Quality Improvement and Patient Safety Committee

John N. Lewis, M.D. and Thomas James, MD – Co-Chairs

Greater Louisville Medical Society

1st Floor Board Room

July 6, 2012

7:00 a.m.

Members Present / Members not Present
Thomas James, MD Co-Chair / David Bybee, MD GLMS President
Kenneth Anderson, MD Co-Chair / D. Antimisaris, PharmD, CGP, FASCP
Lyle Graham, MD / Shawn Glisson, MD
Sue Johnson, KIPDA Area Agency on Aging, Guest Speaker / Kitty Henry MD
A. O'tayo Lalude, MD / James P. Ketterhagen, MD
John N. Lewis, MD / Nate Mitchell, Ph.D.
Cynthia Rigby, MD / Patrick Murphy, MD
Brian Sosnin, DO / Rick Rowe, MD
Ken Wilson, MD / Teresa Campbell, UAW-Ford, KHC
Lelan Woodmansee, GLMS, Exec. Director / Randa Deaton, UAW-Ford, KHC
Jessica Williams, GLMS Mgr. Phy Ed & Practice Support
Joyce Goldin, GLMS Administrative Asst.
3:23
4:15
5:15 / WELCOME AND INTRODUCTIONS
Dr. James welcomed the committee members and stated that future committee meetings will have a call in number for members to participate via phone.
Dr. James welcomed the guest speaker, Sue Johnson, Nutrition/Health Promotion Planner for the KIPDA Area Agency of Aging who presented “A Matter of Balance: Managing Concerns About Falls.”
Sue Johnson stated that she works for the local area Agency On Aging whose mission is for seniors to be able to age in place (i.e., their homes) and to promote health and disease prevention.
Sue stated that A Matter of Balance is not a CDC endorsed program because it is not evidence based. She said there is ongoing research between the Administration On Aging and the CDC due to the anecdotal evidence that people who have participated in A Matter of Balance may avoid falls in the future.
What do we know about falls?
·  Up to 30% of community dwelling adults fall each year
·  About 20% of falls cause physical injury
·  Falls are a leading cause of injury and death for older adults
·  Falls are the leading cause of injury hospitalization in Kentucky for older
adults
·  1/2 to 2/3 of falls occur around the home
·  A majority of falls occur during routine activities
·  Falls usually aren’t caused by just one issue. It’s a combination of things coming together.
·  A large portion of falls are preventable!
Sue said that seniors think that falls are a normal, natural part of aging. “Falls are common, and that’s what we teach them, and that they are very predictable but not a natural part of growing older. We tell them that it is reasonable to be apprehensive or concerned about falls, but we don’t want them to become paralyzed and stop living because they are so afraid of falls. If you get them in a comfortable situation, they will admit they are terrified of falling which leads them to decreased satisfaction with their life.”
Sue also stated that seniors become increasingly frail and lose lean muscle mass if they sit home and do nothing which causes them to become depressed and have limited social activity and mobility. The key to aging successfully in the community is to stay engaged in some way or another. The fear of falling is in itself a risk factor in falling.
A Matter of Balance consists of 8 sessions. Sue said, “We try to impress upon them that they can control falling and they can control their fear of falling. We try to help them with short term goal setting and increasing activity. We want to help them change their environment and we refer to the CDC checklist which tells what they should and should not have in the home.
A Matter of Balance tries to promote exercises to increase their strength and balance. Most of the exercises take place in a chair, next to a chair, or behind a chair to increase ankle, foot and hip strength.”
Sue said that there are lot of group discussions in the program that are more with the women than the men. The groups problem solve, plan activities and share how they were successful or not successful, and problem solve how they can help each other become more successful.
A Matter of Balance also teaches communication skills. Particpants are taught how to be more assertive in order to tell their children what they need to be able to attend a family function.
Who should come to A Matter of Balance:
·  Someone who is concerned about falls.
·  A child with a parent who could be at risk for falling
·  Someone who has fallen in the past
·  Someone who will admit to the fact that they have stopped doing things because they are concerned about falling...church, picnics, grandkids.
·  Interested in improving flexibility, balance and strength
·  Someone 60 and over, ambulatory and able to problem solve. Problem solving is important.
In 2003, the Administration on Aging gave a grant to develop training to teach lay leaders how to present the program in order to free up health professionals, and test it to see whether it was successful when compared to the original research.
The study found that people who took A Matter of Balance compared with those who didn’t:
97% were more comfortable talking about fear of falling
97% were more comfortable with increasing activity
99% plan to continue exercising
98% would recommend A Matter of Balance
Some comments from the participants of A Matter of Balance is that they take their time now, and not worry about pressure from their families. They begin to look at exercise programs and exercise activities that include others. They also report fewer falls after the program.
21:43
29:05 / QUESTIONS:
Dr. Graham: This seems like a long program. What is the initial push back or do people drop out quickly? Is there a cost to the program?
A. I teach the program for four weeks, two times a week. If they complete the first session, they usually come back and stay for the entire program. When a man drops out, the follow up call reveals that the discussions were too “warm and fuzzy,” something that does not appeal to most men.
There is no charge to participate in the program.
Dr. Lewis: How much do you see diagnosed neurological conditions contributing to falls?
A. I am not privy to medical records and I know only what they share with me. They share a variety of things. Most commonly we would see people who have blood pressure or cardiac issues and we do a whole session teaching people how to get out of bed slowly and in stages. We talk a lot about the danger of hurrying to the bathroom late at night and in the dark and we give away night lights.
Dr. Lalude: Have there been any studies about the reasons why men opt out? Is it due to pride?
A. I call them when they drop out and the two things they say are “you know I got that guy thing, I just don’t talk about my feelings.” The other thing they say is “if you could recruit one more fellow….” This age group does not talk about their feelings to anyone. The women do because they have been doing that all their lives. We have some grandpas who would come if their granddaughters would bring them due to the soft spot for the “little girl.” I haven’t had a whole group of men.
Dr. Rigby suggested having an all male group, and Dr. Lewis suggested having a session that is male oriented session that the men could look forward to.
Dr. Wilson: Other than the not-for profit funding stream, are you aware of other funding mechanisms that are out there that support this? Are there any insurance payers that pay for this?
A. Not in Kentucky. The major issue for this particular program is that it is not CDC endorsed. There are other programs that we connect them to such as Silver Sneakers, which is mostly a sit down, strength training exercise program. There is an evidence based fall prevention program called Stepping On that we hope will gain popularity like Silver Sneakers. Silver Sneakers is not yet evidence based.
Sue also reported that people who take Yoga and certain kinds of Tai Chi, and stick with it for the long term, gain huge benefits in fall prevention.
Dr. Wilson: What is out there as it relates as to interfacing with health care systems and locations where elderly people go typically for medical problems? Is it just being aware and referring to programs?
A. I don’t know of any patient education that goes on in a healthcare setting, and certainly this would not be appropriate in a nursing home where there are physical and occupational therapists. We do this in assisted living communities and high rises and also with seniors at their church. We have not been successful getting patient education into a hospital setting or outpatient clinic. Part of my problem is that the program is under the radar and needs the CDC endorsement.
Dr. James asked:
a.  How do physicians go about making referrals?
b.  How to scale up if all of a sudden they did make referrals
c.  Where would this fit in a continuum in a primary care setting - making the assessment of who should go to physical therapy or to A Matter of Balance.
A. The best predictor of falling is having fallen once. Referring patients to A Matter of Balance to address the fear of falling would be appropriate. As far as gearing up, Jennye Grider with the Prevention program that is part of the Kentucky Public Health Department, just got CDC dollars to do training for A Matter of Balance. You could have your staff call me and we can get information out to individual clients.
Dr. Anderson: If falls are not a natural part of aging and if we are waiting for them to have the first fall, how can we identify the risk group before they fall?
A: I should say that falling is not a part of normal aging. We want to empower seniors and let them know this does not have to be a part of their lives and they don’t have to fall. That within itself will help them. (We are not talking about during an illness.)
Dr. James stated that on his call with Dr. Mary Tinetti with the American Geriatric Society, it was agreed that it is not realistic to expect a primary care physician or specialist to fill out a three page questionnaire to assess falls. He stated that we need to have a 2-4 question screening tool. Dr. Tinetti is going to suggest questions to use for screening for falls.
Dr. James said that the Medical Society could possibly take part in reaching out to the community about falls, with Dr. Tinetti’s help coming up with the questions to use for screening. Dr. James said that those who fall should have a longer assessment that could be completed by a physical or occupational therapist and then refer to the programs like A Matter of Balance.
Dr. James asked the committee for feedback on the direction they think GLMS should be working on to get falls prevention into the community so we can be working on this at the same time Dr. Tinetti is working on it
Dr. Rigby asked if a patient in the hospital who is clearly marked as a fall risk could have the assessment be a part of the discharge planning.
Dr. James reported that Dr. Tinetti stated that the assessment for falls in the physician office is to have the patient get up from their chair or exam table, walk 10 feet away and return and sit down again. The patient that gets up and seems unstable is more of risk.
Dr. Rigby asked if a physician has a patient with a protracted illness, and the hospital evaluates them as a candidate for rehab for falls prevention, will you, as Humana, pay for it? Can this be institutionalized for payments with insurance companies?
Dr. James said if falls assessment was institutionalized Humana may pay and his goal is to get the v-code for falls assessment made payable to facilities and providers.
MEDICATION INTERVENTIONS FOR FALL PREVENTION IN THE OLDER ADULT HANDOUT - Dee Antimisarias, PharmD
Jessica stated that the handout that Dee sent was emailed to the committee.
Dr. Jams said it was a modified Beers list that the AGS has been working on and it is informational and reinforces what we have been discussing.
LET’S STOP FALLS IN KENTUCKY AND MY MEDICATIONS APP FROM THE AMA, PREVENTION OF FALLS IN COMMUNITY-DWELLING OLDER ADULTS
The above handouts were reviewed and the link for the My Medications app from the AMA is http://www.ama-assn.org/ama/pub/about-ama/apps/my-medications.page
Link to Prevention of Falls in Community-Dwelling Older Adults http://www.uspreventiveservicestaskforce.org/uspstf11/fallsprevention/fallsprevrs.htm / Dr. James asked the committee for feedback on the direction they think GLMS should be working on to get falls prevention into the community
48:47
1:02:34 / Lelan Woodmansee asked Sue Johnson why A Matter of Balance is not considered a falls prevention program.
Sue stated that the initial research did not collect outcomes because it was intended to address the fear of falling. Although the participants reported that they haven’t fallen since taking the course, the data is anecdotal.
Lelan stated that since the committee is not ready to make a recommendation to the Board of Governors he was going to share what the committee is doing at their meeting next week and also with the GLMS officers.
Dr. James asked the committee to find directions how to help physicians with falls assessments and what resources are available to them.
Sue said that she hopes that Jennye Grider, from the Kentucky Public Health Prevention program will be able to train individuals state-wide to present A Matter of Balance. She also said that she hopes that parts of the Stepping On program can be incorporated into a home program for those that are too far away to attend in person. She also said that she hopes that Jenny Grider, from Kentucky Public Health’s Prevention program, can help solve the problem by training individuals other in parts of the state to present the program.
Dr. James said that falls are a part medical, part social issue and he is going to talk with Dr. LaQuandra Nesbitt, Director of the Metro Health Department to try and formulate a plan as she has stated that she wants Louisville to be a “senior friendly city.”
NEXT MEETING: Friday, August 3, 2012
ADJOURN: 01:02:34 / Committee members to help physicians with falls assessments and resources.

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