Older people who have fallen receive guidance and long-term follow-up from a specialist team in London. Graham Clews reports
OT Claire McIntyre, rehab assistant Jennifer Jules, Sarah Teague, rehab assistant Elli Poder and Jonathan Zulueta. Photo: Charles Milligan
Even in the depths of winter, central London usually escapes the snow, ice and sub-zero temperatures that can make simply stepping out into the street a hazard.
But on this freezing morning in the West End, even the hardiest and fittest of individuals treads carefully along the streets around the Soho Centre for Health and Care.
Inside the centre, a physiotherapist, an occupational therapist, and two rehab assistants will take a group of older people through a series of exercises designed to reduce the likelihood of them falling – even in the most benign outdoor conditions, or in their own homes.
The falls prevention service in Westminster is based on a multifactorial assessment of clients who have had a fall, or have a fear of falling, or choose to self-refer because they feel they would benefit from the education and exercise that can be provided.
Clients are most commonly referred after admission to hospital for treatment following a fall, or by their GP. Referrals also come from the local fracture clinics, the voluntary sector, or through self-referral.
Additionally, a physiotherapist works with a pharmacist visiting care homes to ensure all new residents are given a falls risk assessment within four hours of admission. There are also falls risk workers in hospitals.
OT Claire McIntyre and patient. Photo: Charles Milligan
Physio Sarah Teague, clinical lead for falls and bone health at Central London Community Healthcare NHS Trust, explains that, once assessed, clients are referred to the appropriate level of the falls prevention service.
‘We use the Dawn Skelton model for falls rehabilitation,’ she says. Phase one is the most severe, for people who have been hospitalised. Phase five would be the lowest intervention, such as a community t’ai chi class.
The falls service operates a 12-week programme for phase three and phase four clients. Today’s session is a phase three class.
Jonathan Zulueta, band 7 clinical falls specialist physiotherapist at the trust, says the evidence suggests that 50 hours of participation in exercise is needed for the full rehabilitation of older people who have fallen.
Westminster’s 12-week programme clearly provides only a part of that, but clients are given detailed exercises to continue at home after they are discharged from the service.
The exercises are individually tailored, and each client receives a logbook to record their exercise regime.
They are also encouraged to log the number of falls or near misses they have during that time.
Links forged with a charity have proved fruitful
One unusual aspect of Westminster’s falls programme is the telephone follow up at three, six and 12 months, after clients complete their 12-week programme.
Clients are also asked about their use of GP services, A&E, their exercise pattern, their fear of falling and any recent fractures.
Ms Teague says these calls are used to monitor the efficacy of the service (see ‘healthy outcomes’ panel) and to inform and remind clients of other advice and classes that the falls service provides.
‘The calls are for review purposes but there is good evidence that this can be useful in motivating and encouraging people as well.
‘We want clients to take ownership of their exercise.’
Ms Teague says that during these calls, and during classes, clients are not asked specifically about falls. Instead they are asked to report positive experiences since their previous class.
‘Don’t mention the “f” word,’ she says.
In fact, the most common word among clients at the phase three class is ‘confidence’, and how the sessions improve it.
The exercises at the class are designed to improve physical capability, but also to address balance, and, crucially, to tackle fears of falling.
Clients are also taught how to cope with a fall, both in terms of precautions they can take to deal with the effects, such as pendant alarms, and also how to cope physically.
The service has worked with Transport for London and Metroline, a company that operates nine garages in Westminster, to look at ways of improving safety on buses and reducing the number of falls.
Driver training could be improved as a result of information gathered at focus groups attended by falls prevention service users.
The falls service is also linking up with Open Age, a charity that works with people aged over-50 to sustain physical and mental fitness in the boroughs of Westminster, and Kensington and Chelsea.
It provides services in church halls, libraries, and sheltered housing.
The falls service and Open Age have begun to run ‘Steady and Stable ‘classes for clients at phase five level.
They can be accessed through referral on a client’s completion of an NHS falls programme; through referral if someone drops out of the falls programme; and clients will be told of the classes when they are called to review their progress.
All clients can receive education and training in maintaining physical activity, and this can include help with walking outside, or practical situations such as getting on the bus or tube.
Ms Teague says the establishment of the Steady and Stable classes has plugged a gap in the service for clients who reached phase five level.
‘Beyond the 12-week programme, there was nothing other than t’ai chi, but that was too high a level for many,’ she says.
‘There were chair-based exercise classes, but they weren’t challenging enough.’
The falls service’s health promotion lead heads its attempts to bring hard-to-reach groups into the falls service, targeting older men’s groups, ethnic minority groups, and using data from public health to target specific geographical areas.
The service is also considering using ‘expert patients’ to improve the service provided still further.
‘Some patients have excelled and we want to bring some of them back to emphasise to some clients who are less keen to participate what can be done,’ says Ms Teague.
‘There is strong evidence that peer to peer learning can be particularly effective.’ The falls service is provided by Central London Community Healthcare NHS Trust, which operates in four London boroughs. fl
What went on and clients’ views
The number of clients at a phase three session varies, but on this day eight people attended, seven of them women (women are much more likely to turn up).
After a seated warm up, led by a rehab assistant, Mr Zulueta gave clients advice on their exercises and physically adjusted them. He paid special attention to a client who is registered as blind.
Then Mr Zulueta led a series of standing balance exercises, with clients reaching objects on a shelf with one hand resting on the shelf, then both hands by their sides, then with their eyes shut if possible.
The four staff remained closely behind the clients during these exercise offering physical and verbal support.
The group then split into four pairs for ‘circuit training’, which involved stepping over hurdles; getting up from the floor with backward chaining; and climbing on to and off objects of different heights.
Liz Scott was at her first session.
‘I’m very pleased because I’ve not tried to get up off the floor recently because I’ve been too frightened,’ she said. ‘It’s really good to know you can get up. Fear is really the biggest thing.’
Joanna Boyson attended a 12-week falls programme four years ago. She felt stable and confident enough not to attend phase four or five classes, but another fall meant she was referred for a second course.
‘I had a couple of bad falls and was very nervous,’ she said. ‘I can’t lift my feet very well so I tend to shuffle and fall, but these exercises really help with that.
I didn’t remember the exercises, but the staff are all so patient and already I feel much more confident.’
Rose Meighan’s balance was affected by cancer treatment. Now in remission she sought help from the service.
‘I was falling in the street and at home.
The exercises make a real difference and I really feel more confident when I’m at home or out.’
Falls prevention: healthy outcomes
In an increasingly tough commissioning environment, the cold, hard numbers that highlight success are key.
The Westminster falls prevention service can show commissioners it stops older people falling, reduces GP visits and keeps clients out of hospital.
Its patient recorded outcome measures consist of Berg balance tests, falls efficacy scale, timed up and go, and 30 second unsupported stand.
It uses a patient questionnaire for its patient recorded experience measure.
The service’s 2012 review assessed phase three clients who had completed the 12-week programme in 2011.
One year on, the number of falls reported had fallen by 47 per cent. A&E admissions fell by 25 per cent, and GP visits were cut by 28 per cent.
For phase four clients, there was a drop in falls of 41 per cent, 63 per cent fewer A&E visits, and a cut of 25 per cent in GP appointments.
The Westminster falls prevention service’s quantitative outcome measures from 2012 chart the progress made by clients who took part in the falls programme during the previous year.
More than three clients in four at phase three level moved from high risk to low risk in the National Institute for Health and Clinical Evidence-validated timed ‘up and go’ test.
This records the time a patient takes to stand up from sitting, walk three metres, turn, walk back and sit down.
On the falls efficacy scale, 59 per cent of phase three clients improved during the year, and 69 per cent of phase four clients improved.
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