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Collaborative Approach

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Fall Prevention
By ANGELA MERRETT, PATRICIA THOMAS, ANNE STEPHENS, ROLA MOGHABGHAB and MARILYN GRUNEIR
The four partner organizations formally recognized their commitment and shared vision through a letter of agreement, which specified a framework, definitions and terms for their respective roles and responsibilities. The letter of agreement was intended to foster a sense of belonging among the group and identify leadership and governance for the project. The two site coordinators were responsible for preparing and coordinating the ethical review applications and letters of support. The team decided to use the existing practices of community service providers. To facilitate referrals of participating patients, the team first identified the existing service pathways. The hospital medical director distributed an overview document to inform emergency department physicians of the project, and the clinical nurse specialist reviewed the referral process, protocols and documentation with nursing staff.

ore than ever, health-care providers need to communicate with each other to stay informed about the services clients receive. Working in collaboration is essential to the delivery of effective, efficient and timely care (D'Amour, Ferrada-Videla, San Martin Rodriguez, & Beaulieu, 2005; Interprofessional Care Steering Committee, 2007). We all had roles on the Geriatric Emergency ManagementFalls Intervention Team (GEM-FIT) project, which was aimed at evaluating an alternative service-delivery pathway to reduce the number and consequences of falls in adults aged 65 and older who presented to an inner-city hospital emergency department. The project was based on the Falls Intervention Team (FIT) study, which had evaluated a best practice, multifactorial fall-prevention program for community-dwelling older adults (Baycrest Centre for Geriatric Care, City of Toronto, & Regional Municipality of York, 2006). Like the earlier study, the GEM-FIT project was multidisciplinary. Four organizations participated in the project: St. Michael's Hospital, Toronto Public Health (TPH), Community Occupational Therapy Associates (COTA) Health and the Toronto Central Community Care Access Centre (CCAC). Each assigned management representatives to the project team. In addition, St. Michael's Hospital provided a site coordinator, who was the clinical nurse specialist for geriatric emergency management, and TPH contributed a site coordinator and three public health nurses. COTA Health supplied three occupational therapists, and CCAC provided two hospital coordinators and funded the occupational therapy visits. A total of 14 staff members made up the team.

METHOD
Sample population. The site coordinator from St. Michael's Hospital scanned emergency department records to identify older adult patients at risk of falls (e.g., those taking more than five medications; those who had had a recent fall, gait or balance problems, vision or hearing impairment; those who relied on assistive devices). Both site coordinators completed a literature review for multifactorial fall-prevention initiatives involving emergency departments and community health sectors. They also consulted with four emergency department nurses on approaches and triage tools for referring potential patients to the project. Senior managers from each organization were asked to approve components of these activities before the project planning phase continued.

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Collaboration among health-care providers ha s emerged as a key factor in improving client care. The authors describe

the Geriatric Emergency Management- Falls Inte rvention Team (GEM -FIT) project, a nurse-led research initiati ve to improve fall prevention in older adults through

interdisciplina ry collabo ration. Public health nurs es and occupational therapists assessed particip ants before and after fall-prevention interventions and found

modest improvements in participant outcomes and reductions in modifiable risk factors. The project res ulted in successful collaboration, interdisciplina ry teamwork and improved se rvice delivery to participants. Among the challenges were delayed timelines, complex issues outside the project protocol and communication difficulties. The authors , who se rved on the project team, make recommendations for health-care profes sionals interested in initiating similar projects.

OCTOBER 2011 VOLUME 107 NUMBER 8

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PARTICI PANTS (N = 5)
T1: rNInAl
T2: POST·INTERVENnON
T) : SIX-MONTH

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REPORTED FAllS
1 in last 30 days

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Project design. The team met monthly t o plan , develop and implement t he project. As in the FIT evaluation study, assessments were performed before and after the interventions (Baycrest Centre for Geriatric Care et al., 2006). Emergency department nurses assessed patients using the Triage Risk Screening Tool. screened them for eligibility and asked whether they would be interested in becoming project participants. Patients who gave informed consent were referred t o CCAe. For each referral, an occupational therapist performed the es tablished mobility assessment, and the TPH site coordinator was asked to send a notice of participation letter to the patient's family do ctor. Each participant was assigned to a public h ealth nurse, who made six home visits to the participant over 12-14 weeks (along with a phone call), and to an occupation al therapist, who made a maximum of three home visits (Figure 1). The home visits included one joint visit by the public health nurse and the occupational therapist during the ac tive intervention phase. The post-interventi on phase of the protocol consisted of one followup visit (T2) immediately after the intervention phase, a six-month followup visit (T3) and then discharge. The structure of the T2 and T3 visits was identical to the initial assessment visit (T1), and the same data collection tools were used throughout. Four validated scales were used for all assessments: Berg Balance Scale (Berg. Wood-Dauphinee. Williams. & Gayton. 1989). Timed Up and Go (Podsiadlo & Richardson. 1991). Activities-specific Bala nce Confidence (Myers. Fletcher. Myers. & Sherk. 1998). and Reintegration to Normal Living Index-Postal (Daneski. Coshall. Tilling. & Wolfe. 2003). In addition. nurses and occupational therapists completed a Falls Assessment and Intervention Record (FAIR), which outlined multifactorial strategies and m easured modifiable risk factors before and after the interventions (Baycrest Centre for Geriatric Care et al.. 2006). The FAIR helped the team assess whether these strategies resulted in a change in the number of modifiable risk factors (i.e., postural hypoten sion , use of sedatives, use of five or more medications, urinary and foot problems, environmental hazards, balance impairment, gait disorder, transfer deficit and fear of falling). During the active intervention phase, the nurse and occupational therapist completed a FAIR at every visit, including the joint visit. As interventions occurred, the FAIR was faxed to the other professionals to keep them informed of the participant's care. Finally, t he nurse and occupational therapist taught participants the Home Support Exercise Program developed by the Can adian Centre for Activity and Aging (Jones & Frederi ck, 2003). Participants were given a calendar diary and asked to record th e number of exercises performed on any given day.

Data analysis. The criteria for evaluating outcomes and processes included demographic sta tistics and number of falls reported before and after the interventions. Modifiable risk factors were analyzed, along with the outcome m easures at T1, T2 and T3. Project monitoring and adaptation. The t eam m et monthly to assess the referral rates and discuss other iss ues. TPH facilitated regular m eetings with the public h ealth nurses to review the project implementation. Monitoring becam e less frequent once the intervention protocol was completed for all participants. During the implementation phase, som e patients who lived outside the project catchment area were identified as likely to benefit from an intervention . As a result, the team expanded the service area and ext ended the referral timeline to allow these patients to participate in th e project.

RESULTS
Outcomes for partiCipants. The GEM-FIT project had 22 referrals in an eight-month period. The fi ve participants who co mpleted the entire project from T1 to T3 reported a reduced number of falls (Table 1). Outcome measures also improved between the T1 and T2 visits. However, sco res fell close to baseline at the T3 visit, which occurred six months after t he T2 visit (Table 2). At the T2 assessment, the participants h ad increased their speed by an average of 4.8 seco nds on t he Timed Up and Go scale. Their average scores on the other scales were also improved - by 3.6 points on the Berg Balance Scale, 1.4 points on the Reintegration to Normal LivingPostal scale, and 1.6 points on the Activities-specific Balance Confidence scale. These results from the active intervention phase of the project

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suggest improvements in balance and gait, satisfaction with social participation, and confidence. Exercise adherence was defined as having performed at least one of the home support exercises three times per week. Adherence was high during the intervention phase (100%), but during the post-intervention followup phase, only two of the remaining five participants returned calendar diaries, and data could not be calculated for the group as a whole. Perspectives of team members. A feedback session with the public health nurses and occupational therapists revealed some common themes. One was the need to help participants obtain assistive devices; another was the improvement observed in participants' strength levels after teaching them exercises. Improved collaboration was also highlighted - the nurses and occupational therapists felt they were learning from each other, resulting in better service. The nurses reported that they felt supported by each other through their frequent meetings, which allowed them to solve problems related to care. The FAIR was identified as a good tool for documentation and communication between the different care providers. The team observed that some participants had complex issues, which resulted in early discharge from the project or additional visits outside the protocol. Finally, the team strongly recommended replacing the manual documentation system with the electronic database that was used in the original FIT project, saying that it may have improved communication, allowed access to more complete and timely documentation and resulted in less duplication of work.

DISCU SS ION
Project strengths. The positive outcomes noted at the T2 assessment helped motivate some participants to continue to practise the Home Support Exercise Program. (The importance of practising the exercises regularly was re-emphasized with participants who were more frail.) Some participants stated informally that the equipment they received as a result of the intervention program (e.g., bath transfer seats, bed rails, transfer poles, sofa seats) and the proper adjustment of their existing mobility aids had enhanced their mobility and possibly reduced their risk of falling. The nurses and occupational therapists were enthusiastic about the benefits of teamwork in doing joint home visits and said they appreciated each other's work. Each group indicated that they had learned from the other and felt that their own work was validated. The observed benefits to the participants and the opinions elicited through the team's feedback session corroborate the findings of the original FIT evaluation study (Baycrest Centre for Geriatric Care et aI., 2006) and demonstrate transferability of the initiative. Team members reflected on the positive effects of their collaboration on the participants. By identifying patients in the emergency department who would benefit from targeted interventions with existing resources, such as the occupational therapy rehabilitation service, the team was able to deliver timely and efficient service. Performing comprehensive assessments and having the opportunity to coordinate care in consultation with team members further improved service delivery. During the feedback session, one

Table 2: Average scores and outcomes for participants at different stages of the project
TEST
T1: INITIAL ASSESSMENT T2: POST·INTERVENnON fOLLOWUP 13: SIX·MONTH FOLlOWUP

OUTCOME ATT2

OUTCOMEAT13

Berg Balance Scale" Timed Up and

39.6
18.8

43.2 14.0

43.8 18.8

Improvement (balance) Improvement (speed) Improvement (confidence)

Improvement (balance) Return to baseline

GOb

Activities-specific Balance Confidence< Reintegration to Normal Living Index-Postal d

65.4

67.0

60.0

No improvement (reduced confidence)

1.8

0.4

1.2

Improvement (reintegration)

Improvement (reintegration)

Note. Only the five participants who completed the entire program were included in these analyses. ' Maximum score is 56. Higher score indicates beller performance. "Independent:::'=10 seconds; semi-independent: 11-19 seconds; dependent: ~20 seconds. 'Score represents percentage of confidence. "Maximu m score is 22. Higher score indicates poorer s tatus .

OCTOBER 2011 VOLUME 107 NUMBER a

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(CAC = Commun ity Care Access Cent re CNS = d inical nurse speciali st ED = emergen cy department FIT = Falls Intervention Team GEM = geriatri c emergency management OT = occupa ti onal th erapist

GEM CNS SCREENS PATIENTS FOR GEM-FIT REFERRAL

PHN = publi c hea lth nurse TRST = Triage Risk Screen ing Tool

REFER TO CCAC HOSPITAL COORDINATOR

REFER TO GEM-FIT COMMUNITY SITE COORDINATOR

REFER FOR OTSERVICES

CLIENT ELIGIBLE FOR GEM-FIT RESEARCH STUDY

PARTICIPANT INELIGIBLE; REFER TO CCAC FOR ASSESSMENT

Tl, PHN HOME VISIT #1 - ASSESSMENTVISIT

HV #2 - ASSESSMENT/INTERVENTION PHN/OT JOINT HOME VISIT (COMPLETION OF Tl AND INITIATION OF INTERVENTION PROTOCOL)

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participants as larger priorities than their continued involvement with the project . These developments made it difficult for the team to adhere to the protocol. Finally, the paper documentation system made communication among team members difficult. Forms had to be faxed between organizations to facilitate the next stage in the protocol. Faxes were sometimes unclear, and forms were not always conducive to faxing. Written documentation was often difficult to read.

T3, PHN 6-MONTH REASSESSMENT VISIT

T2, PHN fOLLOWUP
ASSESSMENT VISIT

RECOMMENDATIONS
A formal letter of agreement is recommended as a way of increasing organizational accountability to the agreed upon service. This document outlines roles, responsibilities and scope of work to be provided by all involved, including front-line staff and management. Partners can clearly see the vision and goal for the initiative, where they fit into the project and which clinical settings are involved. The letter of agreement also enhances trust and provides a communication tool that can help with decision-making. In initiatives such as GEM-FIT,

occupational therapist commented that if not for the project, participants might have "slipped through the cracks" of the health-care system. Project challenges. Maintaining a project timeline helped the partners establish their commitment to the project. However, the project planning process took longer than expected, and implementation was delayed for nearly 18 months. Reasons for the delay included lengthy ethical reviews, revision of the application, partners' reviews of the changes, and resubmission. In addition, extensive legal input was required to establish the content, roles and responsibilities outlined in the letter of agreement. The complex issues participants encountered during the intervention protocol were greater than anticipated. New medical diagnoses, eviction threats, bedbug infestations and other life events were often perceived by

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THE EMERGE NCY ROOM EXPERIENCE OF A FRAIL SEN IOR can be int imi dating, exhausti ng and confu s ing. But geriat ric emergen cy ma nagement (GEM) nurses a re seek ing to change t hat. Frail elderly patie nts ente ri ng an emergen cy department are d ire cted to a GEM nurse, who s pend s up to seve ral hours ass es sing the patient - a lifetime in emergen cy department time , says Kerri Fisher, educati o n coordinator at the Regional Geriatric Program of Toronto. "GEM nurses make the experience of a frail elderly person that much better when they go to the emergency room. It's better than just being put in a chair, which is what happens in a normal triage process and which can take a long time. The experience of these elderly patients is that much better, and they get the se rvices they might not get if they were in the normal stream. The GEM nurse looks at their ph ysical condition, their cognition levels, their level of functioning, their social interactions - all aspects that could affect why they're in the emergency department, not just the initial reason they came in. It' s a comprehensi ve assessment," says Fisher. One of the first programs to use the GEM acronym began back in the late 1990S at Toronto 's Sunn ybrook Hospital, says Fisher. In 2004, after a pilot program proved successful, the hospital ' s GEM program was launched and an initial group of eight nurses were hired. Today, there are 90 GEM nurses in hospitals and health centres in Ontario. In Quebec, geriatric emergency initiati ves are interprofessional and focused at the research hospital setting, says Dr. David Ryan, director of education at Toronto's Regional Geriatric Program. British Columbia's provincial geriatric emergency nursing program is now defunct, whereas Alberta has researchers who are working in this area , but no formal program.

careful consideration must be given to timelines, which can have a significant impact on the resources needed for implem entation. Timelines may need to become m ore flexible wh en multiple organizations are involved. Good communication among organizations is essential to delivering timely service. The team recommends adoption of an electronic system that allows real-time documentation and lets multiple service providers at different sites access the sam e record. The GEM-F IT project benefited a select number of older adults disch arged from the emergency department , who succeeded in maintaining or slightly improving their functional capacity between the Tl and T2 assessments. Although this collaborative project required significant time, cost, resources and commitment, the care taken in

designing the initiative strength ened the partnership commitment and made the project a success overall . •
ACKNOWLEDGMENT The authors ackn owl edge Toronto Central CCAC fo r faci litating refe rra ls to COTA Health and provid ing occupational therapy services for t he proj ect. They thank t he other members of the GEM-FIT project tea m forthei r cont ributions in prepari ng this article.

ANGELA MERRETT, RN, BScN, B.A.Sc., MHS, ISA PU BLIC HEALTH NURSE AT TORONTO PUBLIC HEALTH, TORONTO, ONT. PATRICIA THOMAS, RN, MScN, M.Ed., IS MANAGER OF HEALTHY LI VING, INJURY PREVENTION, TORONTO PUBLIC HEALTH , TORONTO, ONT. ANNE STEPHENS, RN, BScN, M.Ed., GNC(C), ISA CLINICAL NURSE SPECIALIST, CLIENT SERVICES-COMMUNI1Y, TORONTO CENTRAL COMMUNI1Y CARE ACCESS CENTRE, TORON TO,ONT. ROLA MOGHABGHAB, RN(EC), MN, NP-AOULT, GNC(C), IS A PhD STUDENT AND A GERIATRIC EMERGENCY MANAG EMENT NURSE PRACTITIONER AT ST. MICHAEL'S HOSPITAL, TORONTO, ON T. MARILYN GRUNEIR, MSW, RSW, IS A CLIN ICAL SUPERVISOR ATCLOSING THE GAP HEALTHCARE GROUP AND A SOCIAL WORKER AT CERTIFIED COUNSELLING SERVICES, TORON TO,ONT.

REFERENCES
Baycrest Centre for Geriatric Care, City of Toronto, & Regional Municipality of York. (2006). Falls Intervention Team (FIn pilot project final report: An evaluation ota best practice model ota seniors' pilot program. Richmond Hill, ON: Authors. Berg, K., Wood·Dauphinee, 5., Williams, J.I., & Gayton, D. (1989). Measuring balance in the elderly: Preliminary development of an instrument. Physiotherapy Canada, 41(6), 304·311. Retrieved from http://utpjournals. meta press .co m / i ndex/tJOn 3 7061661184r.pdf D'Amour, D., Ferrada-Videla, M., San Martin Rodriguez, L., & Beaulieu, M.·D. (2005). The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. journal of Interprofessional Care, 19(5uppl. 1), 116·131. dOi:l0.l080/13561820500082529 Daneski, K., Coshall, C, Tilling, K., & Wolfe, C (2003). Reliability and validity of a postal version of the Reintegration to Normal Living Index, modified for use with stroke patients. Cliniwl Rehabilitation, 17(8),835-839. dOi:l0.1191/0269215503cr6860a Interprofessional Care Steering Committee. (2007).lnterprofessional care: A blueprint (or action in Ontario. Toronto: HealthForceOntario. Retrieved from http://www.healthforceontario.ca/upload/en/whatishfo/ipc%20 blueprint%20final.pdf Jones, G. R., & Frederick, J. A. (2003). The Canadian Centre for Activity and Aging's Home Support Exercise Program. Geriatrics and Aging, 6