Dataset Information

Enhancing referral processes within an integrated fall prevention pathway for older people: a mixed-methods study.

ABSTRACT:

Objectives

Multifactorial interventions, which involve assessing an individual's risk of falling and providing treatment or onward referral, require coordination across settings. Using a mixed-methods design, we aimed to develop a process map to examine onward referral pathways following falls risk assessment in primary care.

Setting

Primary care fall risk assessment clinics in the South of Ireland.

Participants

Focus groups using participatory mapping techniques with primary care staff (public health nurses (PHNs), physiotherapists (PT),and occupational therapists (OT)) were conducted to plot the processes and onward referral pathways at each clinic (n=5).

Methods

Focus groups were analysed in NVivo V.12 using inductive thematic analysis. Routine administrative data from January to March 2018 included details of client referrals, assessments and demographics sourced from referral and assessment forms. Data were analysed in Stata V.12 to estimate the number, origin and focus of onward referrals and whether older adults received follow-up interventions. Quantitative and qualitative data were analysed separately and integrated to produce a map of the service.

Results

Nine staff participated in three focus groups and one interview (PHN n=2; OT n=4; PT n=3). 85 assessments were completed at five clinics (female n=69, 81.2%, average age 77). The average number of risk factors was 5.4 out of a maximum of 10. Following assessment, clients received an average of three onward referrals. Only one-third of referrals (n=135/201, 33%) had data available on intervention receipt. Primary care staff identified variations in how formally onward referrals were managed and barriers, including a lack of client information, inappropriate referral and a lack of data management support.

Conclusion

Challenges to onward referral manifest early in an integrated care pathway, such as clients with multiple risk factors sent for initial assessment and the lack of an integrated IT system to share information across settings.

SUBMITTER: Flannery C

PROVIDER: S-EPMC9396121 | biostudies-literature | 2022 Aug

REPOSITORIES: biostudies-literature

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Publications

Enhancing referral processes within an integrated fall prevention pathway for older people: a mixed-methods study.

Flannery Caragh C Dennehy Rebecca R Riordan Fiona F Cronin Finola F Moriarty Eileen E Turvey Spencer S O'Connor Kieran K Barry Patrick P Jonsson Agnes A Duggan Eoin E O'Sullivan Liz L O'Reilly Éilis É Sinnott Sarah-Jo SJ McHugh Sheena S

BMJ open 20220819 8

<h4>Objectives</h4>Multifactorial interventions, which involve assessing an individual's risk of falling and providing treatment or onward referral, require coordination across settings. Using a mixed-methods design, we aimed to develop a process map to examine onward referral pathways following falls risk assessment in primary care.<h4>Setting</h4>Primary care fall risk assessment clinics in the South of Ireland.<h4>Participants</h4>Focus groups using participatory mapping techniques with prima ...[more]

PMID: 35985777

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Project description:The iSOLVE implementation project established and evaluated integrated processes and pathways, including a decision-making tool and educational interventions for general medical practitioners (GPs) and the upskilling of allied health professionals (AHPs). The study used a mixed-methods (parallel) design comprising surveys, qualitative methodologies, and an embedded cluster randomized controlled trial (RCT). Sampling was conducted within a Primary Health Network (PHN) geographic area in Sydney, Australia. AHP workshops (n = 367 attendees) covered six evidence-based interventions, resulting in increased confidence (p < 0.001) and numerous enhancements in fall prevention delivery. Among GPs, 75 were recruited from 27 practices. GPs in the experimental group were more likely to engage in fall prevention activities, including risk assessments, medication reviews, and providing advice, compared to the control group (p = 0.002). They were also more likely to refer patients to AHPs at 3 months (p = 0.002); however, this effect was not significant at 12 months (p = 0.13), as referral behaviors increased in the control group over time. Responses to free-text questions of practice change highlighted differences, with the experimental group reporting a more proactive and comprehensive approach to fall prevention. In a subset of GP patients (n = 560), no significant effect was observed in reducing the rate of falls (IRR = 0.96). The pragmatic nature of the project and potential contamination across multiple elements likely influenced this outcome. However, an area-wide survey of GPs (n = 562) revealed an increase in fall prevention referrals to AHPs over 5 years, from 70 to 82% (p = 0.028). Our findings highlight the importance of equipping GPs with tools and strategies to adopt a proactive approach to fall prevention among older patients. AHPs play a crucial role in this effort, and fostering relationships and connectivity across primary care networks is essential to maximizing the impact of fall prevention initiatives.Clinical trial registrationAustralian New Zealand Clinial Trials Registry, ACTRN12615000401550, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368286.

Project description:BackgroundThere is growing acknowledgement of the need for a phased approach to scaling up health interventions, beginning with an assessment of 'scalability', that is, the capacity of an individual intervention to be scaled up. This study aims to assess the scalability of a multi-component integrated falls prevention service for community-dwelling older people and to examine the applicability of the Intervention Scalability Assessment Tool (ISAT). The ISAT consists of 10 domains for consideration when determining the scalability of an intervention, and each domain comprises a series of questions aimed at examining readiness for scale-up.MethodsMultiple methods were used sequentially as recommended by the ISAT: a review of policy documents, results from a service evaluation and falls-related literature; one-to-one interviews (n = 11) with key stakeholders involved in management and oversight of the service; and a follow-up online questionnaire (n = 10) with stakeholders to rate scalability and provide further feedback on reasons for their scores.ResultsThree of the ISAT domains were rated highly by the participants. Analysis of the qualitative feedback and documents indicated that the issue of falls prevention among older people was of sufficient priority to warrant scale-up of the service and that the service aligned with national health policy priorities. Some participants also noted that benefits of the service could potentially outweigh costs through reduced hospital admissions and serious injuries such as hip fracture. The remaining domains received a moderate score from participants, however, indicating considerable barriers to scale-up. In the qualitative feedback, barriers identified included the perceived need for more healthcare staff to deliver components of the service, for additional infrastructure such as adequate room space, and for an integrated electronic patient management system linking primary and secondary care and to prevent duplication of services.ConclusionsPlans to scale up the service are currently under review given the practical barriers that need to be addressed. The ISAT provides a systematic and structured framework for examining the scalability of this multi-component falls prevention intervention, although the iterative nature of the process and detailed and technical nature of its questions require considerable time and knowledge of the service to complete.

Project description:IntroductionWheelchair users with spinal cord injury are at a high risk of falls. However, the perspectives of wheelchair users with spinal cord injury on their fall circumstances and their preferences for fall prevention strategies/interventions remain understudied. Therefore, we aimed to: a) describe the circumstances of falls experienced by wheelchair users with spinal cord injury over a six-month period, b) explore their perspectives of why falls occurred in certain situations, and c) explore their perspectives on recommended content/structure of fall prevention strategies/interventions.MethodsThis sequential explanatory mixed methods study had two phases. Phase I involved tracking of falls experienced by wheelchair users with spinal cord injury over six months, in which participants completed a survey after experiencing a fall to track the number/circumstance of each fall. Data from the surveys were descriptively reported. Phase II involved a photovoice focus group discussion of the survey findings and their preferences for fall prevention strategies/interventions. Data from the focus group discussion were analyzed using a thematic analysis.ResultsThirty-two participants completed phase I. More than half of the participants fell at least once in six months. Falls commonly occurred in the afternoon during a transfer, or when participants were wheeling over uneven ground. One-third of the falls caused an injury. Eleven participants that fell during phase I participated in the focus group. Two main themes were identified from the discussion: 1) "circumstances surrounding the falls" (e.g. when falls occurred, the home is a 'safe space') and 2) "suggestions and preferences for fall prevention strategies/interventions" (e.g. fall prevention involves all, fall prevention training available as needed).ConclusionFall prevention strategies/interventions should be an integral component of rehabilitation practices across the lifespan. Participants recommend customizing fall prevention strategies/interventions to their specific needs to guide the structure, content, and delivery of targeted fall prevention programs.

Project description:BackgroundFalls in people with dementia can result in a number of physical and psychosocial consequences. However, there is limited evidence to inform how best to deliver services to people with dementia following a fall. The aim of the DIFRID study was to determine the feasibility of developing and implementing a new intervention to improve outcomes for people with dementia with fall-related injuries; this encompasses both short-term recovery and reducing the likelihood of future falls. This paper details the development of the DIFRID intervention.MethodsThe intervention was designed using an integrated, mixed-methods approach. This involved a realist synthesis of the literature and qualitative data gathered through interviews and focus groups with health and social care professionals (n = 81). An effectiveness review and further interviews and observation were also conducted and are reported elsewhere. A modified Delphi panel approach with 24 experts was then used to establish a consensus on how the findings should translate into a new intervention. After feedback from key stakeholders (n = 15) on the proposed model, the intervention was manualised and training developed.ResultsWe identified key components of a new intervention covering three broad areas: • Ensuring that the circumstances of rehabilitation are optimised for people with dementia • Compensating for the reduced ability of people with dementia to self-manage • Equipping the workforce with the necessary skills and information to care for this patient group Consensus was achieved on 54 of 69 statements over two rounds of the Delphi surveys. The statements were used to model the intervention and finalise the accompanying manual and protocol for a feasibility study. Stakeholder feedback was generally positive and the majority of suggested intervention components were approved. The proposed outcome was a 12-week complex multidisciplinary intervention primarily based at the patient's home.ConclusionsA new intervention has been developed to improve outcomes for people with dementia following a fall requiring healthcare attention. The feasibility of this intervention is currently being tested.Trial registrationISRCTN41760734 (16/11/2015).

Project description:BackgroundMultiple sclerosis (MS) is a chronic, neurodegenerative disease that causes a range of motor, sensory, and cognitive symptoms. Due to these symptoms, people with MS are at a high risk for falls, fall-related injuries, and reductions in quality of life. There is no cure for MS, and managing symptoms and disease progression is important to maintain a high quality of life. Mobile health (mHealth) apps are commonly used by people with MS to help manage their health. However, there are limited health apps for people with MS designed to evaluate fall risk. A fall risk app can increase access to fall risk assessments and improve self-management. When designing mHealth apps, a user-centered approach is critical for improving use and adoption.ObjectiveThe purpose of this study is to undergo a user-centered approach to test and refine the usability of the app through an iterative design process.MethodsThe fall risk app Steady-MS is an extension of Steady, a fall risk app for older adults. Steady-MS consists of 2 components: a 25-item questionnaire about demographics and MS symptoms and 5 standing balance tasks. Data from the questionnaire and balance tasks were inputted into an algorithm to compute a fall risk score. Two iterations of semistructured interviews (n=5 participants per iteration) were performed to evaluate usability. People with MS used Steady-MS on a smartphone, thinking out loud. Interviews were recorded, transcribed, and developed into codes and themes. People with MS also completed the System Usability Scale.ResultsA total of 3 themes were identified: intuitive navigation, efficiency of use, and perceived value. Overall, the participants found Steady-MS efficient to use and useful to learn their fall risk score. There were challenges related to cognitive overload during the balance tasks. Modifications were made, and after the second iteration, people with MS reported that the app was intuitive and efficient. Average System Usability Scale scores were 95.5 in both iterations, representing excellent usability.ConclusionsSteady-MS is the first mHealth app for people with MS to assess their overall risk of falling and is usable by a subset of people with MS. People with MS found Steady-MS to be usable and useful for understanding their risk of falling. When developing future mHealth apps for people with MS, it is important to prevent cognitive overload through simple and clear instructions and present scores that are understood and interpreted correctly through visuals and text. These findings underscore the importance of user-centered design and provide a foundation for the future development of tools to assess and prevent scalable falls for people with MS. Future steps include understanding the validity of the fall risk algorithm and evaluating the clinical utility of the app.

Project description:BackgroundShock-absorbing flooring may minimise impact forces incurred from falls to reduce fall-related injuries; however, synthesized evidence is required to inform decision-making in hospitals and care homes.MethodsThis is a Health Technology Assessment mixed methods systematic review of flooring interventions targeting older adults and staff in care settings. Our search incorporated the findings from a previous scoping review, MEDLINE, AgeLine, and Scopus (to September 2019) and other sources. Two independent reviewers selected, assessed, and extracted data from studies. We assessed risk of bias using Cochrane and Joanna Briggs Institute tools, undertook meta-analyses, and meta-aggregation.Results20 of 22 included studies assessed our outcomes (3 Randomised Controlled Trials (RCTs); 7 observational; 5 qualitative; 5 economic), on novel floors (N = 12), sports floors (N = 5), carpet (N = 5), and wooden sub-floors (N = 1). Quantitative data related to 11,857 patient falls (9 studies), and 163 staff injuries (1 study). One care home-based RCT found a novel underlay produced similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to a plywood underlay with vinyl overlay and concrete sub-floors. Very low-quality evidence suggested that shock-absorbing flooring may reduce injuries in hospitals (Rate Ratio 0.55, 95% CI 0.36 to 0.84, 2 studies; 27.1% vs. 42.4%; Risk Ratio (RR) = 0.64, 95% CI 0.44 to 0.93, 2 studies) and care homes (26.4% vs. 33.0%; RR 0.80, 95% CI 0.70 to 0.91, 3 studies), without increasing falls. Economic evidence indicated that if injuries are fewer and falls not increased, then shock-absorbing flooring would be a dominant strategy. Fracture outcomes were imprecise; however, hip fractures reduced from 30 in 1000 falls on concrete to 18 in 1000 falls on wooden sub-floors (OR 0.59, 95% CI 0.45 to 0.78; one study; very low-quality evidence). Staff found moving wheeled equipment harder on shock-absorbing floors leading to workplace adaptations. Very low-quality evidence suggests staff injuries were no less frequent on rigid floors.ConclusionEvidence favouring shock-absorbing flooring is uncertain and of very low quality. Robust research following a core outcome set is required, with attention to wider staff workplace implications.Trial registrationPROSPERO CRD42019118834 .

Project description:BackgroundFalls are the most common hospitalized injury mechanism in children aged ≤1 years, and currently, there are no targeted prevention interventions. The prevention of falls in children of this age requires changes in the behavior of their caregivers, and theoretically informed digital behavior change interventions (DBCIs) may provide a unique mechanism for achieving effective intervention. However, user acceptance and the ability of DBCIs to effect the required changes in behavior are critical to their likelihood of success.ObjectiveThis study aims to evaluate a behavior theory-informed digital intervention developed following a user-centered approach for user experience, the potential for this intervention to prevent infant falls, and its impact on behavioral drivers underpinning fall risk in young children.MethodsParents of infants aged <1 year were recruited and asked to use the intervention for 3 months. A pre-post longitudinal design was used to examine the change in the potential to reduce the risk of falls after a 3-month exposure to the intervention. Postintervention data on behavioral drivers for fall prevention, user acceptability, and engagement with the app were also collected. Interviews were conducted to explore user experiences and identify areas for further improvement of the intervention.ResultsA total of 62 parents participated in the study. A statistically significant effect on the potential to reduce falls was observed after the intervention. This effect was higher for new parents. Parents agreed that the intervention targeted most of the target behavior drivers. The impact of behavior drivers and intervention on the potential for fall prevention had a positive correlation. The intervention demonstrated good levels of acceptability. Feedback from participants was mostly positive, and the primary area identified for further improvement was widening the scope of the intervention.ConclusionsThis study demonstrated the promise of a newly developed digital intervention to reduce the risk of infant falls, particularly among new parents. It also showed a positive influence of the DBCI on the drivers of parental behaviors that are important for fall reduction among infants. The acceptability of the app was high, and important insights were gained from users about how to further improve the app.

Dataset Information

Enhancing referral processes within an integrated fall prevention pathway for older people: a mixed-methods study.

Objectives

Setting

Participants

Methods

Results

Conclusion

Publications

Enhancing referral processes within an integrated fall prevention pathway for older people: a mixed-methods study.

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