Accolades for Community Falls Follow Up program

A joint initiative that supports older people at risk of fall-related injuries has earned Brisbane North PHN’s Team Care Coordinators second place in the Metro North Staff Excellence Awards, presented on Thursday, 26 November 2020.

The Community Falls Follow Up program is a collaboration between the Metro North Hospital and Health Service (HHS) Community and Oral Health Directorate, the Queensland Ambulance Service (QAS) and the PHN. As runner-up in the ‘Excellence in Integrated Care’ award category, the program was highly commended for developing a community falls response pathway focused on supporting over 65s across the North Brisbane and Moreton Bay region.

The pathway allows QAS to refer clients to Team Care Coordination, via the Metro North HHS Central Referral Unit, if they have fallen at home and do not need to go to hospital.

Sharon Gavioli, Manager of the PHN’s Care Coordination team, said the Community Falls Follow Up program had performed well against the six other worthy finalists in its award category.

“Recognition provided through the Metro North Staff Excellence Awards is very welcome,” Ms Gavioli said.

“We are grateful for the opportunity to show how this model of care improves health outcomes and reduces hospitalisation among older people who have experienced a fall,” she said.

Team Care Coordination processed 108 QAS referrals during the six-month pilot project and the final report found that clients who accepted services were less likely to represent to hospital.

With continued support from Metro North HHS, the ongoing program received 306 QAS referrals in the 12 months to September 2020 and is now working on strategies to increase the acceptance rate among referred clients.

QAS referrals to the program commenced in June 2019 and comprised just 3.3 per cent of all program referrals in the 2018- 19 financial year.

However, this proportion increased to 16.8 per cent the following year. Team Care Coordination Clinical Lead and Clinical Nurse Annie Hemms said clients referred by QAS paramedics often tended to be people who were coping with multiple medical conditions, but receiving minimal help in the community.

“We go out and see them as a high priority, which usually means a visit within three days,” Ms Hemms said, “and my job is a really complex one. We are usually the first health professional to knock on these peoples’ doors”, Ms Hemms said.

“These people have felt so scared that they’ve called for an ambulance to help them out of the situation that they’re in,” she said.

“They clearly haven’t needed hospitalisation, but they then welcome you into their home to look at ways to reduce the chance of that fall from happening again.”

“We’re able to help identify where our clients can benefit from having some support. We can spot the gaps and the areas of potential concern and then use our specialist nursing knowledge to help our clients access the support they need to reduce their risk of falls,” she said.

Ms Hemms recalled a client she had helped during the pilot project, a man in his late 80s who had fallen in his bathroom.

“He was a very proud man and lived on his own, and the fall really shook him up…physically and emotionally. It turned out he’d been having lots of little falls, over a period of time,” she said.

After explaining how Team Care Coordination’s informal approach puts clients at ease, (e.g. lack of uniform and keeping interactions on a first name basis) Ms Hemms said, “He really opened up to how desperate he felt without any help at home”.

“And although we want him to remain as independent as possible, we also realised there were some things we could do to help,” she said.

Ms Hemms said she arranged for an Occupational Therapist to visit the man shortly afterward to make changes around his home and reduce his risk of further falls.

In addition to QAS referrals, Team Care Coordination also accepts referrals from hospital clinicians through the ‘Staying Healthy, Staying Home’ referral stream, and from GPs and other primary care providers.

An independent evaluation, published in October 2017, confirmed that Team Care Coordination was effective at reducing Emergency Department attendances, hospital admissions and the severity of patient illness.

For more information, call the PHN’s Service Navigator on 1800 250 502 or visit the Team Care Coordination page.

Pictured above L-R: Matt Green (Queensland Ambulance Service), Kate Schultz (Metro North HHS), Sharon Gavioli (Brisbane North PHN), Mary Wheeldon (Metro North HHS), Dr Robert Franz (Metro North HHS) and Mark Butterworth (Metro North HHS).