whom 1399 were screened for fall risk. Three hundred patients screened positive for high fall risk, of whom 138 patients received a gait, balance and strength evaluation. Among the 92 patients who had some kind of gait, balance or strength problem on evaluation, two had advanced dementia and poor prognosis; among the remaining 90 patients, 30 were offered physical therapy or exercise (or the patient had recent physical therapy, recent supervised exercise program or declined physical therapy).
Our redesigned electronic clinical reminder for fall prevention screening proved to be useful in primary care, building on the existing VA administrative, clinical and informatics infrastructure. However, given the small number of patients actually referred to exercise programs, the effect of reminder use on clinical outcomes remains uncertain.
- Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Medical care. 2013 Mar 1; 51(3 Suppl 1):S37-43.
- Ganz D, Miake-Lye I, Saliba MD, Shekelle PG. Improving Implementation of Fall Prevention Programs for older Veterans. Poster session presented at: VA Career Development Award Program Annual Conference; 2010 Feb 25; San Francisco, CA.