Falls are multifactorial in their origin and are successfully addressed only through multifactorial interventions. Here in England we are provided with clear guidance on how to approach the problems of falls through the NICE (National Institute for Clinical Excellence) guidelines. In the USA, the CDC provides similar useful information. Putting that information together and creating successful interventions and services is not so straightforward and can be left up to lots of interpretation.
Assessing How We Treat Falls
In 2011 we reflected upon our falls service through the Kaizen process, we examined not only how our own service operated, but how neighboring services set up their practice as well. What we found were most of the services, including our own, relied upon one professional doing an initial assessment and then referring onward for additional interventions, as they believed necessary. One service was different in that it had four professions (PT, OT, nursing, and MD) in one clinic, however each was in a separate room and the patients went room to room telling their history four times and undergoing four different assessments. Everyone was working alone in their own silo of care.
We had a radical idea, what if we combined the nursing and physiotherapy assessment and did them at the same time in the same room? In this way the patient tells their story once and they get a much more comprehensive single assessment. The MD and the OT gave us clear guidance on when to refer on to them. To be clear, OTs function a bit differently here in the UK than in the USA. They are much more geared towards assessment and use of equipment for both the environment and for mobility. In the USA they have a greater role in cognitive assessment and rehab. A nurse generally addresses that aspect here.
At first the nurse and I (the physio) had very clear roles and responsibilities in the assessment, but inevitably we began to learn from each other. Prior to working in this way, I knew a very limited amount about medication management for older adults. I now can step in and do the medication review. The nurse knew little about assessing strength and gait. Now she can identify weak hip abductors and prescribe walking aids appropriately. We both now read and interpret the ECG and lying and standing blood pressure results.
Improved Results for Patients
Most importantly, at the end of one hour, the patient has a clear understanding of why they have fallen, what can be done about it, and has the appropriate walking aid to prevent further falls until the muscle weakness, or cardiac arrhythmia, or excessive amounts of hypertension medications, or environmental modifications, or sometimes all the above, can be sorted out. This is where we leave multidisciplinary silos behind and become interdisciplinary innovators.
Our results speak for themselves. I presented them at the last Physiotherapy UK conference in Birmingham last October. We demonstrated an 81% reduction in reported falls when we compared total falls 6 months prior to intervention to 6 months after discharge for all the people we treated in the year 2012. We were also able to demonstrate a savings to the NHS of nearly £600,000.00 for that year. We believe this is due to the changed way we perform our assessments. We get it right the first time!
Leave Your Silo
Working in this fashion is particularly difficult in the USA as the reimbursement system facilitates separation of treatments. How easy was it the last time you wanted to do a joint treatment with another discipline? However, I read with some degree of frequency about “turf disputes” among disciplines. This seems to be at odds with providing patient centered care. Yes, we should speak out if we observe someone working beyond their scope of practice, but there is also lots of overlap between our professions. By embracing that overlap we create a more powerful healing force for our patients, improve their journey of recovery, and grow our own knowledge base and expertise.
I can’t encourage this enough…leave your silo behind.
Guest Blogger Bio
Dean Metz has been practicing since 1992, after graduating from SUNY Brooklyn. Most of that time has been with older adults in community care in New York City, Florida, and Northern England. Dean was an instructor with the PTA program of New York University for seven years. He relocated to England for marriage in 2009 and starting working in the National Health Service, giving him a completely new perspective on health care delivery. He earned a Masters in Public Health with the goal of giving rehab a voice in the world of prevention and primary care. Dean’s goal is to move from changing one life at a time to affecting the health of whole populations.
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