Stakeholder and Data-Driven Fall Screen in a Program of All-Inclusive Care for the Elderly: Quality Improvement Initiative

Abstract

Background and Purpose: The Program of All-Inclusive Care for the Elderly (PACE) delivers community-based long-term care services to low-income, nursing home eligible adults. In the PACE population, one of the most common reasons for hospitalizations is falls. The purpose of this quality improvement study was to create a stakeholder-driven process for developing a fall risk screen and evaluate how well this process discriminated injurious and noninjurious fallers. Methods: The quality improvement design was a prospective, longitudinal data collection for 5 PACE programs in Colorado. Physical therapists collected the Short Physical Performance Battery (SPPB) on participants at least annually. The Kotter practice change framework guided the processes for practice and organizational change in developing and implementing a fall screen. Results and Discussion: An iterative, stakeholder, and data-driven process allowed our team of researchers and a PACE program to establish a fall risk screen to stratify PACE participants. We provided feedback to PACE staff regarding screening rates and results on discrimination of faller status to promote continued uptake of screening and discussion regarding next steps. Rehabilitation therapists screened 66% of the PACE population, and participants were stratified into high risk (1-7 points) or low risk (8-12 points) based on the SPPB. Participants with low SPPB scores had 79% greater risk of a fall (risk ratio [RR] = 1.8; 95% confidence interval [CI], 1.5-2.1) and 86% greater risk of an injurious fall (RR = 1.9; 95% CI, 1.4-2.4), compared with those with high SPPB scores. Conclusions: Our study describes a collaboration to address fall rates in a PACE population. Program of All-Inclusive Care for the Elderly clinicians can use the identified cut-offs to stratify PACE populations at risk for falls and allocate scarce rehabilitation resources efficiently to best serve participants at highest risk, while using less resource-intensive interventions for those at lower risk.

The Use of Quality Improvement in the Physical Therapy Literature: A Scoping Review

“…The acute care setting accounted for the largest number of included studies ( n = 41, 59%), 27,28,33,34,37,39-42,45,46,48,50,52,53,55,58,59,62,66,68,70-74,76-78,88,89,95-98,100-105 followed by the outpatient setting ( n = 19, 27%). 29-32,36,38,47,49,54,56,60,61,64,67,69,79,80,93,99 Other practice settings included inpatient rehabilitation ( n = 6, 8.6%), 36,43,57,65,75,76 home health ( n = 2, 2.9%), 44,63 other ( n = 2, 2.9%), 19,81 and academia ( n = 2, 2.9%). 35,51 The other category comprises a scoping review by Jesus et al 19 and a study by Steenbruggen et al 81 in which the practice setting was not made clear.…”

“…Of the 70 total included studies in this review, 18 (26%) 28,37,39,40,43-45,48,52,60,68,70,73,74,77,79,96,102 were approved by local ethics boards, 19 (27%) 32-34,36,41,46,47,49,50,53,55,56,58,63,64,67,81,97,100 sought approval but were considered exempt, 15 (21%) 19,35,38,42,57,59,61,62,65,71,72,75,78,80,93 reported that seeking approval was not necessary at their institution based on the type of project proposed and current regulations, and 18 (26%) 27,29-31,51,54,66,69,76,88,89,95,98,99,101,103-105 made no mention of ethics oversight.…”

“…82 The median QI-MQCS score for the 66 nonreview studies was 12 (range 7–15). Of the scored studies, 9 (13%) 27,36,60,61,63,64,79,99,105 were rated as insufficient quality, 31 (44%) 29,32-35,39,42,44,50,53-55,59,65-70,74,77,80,81,88,89,95,98,100-102,104 were rated as moderate quality, and 26 (37%) 28,30,31,37,38,40,41,43,45-48,52,56-58,62,72,73,75,76,78,93,96,97 were of good quality. Five of the 16 QI-MQCS categories were not reported in a majority of studies—sustainability (50%), adherence/fidelity (47%), organizational readiness (50%), penetration/reach (21%), and spread (14%) (Figure 2).…”

Implementation of a rehabilitation model in a Program of All‐Inclusive Care for the Elderly (PACE): Preliminary data

“…Participants who reported a recent fall were also recruited. The falls risk screen and scoring criteria are described elsewhere 13 . Exclusions included contraindications to high‐intensity exercise, 22 weight‐bearing precautions, neurodegenerative or acute neurological diagnoses (e.g., Parkinson's Disease, stroke, traumatic brain injury), inability to give consent due to cognitive impairment, or residing in long‐term care.…”

“…To determine the association between falls and physical function in a PACE population, our research team collaborated with InnovAge PACE in Colorado for two years to collect objective measures of physical function on all participants. From those data, we created a fall screening assessment to stratify fall risk 13 . While falls among PACE participants are multifactorial, our findings demonstrated that a frequent primary or contributing factor is reduced physical function 14–16 .…”