Falls mainly affect older people, especially people aged over 80. Therefore many people who fall may have other medical conditions and require an integrated approach wherever possible. The Falls and Bone Health Service is provided by Nottingham CityCare Partnership who link with secondary care, social care and the third sector.
The Nottingham Falls Pathway may be found at Appendix 1
Nottingham and Nottinghamshire have also developed a Guide to Action for Falls Prevention tool (GtAT) and the Guide to Action for Care Homes (GtACH) to help anyone working with older people to recognise and mitigate falls risks. The tool has been designed to raise awareness of falls and fractures and offers advice on reducing risk, advice on further management and referral to the Falls and Bone Health or Rehabilitation Service. Appendix 2
Nottingham and Nottinghamshire’s Osteoporosis Guidelines have been reviewed and are available at: http://www.nottsapc.nhs.uk/index.php/clinical-guidelines
The section below is an overall summary of the services available
Primary prevention aims to prevent the first fall in a person who is vulnerable to falling because of, for example, unsteady gait, but who has not yet fallen. The Guide to Action tool helps to identify those at risk of falling in order to target effective intervention(s).
People aged over 65 may be at risk of vitamin D deficiency and Public Health England has published new guidance about protecting bone health by ensuring people have sufficient Vitamin D. https://www.gov.uk/government/publications/vitamin-d-for-healthcare-professionals-and-the-public
The local Vitamin D guideline is currently under review (2015) and can be found at: http://www.nottsapc.nhs.uk/attachments/article/3/vitamin%20d%20guideline.pdf
The Public Health England Report Everybody Active, Everyday (September 2014) finds that older adults who remain active, are more engaged in the community, contribute more to society, and protect themselves from falls and circulatory problems. The Report further recommends that older adults at risk of falls should incorporate physical activity to improve balance and co-ordination on at least two days a week.
Secondary interventions are targeted at a person who has already fallen or who has a history of falls.
Primary Care (GPs and Medicines Management)
GPs may undertake a multi-factorial clinical assessment to exclude medical causes of falls and injuries from falls e.g. Parkinson’s, dizziness, medication, osteoporosis. For patients in hospital, this may be carried out by a hospital doctor.
Medicines management pharmacists (and others) may undertake medication reviews with a particular focus on falls and bone health in older people.
Community Rehabilitation Teams
Rehabilitation Teams assess and provide treatment to patients who have fallen but without injury. Referrals can be made by GPs, health and social care, the voluntary sector or by self-referral.
The Falls and Bone Health Service (FBHS).
The Falls & Bone Health Service is a specialist team, provided by Nottingham CityCare and offering a service to people aged over 65 with complex conditions associated with falls. The service receives the majority of referrals from the NUH Emergency Department, where people have been seen as a result of an injury caused by a fall. 2000-2500 referrals are screened each year and of these, approximately 1500 will be seen by the FBHS. For people experiencing falls, or with a fear of falling, the service provided offers:
Full nursing assessment
Bone health checks
Equipment & aids
Home safety assessments
Postural stability classes
The service can be accessed by anyone over the age of 65 who has a City GP, and the referral can be made by anyone. Patients are seen in their own home. Further information is available at: http://www.nottinghamcitycare.nhs.uk/
Nurse-led Falls and Bone Health Clinics
Nurse-led clinics have been commissioned in Nottingham City following the ‘Better Balance, Better Bones’ project in 2012. The project involved case-finding from GP databases to generate lists of patients requiring assessment for falls and fractures risk. Patients are seen in clinic, at home or in a care home, for assessment and treatment, lifestyle changes or referral on to other services. Where appropriate, patients are added to the osteoporosis QOF register.
Outcomes from the Falls and Bone Health Service
The service conducts an annual audit which measures outcomes from national and local standards and guidelines. These include:
Improved support, advice and information available to older people who fall and their carers
The promotion of effective medicines management
A reduction in the pressure on the Emergency Care Pathway by a reduction in:
unplanned hospital admissions and emergency bed days due to falls
attendances at the Emergency Department due to falls
A reduction in hospital admissions from care homes precipitated by falls
A reduction in hip fractures resulting from falls
The 2013/14 audit showed a reduction in the average number of falls, in patients seen by the service, from an average of 4.9 each, to only 7% of patients reporting a further fall at 6 months following intervention.
Social Care Services and Voluntary Sector Support
Nottingham CityCare Partnership and Nottingham City Council work in partnership to offer a single point of access to community health and adult social care services for local people. Nottingham City Council’s Adult Social Care department provides a range of services that enable people to live at home independently. These include:
Social Worker and Occupational Therapy Assessment, Home Care, Day Care, Meals at Home, Care Homes for Older People, Carer Support Assistive Technology, Preventive Adaptations service (PAD), Telecare support
General information about the services above is available at: http://www.nottinghamcitycare.nhs.uk/
The Preventive Adaptations service (PAD) installs aids and adaptations such as grab rails, stair rails, half steps for both tenants and people who own their own home. The team prioritises people being discharged from hospital.
Telecare is the community alarm service provided by Nottingham City Homes which monitors and responds to approximately 13,000 alarms and other monitoring systems across the City. The service works closely with the FBHS. Further information about Nottingham on Call is available at: http://www.nottinghamcityhomes.org.uk/supported_housing/nottingham_on_call.aspx
The Sixty Plus Nottingham City Signposting service enables older people and frontline staff to access services provided by a range of organisations which help to promote and maintain people at home. Further information is available at:
East Midlands Ambulance Service (EMAS)/ Falls & Bone Health Service (Nottingham CityCare) Falls Rapid Response Team (FRRT)
The integrated team is one of the first in the country and specialises in providing an emergency, health and social care response to non-life threatening falls for patients coming through 999 and 111 referrals. The service commenced in April 2013 and has been commissioned by Nottingham City for 3 more years from August 2014. Rushcliffe, Nottingham West and Nottingham North and East have so far also commissioned year one.
During 2013/14, the FRRT saw 864 patients in the City CCG area alone (and over 1,600 in total). 68% of patients were treated at home and not taken to hospital compared with a baseline of 50%. This means out of 864, 588 patient were not conveyed, that is an additional 156 patients were treated at home and avoided the Emergency Department and associated acute admission.
Acute Hospital Care
Falls, with or without an injury, are a major cause of admission to hospital for people over 65. Reducing demand on hospitals in the form of Emergency Department attendances, acute admissions and potential loss of independence following a hospital stay, is an important priority across health and social care. (see also Section 3 for NUH’s performance in relation to the Best Practice Tariff for hip fractures.)
In Nottingham City, the Emergency Department Falls pathway is directly linked to the community Falls and Bone Health service and patients are directly referred into this service without the need for the GP to refer. A letter is sent to the GP notifying them of the referral (see pathway attached) Appendix 1.
An important addition to the NICE guidelines CG161 June 2013 is the identification and inclusion of inpatients at risk of falling in hospital. The guideline includes:
all patients aged 65 years or older
patients aged 50 to 64 years who are judged by a clinician to be at higher risk of falling because of an underlying condition
NUH has set targets to reduce the number of falls and the number of harmful falls for inpatients.
Care Homes & Nursing Homes
Research has shown that people being admitted to a care home have a number of predominant characteristics and that a fall requiring a healthcare intervention is one of these. People in a care home or nursing home continue to have a higher risk of falling [i]
The Health Promotion Specialist within the Falls and Bone Health Service works with Social Care to provide training for staff across Care Homes (including Learning Disability Homes), Day Centres and Home Care Teams (independent sector and Social Services). The Falls and Bone Health Service also support care homes in the City using the GtACH tool to develop care plans and strategies to reduce the risk of falls.
A Guide to Action Tool has been developed specifically for care homes to use. Where a risk is identified, homes are expected to refer to the GP and Falls services for assessment.
Falls and Bone Health service
2000-2500 referrals are screened each year and of these, approximately 1500 will be seen by the FBHS. This service impacts on hospital admissions and hip fracture rates in the City (see above).
The graphs below show total number of admissions for a fall with or without injury and admissions for a fall where there was no injury. These graphs relate to the performance measures in Section 3 above and additionally show:
Trends in admission rates caused by a fall 65+ per 1000 population since 2004
Trends in admission rates by District
The data are only up to December 2012 and are not currently available to update. This may be revisited in the future however, it does show a useful picture of trends over the last decade.
Nottingham has a higher rate of admissions compared with Nottinghamshire County, however this rate reflects the level of relative socio-economic deprivation in the City. There is a strong relationship between the rate of emergency admissions generally (including falls) and deprivation. In areas where the most deprived 10% of the population live, the rate of admissions can be more than twice that seen in the most affluent areas. (NHS England, Reducing Emergency Admissions at http://www.england.nhs.uk/wp-content/uploads/2014/03/red-acsc-em-admissions.pdf
The overall trend in injury admissions caused by a fall (first graph) shows an increase in all areas including Nottingham City. This increase may be partly explained by the growth in the number of people aged over 65. However admissions for hip fractures have reduced from 319 in 2010/11 to 220 in 2012/13.
All admissions caused by a fall, the second graph, shows a decrease in the majority of areas, including Nottingham City, for 2010-12.
The two graphs taken together show that the number of people admitted, who have not suffered an injury, has reduced as a proportion of all admissions caused by a fall. This suggests that people are being admitted to hospital more appropriately.
[i] Oxford Brookes University, Institute of Public Care (IPC) Nottinghamshire County Council, Research for Preventative Approaches to Reducing Older People’s Need for Care, July 2013