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Improving Implementation of Fall Prevention Programs for Older Veterans
David Avram Ganz, MD PhD MPH
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
West Los Angeles, CA
Funding Period: August 2008 - July 2013
As the evidence base in the field of geriatric medicine matures, there has been increased interest among leaders in geriatrics in developing better ways to implement evidence-based practices. Implementation research in geriatrics is particularly relevant to the Department of Veterans Affairs, which cares for a disproportionately older population. The research plan for my Career Development Award focuses on developing an intervention to implement evidence-based practices in geriatrics, using the condition of falls and mobility disorders as a case study. About one-third of older adults fall every year, resulting in annual medical care costs of at least $19 billion in the United States alone. These falls have numerous negative consequences, including major injuries (e.g., hip fractures), nursing home placement, or restriction of daily activities. Over the past twenty-five years, evidence from basic epidemiologic research and studies on the mechanics of gait and balance has led to successful randomized, controlled trials of interventions to prevent falls. Multiple options exist to detect and evaluate patients at high fall risk, but these strategies, which primarily apply to the ambulatory care setting, have not been widely adopted in practice.
Beginning in Fiscal Year 2007, the VA External Peer Review Program (EPRP) began to monitor the quality of care for fall detection and evaluation among Veterans age 75, finding that only about one-third of recommended care for falls was provided. Moreover, quality of care for falls was highly variable throughout the VA system - for example, rates of asking about falls in the past year for Veterans age 75 vary from 9% to 91% depending on the VISN. As a result, the same older Veteran could expect to receive dramatically different care for falls depending on where he or she lives. These findings support the need for a more structured approach to implementing fall prevention within the VA to produce reliably high quality of care throughout the system.
Specific Aim 1: To develop an intervention to improve the quality of care for fall prevention among outpatient veterans within VA Greater Los Angeles Healthcare System (VAGLAHS).
Specific Aim 2: To test the feasibility and short-term sustainability of the intervention developed.
Specific Aim 3 (revised): To conduct a formative evaluation of the intervention carried out in Specific Aim 2.
For Specific Aim 1, experts in fall prevention, primary care clinicians, clinic staff, senior managers and veterans collaboratively developed a model for improving 1) the rates of screening for falls in primary care clinics and 2) rates of triage of high-risk patients to clinicians who specialize in fall prevention.
For Specific Aim 2, we developed a telephone-based program to screen patients for risk factors for falls. This program ended in April 2010. We then developed a second program that involves nurses screening patients for fall risk in primary care, with primary care providers further assessing patients who were found to be at high risk for falls by the nurse.
For Specific Aim 3, we conducted in person and telephone interviews with nurses and primary care providers to determine the usefulness of the primary care program carried out in Specific Aim 2. We walked nurses and primary care providers through the electronic clinical reminder used to facilitate the primary care program in Specific Aim 2 to learn how the reminder could be improved. We also used electronic clinical reminder reports to determine how the reminders were being used by nurses and primary care providers.
Not yet available.
This project has led to increased identification of Veterans at risk for falls, and a better understanding of effective strategies to implement clinical reminders into routine care. The clinical reminder developed from this project has been shared with other interested sites throughout the VA.
External Links for this Project
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DRA: Aging, Older Veterans' Health and Care, Musculoskeletal Disorders
DRE: Prevention, Technology Development and Assessment
MeSH Terms: none