HOW IT WORKS
Recognition that falls and fall-related injuries among older people were leading to higher than average hospital admissions in the Canterbury region motivated the Canterbury Clinical Network (CCN) to develop an individual exercise and home-safety program for patients at high risk of falls. This program draws on the expertise of physiotherapists and nurses specially trained in fall prevention, driving the management of fall risk in collaboration with general practitioners (GPs) and other primary care providers. The program provides older people with education on developing skills to prevent falls and focuses on collaboration and information-sharing, especially with GPs. Eligibility rules for CCNFP are intentionally broad and patient-centered, with patients selected after a comprehensive assessment based on the judgment of the lead clinician (a physiotherapist or nurse). GPs receive assessment and progress reports from community-based fall prevention program staff. Design input from patients and caregivers resulted in a program which focuses on promoting independence, not just fall prevention.
CCNFP has served more than 9,000 patients since 2012. The program is based in a single health region but will likely be expanded to other regions across New Zealand. Data is routinely collected and reported to CCN, an alliance of local health care professionals and providers that has committed ongoing funds to the program. The program has undergone a formal evaluation by the funder.
The care provider, either a nurse or physiotherapist, sends updates to GPs on each patient’s progress and helps establish inter-professional case conferences where the team addresses clinical tasks. Although GPs are not the providers directly responsible for delivering care within the program, they interact regularly with the fall prevention team. The program heavily promotes coordination among the inter-professional team members, who come from different organizations.
The organizational culture is very focused on meeting the local community’s needs as identified by patients and caregivers. Providers are trained to focus on patient-centered care. CCNFP offers an educational program that teaches older people a set of exercises that can be completed independently at home, promoting self-directed management of fall risk and more independence in general.
Nurses and physiotherapists have a high degree of independence and control, helping to promote local leadership of program execution. Program representatives regularly present data to governing members of the CCN and other stakeholders at the local health system planning level.
Local population planning and funding control are essential. As health system funding is based on return on investments in population health, CCNFP benefits from investing in prevention activities. Staff are salaried and program leaders believe that engaging clinicians in funding decisions promotes flexibility and creativity in implementation at the local level. This “ring-fenced” funding style was provided for the fall prevention program.