Creatively Preventing Falls:

The North Tyneside Falls Prevention Service

Integrated Care Pilot

Dr Steve W Parry, Clinical Lead, North Tyneside Falls Prevention Service

Senior Lecturer, Institute for Ageing and Health, Newcastle University

Consultant Physician, Falls and Syncope Service and Clinical Director, Medicine

Newcastle Hospitals NHS Foundation Trust

Outline

• The North Tyneside Falls Prevention Service ICP

• Setting up, the importance of multi-agency service

development and provision

• Creative Comprehensive Geriatric Assessment

• Preliminary results

– Diagnostic

– Personal

• Age UK strength and balance training classes

– Health economic

• Top tips for getting your service commissioned

The North Tyneside Falls Prevention

Service: DH Integrated Care Pilot

• Local gaps in service provision

• Idea to fill the gap

– Enhance case finding

– Preventive service provision

• Involvement of key stakeholders to further the vision

• Commissioning perspective and involvement

• Multi-agency falls prevention service

• Service delivery, evaluation and justification

• 1 of 16 DH ICPs

Overview

• Falls and blackouts

– Common and overlapping

• 35-60% of over 65 years

– A Fib 1%; Heart failure 5%

• 10% suffer fractures

– Expensive

• >£4 billion per annum

– Devastating

• Personal, carer, health economic effects

NICE guidance on falls 2004

“ All health professionals coming into contact with older

patients should ask whether they have fallen in the last year”

“Refer for specialist assessment if 2 or more falls”

Chapter 8 CHD NSF Quality

Requirements:

“Service improvements locally via…improving access to

a higher level of expertise by the development of

multi-disciplinary arrhythmia and/or blackout clinics”

“People presenting with arrhythmias, in both emergency

and elective settings, receive timely assessment by

an appropriate clinician to ensure accurate diagnosis

and and effective treatment and rehabilitation”

The North Tyneside context…..

• 192,000 patients

– 44,160 >60 years

– 15,900 >75 years

• Lower prevalence estimate of 35%

– 15,500 fallers

• Approx 1500 seen by existing services

• Seen late in falls and blackouts “career”

– (14,000 not being seen at all)

• >60 years to rise from 23% to 32% in next decade

• Good evidence base to show that MDT approach is

both clinically and health economically effective

Tip #1

• Get your facts straight

– Help your commissioners to “see the light”

– Show why your service is needed within the local

context

– Don’t shroud wave

– Don’t over-egg the pudding; present the facts

without spin – its always obvious

– Understand that your commissioning team also

want to promote good healthcare

– Make extrapolations explicit and sensible

– Cost savings estimates rarely do as they say they

will – be realistic

Tip #2

• Get the right team around the table BEFORE you

tackle commissioning issues

– Newcastle Hospitals Foundation Trust

– Private primary care provider (Norprime)

– Age UK

– Newcastle University

– North of Tyne PCT

– North Tyneside Social Services

– North East Ambulance Service

Enhancing case finding

• Electronic screen of GP casenotes of all over 60s

• Falls risk factors

– Previous fall or blackout with secondary care

attendance

– Previous fragility fracture

– 4 or more prescribed meds (psychoactive,

antihypertensive)

– Falls or blackouts recorded by GP

• Screening questionnaire sent to those identified

• Invited to attend based on responses

Enhancing case finding

• Screening questionnaire sent to those identified

– Excluded if part of PD Service, seen by other falls

services

– Stroke

– Falls or blackouts in last year, fragility fracture

– ED or inpatient as result of falls or blackouts

– Dizziness or balance problems affecting ability to

walk properly

– 76% response rate

• Invited to attend based on responses

– 3900 seen in 4 years, 5 clinic sessions per week

Creative Comprehensive Geriatric Assessment:

Targeted specialist falls and blackouts assessment

in community setting

• Senior physiotherapy assessment and treatment

• Band 2 HCA review

• ECG, lying and standing blood pressure

• Geriatric depression scale, MMSE, FES-I, visual acuity

• Medical assessment

• History, examination, bone health risk assessment (FRAX)

• Review of findings, education, counselling

• Recommendations to primary care

• Referrals to secondary care, Age UK strength and

balance training classes, social services, physio

• Paper less service (SystmOne)

– Individualised care plan

Tip #3

• Ensure service users are represented in the

development of your service plan

• Ensure appropriate partnership in terms of service

provision

– Age UK key partner

– Service design and development

– Novel service provision using existing

infrastructure and organisation

• Targeted strength and balance training classes

Tip #4

• Destructive innovation and serendipitous planning

• Aka pick your moment and don’t be afraid to escalate

given the opportunity

– Partnerships in place

– Service model developed

– Commissioning team interested and going through

usual channels

– Opportunity to present to PCT Executive

• Rapid escalation to service provision

What can be accomplished:

The first 3308 patients.........New diagnoses

• 1999 (60%) ADDITIONAL diagnoses

– Diagnoses making a difference to falls and syncope

risks or relevant to national guidance and targets (eg

early identification of cognitive impairment)

– NOT existing diagnosis

• 1264 (38%) significant gait and balance

abnormalities

– All given home exercises, individualised

– Additional physio advice, day hospital, community

physio

– 25% referred for Age UK strength and balance training

classes

The first 3308 patients....

• Osteoporosis

– All undergo FRAX

– 90 high risk “recommend treatment”

– 411 (12.4%) referred for DEXA, 1/3 treated

– 200 newly treated

• 727 with falls efficacy scale score >23

• Ongoing £840k NIHR HTA funded RCT of cognitive

behavioural therapy for this patients

• Independent data from DH evaluation of patient

satisfaction (3.8/4 overall)

N=3308 No. %

Referred for Dexa following FRAX tool 411 12.4

New cognitive impairment (MMSE<24) 145 4.4

Benign positional paroxysmal vertigo 113 3.4

New atrial fibrillation 53 1.6

Orthostatic hypotension 129 3.9

Absolute indication for permanent pacemaker 17 0.5

Long QTC 13 0.4

Vasovagal syncope 116 3.5

New depression (15 item GDS>10) 117 3.5

Reduced visual acuity/review lenses 90 2.8

New murmur 96 2.9

High risk FRAX, treat osteoporosis 90 2.7

What can be accomplished:

The first 3308 patients.....New diagnoses

N=3308 No. %

Low BP,culprit meds 50 1.5 Asymptomatic bradycardia, culprit meds to reduce 62 1.9

Syncope requiring investigations 57 1.7

New neurological signs requiring referral 35 1.1 Orthopaedic referral suggested- unstable knees/

surgical intervention 88 2.7 Orthotist - leg length, foot drop and foot

indications 44 1.3

Other 273 8.3

Significant gait and balance abnormalities 1264 38.2

Total significant new diagnoses 1999 60.4

What can be accomplished:

The first 3308 patients.....New diagnoses

Benign positional paroxysmal vertigo

• 2450 patients assessed in first 2 years

• 95 new diagnoses of posterior canal BPPV were made as a

result of a positive Dix-Hallpike test -3.8% prevalence

• Mean age 74.3 years; range 60-89 ; 76 females ; 48 had

fallen

• 50 right BPPV, 37 left BPPV and 8 bilateral

• Additional diagnoses made:

– Lower level gait disorder in 45, 20 referred to Age UK balance group

– 5 required osteoporosis medication as per guidelines

– 14 referred on for DEXA on basis of FRAX tool

– 7 orthostatic hypotension

– 3 bradycardia requiring medication review

– 1 new atrial fibrillation

– 1 new cognitive impairment

– 3 depression

Baseline TUG

Mid point TUG

(5weeks)

Final TUG

(10 weeks)

mean

(sec) 15.33 11.46 11.43

SD 6.27 4.53 4.59

t test

Baseline v mid

p=0.0072

Baseline v Final

p<0.000001

Timed Up and Go Test Results in North Tyneside Elders

attending Age UK Strength and Balance Training Classes

Total 187

Mean age 76.6 years(range 60-89)

129(69%) female

TUG results as below:

Super Cool Jack, 86 years

Health economic analysis

• Institute of Health and Society, Dr Peter McMeekin

• Patients attending NTFPS versus comparator

• North Tyneside versus Newcastle

• Clinical effectiveness

– Deaths, hip fracture rates and associated deaths

• Costs

– Hospital recorded length of stay bed days

– cost of ED admittance, from PBR tariffs.

– Programme costs (an average: total spend divided

by the eligible population; £220 PBR tariff per

attendance)

• Cost effectiveness expressed in QALYs and costs

per QALY

•No changes to services

apart from N Tyne Falls

Prevention Service

•North Tyneside population

over 60:

•40,572

•Newcastle population over

60

•46,670

Difference in 2010-11

of 51 hip fractures

Average tariff of

£10,000

£510,000 saved

Note 30% mortality

rate

25% res/NH care 250

260

270

280

290

300

310

320

330

2008-09 2009-10 2010-11

Fracture Neck of Femur

North Tyneside Newcastle

2009-10 2010-11

Newcastle 3.21 11.42

North Tyneside -6.27 2.46

-10

-5

0

5

10

15N

OF

%

Year on year change in FNOF rates

Non-elective admissions: N Tyne Falls Prevention Service

Patients versus Cramlington Control Group

0 100 200 300 400

0.9

00

.92

0.9

40

.96

0.9

81

.00

Days

Ra

te fr

ee

fro

m fa

ll re

late

d h

osp

ital a

dm

issi

on

420 day Kaplan-Meier survival curves

Control groupIntervention group

Non-elective admissions: N Tyne Falls Prevention

Service Patients versus Cramlington Control Group

• N Tyne Falls Prevention Service

– 741 non-elective admissions per 10,000 population

• Cramlington Control Practice

– 768 non-elective admissions per 10,000 population

– 27 non-elective admissions saved @ £5,000 ie

£135,000

• For North Tyneside with 40,000 >65s: £540,000

Reduction in mortality at 18 months

Health economic analysis: QALY estimates

Tip #5

• Ongoing service evaluation and reporting to those

commissioning

– Make your evaluation relevant to the local health

economy

– Refer to local, regional and national priorities and

guidelines

– Without this, you are doomed……

Patients seen

at NTFPS

Number with

falls self

report (%)

Number with

falls recorded

by GP

% of self

report falls

Practice A 349 242 (69) 58 24

Practice B 213 136 (64) 0 0

Total 562 378 (67) 58 15

Patients seen

at NTFPS

Number with

syncope self

report (%)

Number with

syncope

recorded by

GP

% of self

report

syncope

Practice A 349 23 (7) 4 17

Practice B 213 12 (6) 2 17

Total 562 35 (6) 6 17

Why a case finding approach is important……

Presenting Complaint N=994 (%)

Drop attack 37 (4%)

Syncope 95 (10%)

Vertigo 110 (11%)

Dizziness 381 (38%)

Falls 592 (60%)

Fragility fracture 158 (16%)

Soft tissue injury needing medical attention 185 (17%)

Why a case finding approach is important……

So...creative CGA with a falls and syncope bias….

• Evidence-based approach based on national and

international guidance and best practice

• Informed by local and regional priorities

• Partnership approach

• Multi-agency, multidisciplinary

• Coherent case, with qualitative, quantitative and

health economic dimensions

• Measurable, reportable, sustainable in the longer

term

• Importance of third sector and other partners in

informing service design and providing service

delivery

…and what can be achieved….

• Service that all partners can take credit for

• Clear benefits to patients previously not seen by

services

– Significant additional diagnoses with further quality

and cost implications

– Case finding for atrial fibrillation, osteoporosis,

dementia, depression, recurrent syncope

– 25% strength and balance training classes with

enormous benefits

– Less tangible public health dimension

• Smoking, weight loss, alcohol intake, exercise

…and what can be achieved….

• Clear evidence of reductions in:

– Fall related hospital admissions

– Hip fracture

– Mortality

• Further data awaited (other fragility fractures, head

injury, stroke, syncope, readmissions and LOS data)

• Tangible initial cost savings conservatively estimated

at £645,000 (annual cost to PCT £280k)

– But no ward to close……

Problems and pitfalls

• Runner up in BMJ Innovation Awards 2012

• DH Integrated Care pilot winner 2009

• Superb results, 3900 seen in 3 years, clinically and

cost effective

• De-commissioned January 2014

• A little too novel, commissioning climate state

of flux

• “Easier to stop you than take money out of big

Foundation Trusts”

• Destructive innovation

– Private primary care provider

– Deep dislike from some of “usual route” team

– Keep all onside

Hazel’s tale.........

“I don’t use the walking sticks at all in the house

now,and use them much less outside as well. It’s

easier to get in the shower above the bath, and up

and down the back step. Because I’m not holding the

sticks any more I can reach things, cook and clean

more easily – it’s great to be able to do these myself .

I’m also finding it easier to use public transport again,

instead of always needing to get a taxi.”

1. Age UK

Sandra Gray, Alma Caldwell, Phil Earley

2. Newcastle Hospitals NHS Foundation Trust

David Green, Joanna Lawson, Emma Vardy,

Ahmed Jaafar, Sir Len Fenwick, Wendy Baker,

Judith McNaught, Pat Sherwood

3. Norprime

Nick Lawson, Richard Mayland

4. The Physiotherapy and Sports Clinic

Heidi Trundle

5. North Tyneside Social Services

Susan Meins, Eleanor Binks

6. North East Ambulance Service

Phil Kyle

7. North of Tyne PCT

Lynn Dixon, Chris Reid