BACKGROUND/RATIONALE:
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.

OBJECTIVE(S):
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.

METHODS:
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.



FINDINGS/RESULTS:
Not yet available.

IMPACT:
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.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Ganz DA, Almeida S, Roth CP, Reuben DB, Wenger NS. Can structured data fields accurately measure quality of care? The example of falls. Journal of rehabilitation research and development. 2012 Dec 1; 49(9):1411-20. [view]
2. Ganz DA, Yano EM, Saliba D, Shekelle PG. Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system. BMC health services research. 2009 Nov 16; 9:206. [view]
3. Min LC, Reuben DB, Adams J, Shekelle PG, Ganz DA, Roth CP, Wenger NS. Does better quality of care for falls and urinary incontinence result in better participant-reported outcomes? Journal of the American Geriatrics Society. 2011 Aug 1; 59(8):1435-43. [view]
4. Miake-Lye IM, Amulis A, Saliba D, Shekelle PG, Volkman LK, Ganz DA. Formative evaluation of the telecare fall prevention project for older veterans. BMC health services research. 2011 May 23; 11:119. [view]
5. Hempel S, Newberry S, Wang Z, Booth M, Shanman R, Johnsen B, Shier V, Saliba D, Spector WD, Ganz DA. Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society. 2013 Apr 1; 61(4):483-94. [view]
6. Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of internal medicine. 2013 Mar 5; 158(5 Pt 2):390-6. [view]
7. Min LC, Reuben DB, Keeler E, Ganz DA, Fung CH, Shekelle P, Roth CP, Wenger NS. Is patient-perceived severity of a geriatric condition related to better quality of care? Medical care. 2011 Jan 1; 49(1):101-7. [view]
8. Ganz DA, Alkema GE, Wu S. It takes a village to prevent falls: reconceptualizing fall prevention and management for older adults. Injury Prevention : Journal of The International Society For Child and Adolescent Injury Prevention. 2008 Aug 1; 14(4):266-71. [view]
9. Ganz DA, Fung CH, Sinsky CA, Wu S, Reuben DB. Key elements of high-quality primary care for vulnerable elders. Journal of general internal medicine. 2008 Dec 1; 23(12):2018-23. [view]
10. Ganz DA, Koretz BK, Bail JK, McCreath HE, Wenger NS, Roth CP, Reuben DB. Nurse practitioner comanagement for patients in an academic geriatric practice. The American journal of managed care. 2010 Dec 1; 16(12):e343-55. [view]
11. Rubenstein LZ, Ganz DA. Preface: Falls and their prevention. Clinics in geriatric medicine. 2010 Nov 1; 26(4):xiii-xiv. [view]
12. Spears GV, Roth CP, Miake-Lye IM, Saliba D, Shekelle PG, Ganz DA. Redesign of an electronic clinical reminder to prevent falls in older adults. Medical care. 2013 Mar 1; 51(3 Suppl 1):S37-43. [view]
13. Min L, Wenger N, Walling AM, Blaum C, Cigolle C, Ganz DA, Reuben D, Shekelle P, Roth C, Kerr EA. When comorbidity, aging, and complexity of primary care meet: development and validation of the Geriatric CompleXity of Care Index. Journal of the American Geriatrics Society. 2013 Apr 1; 61(4):542-50. [view]

Conference Presentations

1. Yung VY, Walling AM, Min LC, Wenger NS, Ganz D. Advance Care Planning and End-of-life Care Preferences in Community-dwelling Elders. Poster session presented at: American Geriatrics Society Annual Meeting; 2009 Apr 30; Chicago, IL. [view]
2. Bergman J, Logan S, Fink A, Ganz D, Peterson MA, Litwin MS. Caring for the Uninsured with Prostate Cancer: A Comparison of Four Policy Alternatives in California. Paper presented at: American Urological Association Annual Meeting; 2009 Apr 28; Chicago, IL. [view]
3. Ganz DA, Saliba DM, Shekelle PG, Yano EM. Health System Variation in Guideline Adherence for Falls. Paper presented at: American Geriatrics Society Annual Meeting; 2008 May 1; Washington, DC. [view]
4. Almeida S, Roth CP, Reuben DB, Wenger NS, Ganz D. How does structured data entry affect measured quality of care? Paper presented at: Western Student Medical Research Forum; 2010 Jan 29; Carmel, CA. [view]
5. Ganz D. Improving Implementation of Fall Prevention Programs for Older Veterans. Paper presented at: RWJ Foundation Physician Faculty Scholars Program National Meeting; 2009 Dec 8; Coronado, CA. [view]
6. Ganz D, Miake-Lye I, Saliba MD, Shekelle PG. Improving Implementation of Fall Prevention Programs for older Veterans. Poster session presented at: VA Career Development Award Program Annual Conference; 2010 Feb 25; San Francisco, CA. [view]
7. Wenger NS, Roth CP, Ganz D, Hall W, Rosen M, Beckman R, Minihan J, Snooks Q, Snow V, Reuben DB. Practice Redesign Improves Primary Care for Falls and Urinary Incontinence. Paper presented at: Society of General Internal Medicine Annual Meeting; 2009 May 14; Miami, FL. [view]
8. Wenger NS, Roth CP, Martin DC, Nickels LD, Mach J, Ganz D. Quality of care provided in a special needs plan using a nurse care manager model. Poster session presented at: American Geriatrics Society Annual Meeting; 2010 May 14; Orlando, FL. [view]
9. Ganz D, Koretz BK, McCreath HE, Wenger NS, Roth CP, Bail JK, Reuben DB. The effect of nurse practitioner co-management on quality of care of patients with chronic conditions in an academic geriatric practice. Paper presented at: American Geriatrics Society Annual Meeting; 2010 May 14; Orlando, FL. [view]

DRA: Aging, Older Veterans' Health and Care, Musculoskeletal Disorders
DRE: Prevention, Technology Development and Assessment
Keywords: Falls
MeSH Terms: none