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INTERPROFESSIONAL PRACTICE AND EDUCATION

INTERPROFESSIONAL PRACTICE AND EDUCATION Physical and Occupational Therapy Practice Improvement Following

Physical and Occupational Therapy Practice Improvement Following Interprofessional Evidence-Based Falls Prevention Training

Emma Wheeler, DPT Constance L. Coogle, PhD Robert C. Fix, OTR/L Myra G. Owens, PhD Leland H. Waters, PhD

AIMS: Evaluate changes in physical therapy (PT) and occupa- tional therapy (OT) practice following evidence-based prac- tice (EBP) interprofessional modules that teach assessments and interventions to reduce falls in community-dwelling older adults. METHODS: Medical records of post-fall patients in three Programs of All-Inclusive Care for the Elderly (PACE) sites were analyzed to assess differences in documented falls and the OT and PT use of EBP assessment and interventions implemented following fall prevention training. RESULTS: In training year 1, PT demonstrated a 34.6% practice improve- ment in risk assessments performed (z=3.0, p<0.005). In train- ing year 2, PT demonstrated a 66.7% practice change in the implementation of EBP interventions (z=2.1, p<0.05) and OT demonstrated a 22.2% practice improvement in the imple- mentation of recommended EBP interventions (z=2.0, p<0.05). In training year 3, OT achieved a 6.8% increase in the execution of home environment modifications (z=2.0, p<0.05), and PT demonstrated a 23.3% practice improvement in the implementation of recommended EBP interventions (z=3.1, p<0.005). CONCLUSION: The delivery of EBP assess- ment and intervention training modules for falls prevention resulted in PT and OT practice changes and improved adher- ence to published guidelines. J Allied Health 2018; 47(1):9–18.

ADULTS OVER AGE 65 will comprise 20% of the United States population by 2030, and the future healthcare workforce may not be adequately trained to

Dr. Wheeler is with the Department of Physical Therapy, Drs. Coogle, Owens, and Waters are with the Virginia Center on Aging, and Mr. Fix is with the Department of Occupational Therapy, School of Allied Health Professions, Virginia Commonwealth University, Richmond, VA.

Funding for this research provided by the Bureau of Health Profes- sions (BHPr), Health Resources and Services Administration (HRSA), Dep. of Health and Human Services (DHHS), under grant no. UB4HP19210 (Virginia Geriatric Education Center). Funding for REDCap provided by grant award no. UL1TR000058 from the National Center for Research Resources (NCRR). The authors report no conflicts of interest related to this study.

IP1790—Received Oct 15, 2016; accepted Mar 7, 2017.

Address correspondence to: Dr. Emma Wheeler, Dep. of Physical Therapy, Virginia Commonwealth University, 1200 East Broad Street, Richmond, VA 23298-0224, USA. Tel 804-828-0234, fax 804-828-8111. ewheeler@vcu.edu.

© 2018 Association of Schools of Allied Health Professions, Wash., DC.

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meet their healthcare needs. 1 Thirty percent of older adults fall each year, resulting in over $30 billion spent annually in medical costs. 2 Falls in older adults are the leading cause of fractures and injuries that result in hos- pitalization, disability, and increased nursing home admissions. 3 The cause of falls in older adults is multi- factorial, stemming from intrinsic and extrinsic factors, some of which are modifiable. 4,5 A growing body of research on risk factors, interven- tions, and strategies to prevent falls has provided evi- dence for the development of best practice recommenda- tions for fall risk screening. The American Geriatrics Society/British Geriatrics Society (AGS/BGS) have pub- lished a clinical practice guideline for the prevention of falls in older persons. 6 The guideline emphasizes multifac- torial fall risk screening, targeted assessment, and individ- ualized interventions that are effective for reducing falls. 6 The Centers for Disease Control and Prevention published a toolkit called the STEADI (Stopping Eld- erly Accidents, Deaths & Injuries) that outlines best practice recommendations for fall risk screening and interventions. 7,8 The STEADI guidelines recommend all health care providers ask older adults if they have fallen in the previous year and if they have concerns about balance or walking. Elders identified at risk for falling should be referred for a multifactorial assess- ment that includes measures of balance, mobility, vision, safe performance of daily activities, and home environment safety. Physical therapists (PT) and occu- pational therapists (OT) routinely evaluate these fall risk factors and then prioritize findings into an individ- ualized client-centered plan of care. Additional guidelines published by The American Physical Therapy Association (APTA) and the Ameri- can Occupational Therapy Association (AOTA) fur- ther outline the role of these professionals in the pre- vention of falls in older adults. 9,10 One criticism of the current published clinical practice guidelines for PT and OT is that they lack specificity. The APTA recom- mends that more precise screening and assessment measures with validated cut points and more guidance

for interventions such as exercise dosage are needed in PT. 9 Leland et al. 11 recommended a more defined and perhaps expanded role for OT in fall prevention, with additional research needed to evaluate OT’s role in managing postural hypotension and medications and in modifying risk behaviors to reduce fear of falling. Although substantial evidence demonstrates screen- ing for risk factors and applying targeted interventions to reduce risk can prevent falls, falls in older adults con- tinue to be a persistent problem. Success in fall reduc- tion may be limited because many elders are not aware of fall prevention measures and the adoption and appli- cation of the published evidence-based guidelines is not widespread in clinical practice. 1214 Medical record review has been used by other researchers to demonstrate also that fall practice guide- lines are not fully embraced by practitioners. Said et al. 15 found that patients at risk for falling often did not receive a comprehensive assessment. Rubenstein et al. 16 found community-based physicians do not fully evalu- ate and document patient falls, which could lead to inadequate recommendations; the authors advocated for more adherence to published guidelines. Phillips et al. 13 suggested that the lack of dedicated training of healthcare professionals and access to appropriate resources can be significant barriers to implementation of guideline recommendations in clinical practice. Thomas et al. 14 showed that in acute care assessment of patients post-hip fracture, PTs documented fall risk fac- tors less than 10% of the time and only 8% made a refer- ral to a community service provider to further address fall prevention strategies. Interprofessional geriatrics education has been suc- cessfully used to disseminate fall prevention evidence and enhance practice changes among health profes- sionals. 12 Yet, training programs to teach health profes- sionals how to best implement the published guideline recommendations in clinical practice need to be better evaluated. 17 Falling continues to be a significant problem among older adults, even though substantial research evidence has shown fall reduction interventions targeted to older adults at highest risk are effective when individually pre- scribed by knowledgeable professionals. 6 PTs and OTs are uniquely positioned to become team leaders for evaluat- ing fall risk factors and delivering individualized patient interventions. Therefore, interprofessional instruction designed to modify PT and OT practice behaviors and improve adherence to published fall reduction guidelines may result in fewer falls in older adults.

Purpose: The purpose of this study was to evaluate PT and OT practice change following instruction in evidence-based practice (EBP) interprofessional teach- ing modules focused on EBP assessment and interven- tions shown to reduce falls in community-dwelling older adults.

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Methods

Training Intervention

Six, 2-hour, face-to-face training sessions covering 7 learning modules (Table 1) were used to deliver the EBP fall prevention content. EBP module content was derived from the AGS/BGS community-based guideline, 6 the STEADI, 7 and the APTA 9 and AOTA 10 best practice guidelines for elderly fall prevention and management. The seven training modules were provided to Vir- ginia Programs of All-Inclusive Care for the Elderly (PACE) sites. PACE provides interprofessional compre- hensive medical and social services for community- based adults 55 years of age or older who are nursing home-eligible. 18 In years 1 and 2, the training was pro- vided at two separate PACE health systems. In year 3, the training series was conducted on site at one PACE site and simultaneously broadcasted to four additional PACE sites within the same health system. The sessions were taught by interprofessional teams of faculty/clinicians and could include presenters from social work, pharmacy, medicine, nursing, PT, and OT. This interprofessional approach for training was designed to mimic the interprofessional teams deliver- ing patient care at the different PACE sites. Interprofessional clinical practice sites were recruited because the training focused on promoting interprofes- sional practice. Interprofessional team training was designed to increase the number of different professions engaged in falls assessment and intervention as well as to improve interprofessional team communication and the development of interprofessional care plans. In total, 70 professionals were trained across three training sites, one site each year over the course of 3 years. How- ever, only 26 professionals (see Table 2 for demograph- ics) produced post fall documentation. Over the 3 years of the study, 10 PTs and 1 PTA and 5 OTs and 1 OTA produced post fall patient documentation. Physicians and nursing were not included in the analysis to narrow the focus of this paper on PT and OT practice changes. The remaining professionals trained, such as adminis- trators and transportation, did not document in the medical chart.

Data Abstraction

An evaluation team (comprised of two doctoral-level faculty and three research assistants) assessed clinician practice change by abstracting medical records informa- tion to a secure web-based application (Research Elec- tronic Data Capture, REDCap). 19 The evaluation team employed a consensus review process 20,21 for abstracting information contained in medical charts. Each case note was simultaneously reviewed by at least two data abstractors and an arbitrator to reach a consensus judg-

WHEELER ET AL., Practice Improvement with Falls Prevention Training

TABLE 1. EBP Learning Modules

 

Overall Objectives

Provide a definition of falls that can be operationalized in an interprofessional setting. List at least 5 potentially modifiable risks for falls. Conduct an interprofessional assessment specific to falls, including gait assessment. Identify 5 evidence-based interventions that can reduce future falls. Develop an interprofessional plan of care that can reduce the rate of falls and reduce falls.

Module

Presenter Disciplines

Objectives

The Evidence Base

Gerontology/medicine/

U.S. Preventative Services Task Force (USPSTF) recommendations AGS guidelines when working with older adults Design, results, and conclusions of Tinetti’s FICSIT trial Findings of key systematic reviews that pertain to reducing falls in the elderly Elements of successful programs that have reduced falls in clinical trials

pharmacy

Defining Falls, Risk Factors, and Teamwork

Nursing/SW

Strategies for achieving consistency in the classification and reporting of falls Strongest predictors of fall risk among community-living older adults Potentially modifiable risk factors for falling in older adults The advantages to working on interprofessional teams Barriers to overcome when working on interprofessional teams Responsibilities of interprofessional team members Stages of team formation Establishing team norms Traits of effective interprofessional teams

Falls Assessment Part I

Pharmacy/SW

Differentiate falls from other causes of involuntary postural change Assessment tools that measure FOF Key elements of screening for medication-related fall risk Fear of falling as part of ongoing, interdisciplinary geriatric assessment Empirically tested assessment tools that measure FOF Important elements of a medication history Key elements of screening for medication-related fall risk

Falls Assessment Part II

Nursing/ medicine/PT/OT

Nursing tools used in fall risk assessment Role of the primary care clinicians in falls assessment Common assessment tools used by PTs and OTs

Interventions Part I

Pharmacy/OT/PT

EBP interventions related to medication management and alcohol risk reduction EBP interventions that address sensory deficit and environmental hazards EBP interventions to improve muscle weakness, gait, and balance

Interventions Part II and Care Planning

Nursing/SW

Intrinsic and extrinsic risk factors Individualized care planning strategies that target specific risk factors Value of an interdisciplinary approach to care planning Review of quality improvement data

FOF, fear of falling; SW, social work.

ment on what should be recorded. The arbitrator, as the most knowledgeable member of the team about falls, clinical practice guidelines, and medical charting prac- tice, took the lead in facilitating agreement about case note items. Operational assumptions underlying this process were: 1) multiple perspectives were more likely to be free from researcher bias, 2) no preconceived notions existed about findings, and 3) the potential for group- think was minimized by encouraging diverse interpreta- tion of information and establishing a collegial environ- ment of mutual respect and equal involvement. All data were abstracted from patient medical records at least 1 year after delivery of EBP training to healthcare practitioners. The abstractors compared three time intervals: T1 (baseline), patients who had experienced at least one fall in the 3 months prior to the site training; T2, the 3-month period immediately fol-

Journal of Allied Health, Spring 2018, Vol 47, No 1

lowing the completion of the training; and T3, the next 3-month period ending 6 months post-training. Only patients who fell and received post-fall assessment/ intervention from practitioners who received the EBP training were included for analyses. A nonexperimental within-subjects pre-post intervention design was uti- lized. The goal of analyses was to determine whether practitioner use of EBPs significantly increased in fall patients as a result of the training intervention. The data collection process was changed over the course of the 3-year process. It was determined in the second year that it would be more advantageous to doc- ument implemented as well as recommended interven- tions. Therefore, recommended interventions were counted in years 1 and 2 only, while implemented inter- ventions were only counted in years 2 and 3. Figures 1 and 2 show the formulas used to evaluate practice

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TABLE 2. Demographic Characteristics of Practitioners Included in the Medical Chart Review by Training Year

 

All Years (n = 26)

Year 1 (n = 6)

Year 2 (n = 7)

Year 3 ( n = 3)

Characteristic

N%N%N%N%

Gender

Female

22

85%

5

83%

6

86%

11

85%

Male

4

15%

1

17%

1

14%

2

15%

Age Categories

20-29

3

12%

2

33%

0

0%

1

8%

30-39

9

35%

2

33%

2

29%

5

38%

40-49

4

15%

2

33%

0

0%

2

15%

50-59

8

31%

0

0%

4

57%

4

31%

60 or older

2

8%

0

0%

1

14%

1

8%

Race/Ethnicity

African American, non-Hispanic

4

17%

0

0%

1

14%

3

23%

Asian

2

9%

1

17%

1

14%

0

0%

Caucasian, non-Hispanic

18

69%

4

67%

5

71%

9

69%

Hispanic

2

8%

1

17%

0

0%

1

8%

Unknown

0

0%

1

17%

0

0%

1

8%

Highest Degree

Associate’s

2

8%

1

17%

0

0%

1

8%

Bachelor’s

7

27%

1

17%

3

43%

3

23%

Diploma

2

8%

0

0%

2

29%

0

0%

Doctorate

6

23%

2

33%

0

0%

4

31%

Master’s

6

23%

1

17%

2

29%

3

23%

MD

3

12%

1

17%

0

0%

2

15%

Occupation

Nurse practitioner

1

4%

1

17%

0

0%

0

0%

OT

4

15%

1

17%

1

14%

3

23%

OTA

1

4%

0

0%

0

0%

1

8%

PTA

1

4%

1

17%

0

0%

0

0%

PT

10

38%

2

33%

1

14%

7

54%

Physician

4

15%

2

33%

0

0%

2

15%

Registered nurse or BSN

5

19%

0

0%

5

71%

0

0%

change. Practice changes for each assessment or inter- vention were calculated (Figure 1). The improvement in our data collection process after the first year also allowed us to implement a measure of practice change based on the cumulative number of AGS/BGS inter- ventions implemented (Figure 2). Virginia Commonwealth University’s Institutional Review Board (IRB) approved the training and evalua- tion protocol for years 1 and 3 by expedited review (IRB# HM14409). Year 2 training and evaluation proto- col was approved by the IRB for Eastern Virginia Med- ical School (IRB# 13-04-Ex-0071) and included an IRB reliance agreement. Health Insurance Portability and Accountability Act (HIPAA) waiver of patient authori-

% Practice Change =

T2 # of patients receiving EBP T2 # of post-fall patients

T1 # patients receiving EBP T1 # of post-fall patients

× 100

FIGURE 1. Practice change formula for each assessment or intervention.

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zation was requested and approved by both IRBs for review of medical records.

Analysis Approach

Practice change outcomes were calculated for “All Post- Fall Patient Encounters” and for “All Post-Fall PT and OT Patient Encounters.” “All Post-Fall Patient Encounters” rep- resented the number of patients who fell and had chart documentation by at least one or more of the following disciplines: physician, nurse, PT, or OT. “All Post-Fall PT and OT Patient Encounters” represented the number of patients who fell and had chart documentation by PT and OT practitioners. The proportion of post-fall

% Practice Change =

Interventions implemented at T2 T2 # of post-fall patients

– Interventions implemented at T1 T1 # of post-fall patients

× 100

FIGURE 2. AGS/BGS cumulative practice change.

WHEELER ET AL., Practice Improvement with Falls Prevention Training

patients with documented information related to assessments or interventions was calculated as a per- centage of all post-fall patients who received assess- ment or intervention from at least one practitioner who participated in the training (“All Post-Fall Patient Encounters”). All post-fall patients were eligible for evaluation and/or treatment by the healthcare team. It was rea- soned that not all post-fall patients would be referred for rehabilitative assessment, so a more precise denominator would allow us to consider practice changes as a proportion of only those patients exam- ined or treated by the providers of interest (i.e., PT or OT). Therefore, a second set of analyses was per- formed (“All Post-Fall PT and OT Patient Encounters”). Pre- and post-training data were collected and ana- lyzed using descriptive and inferential statistics. Two- tailed z-statistics were used to determine whether the proportional differences in pre- and post-training use of EBPs were statistically significant.

Results

Tables 3 to 6 summarize PT and OT practice changes measured through data abstraction. Percent change and frequency counts of the number of patients PT and OT documented related to assessment or intervention vari- ables in each category are listed for T1, T2, and T3 for years 1, 2, and 3.

Assessment and Intervention Practice Changes for All Post-Fall Patient Encounters

Year 1 Abstracted data included a total of 7 providers (PT or PT assistant = 3, OT = 1, medicine = 2, advanced nursing practice = 1) who collectively encountered 33 post-fall patients during T1, 43 post-fall patients during T2, and 35 during T3. The OT assessed at least 1 patient at T1, but no patients were seen during T2 or T3 and medical records were therefore not reviewed. The proportion of all post-fall patients who had risk factors assessed by the PTs increased 34.6% (z=3.0, p<0.005) from T1 to T2. This practice change improve- ment was sustained at 33.1% (z=2.8, p<0.005) during T3. The PT also showed statistically significant improve- ment in the proportion of documented fall causes for all post-fall patients from T1 to T2 with an increase of 54.6% (z=4.7, p<0.001). An increase of 50.6% was docu- mented from T1 to T3, indicating that the improve- ment had been maintained (z=4.2, p<0.001). Similarly, the proportion of post-fall patients with the fall circum- stances documented increased by 46.2% from T1 to T2 (z=4.0, p<0.001). This improvement was sustained into T3 with a 38.8% increase from T1 (z=3.2, p<0.001). No statistically significant practice improvements in the implementation of the recommendation of EBP inter- ventions were found (p>0.05).

Journal of Allied Health, Spring 2018, Vol 47, No 1

Year 2Medical record reviews included a total of 7 providers (nursing = 5, PT = 1, OT = 1) who collectively encountered 21 post-fall patients during T1 and 26 post- fall patients during T2. The medical record review did not reveal any statistically significant practice improve- ments related to any of the assessment measures (p>0.05). Consequently, practice changes during T3 were not examined. Practice change for the PT’s implementation of AGS/BGS recommended interventions was not statis- tically significant (p>0.05). The OT demonstrated a 22.2% practice improvement in the number of interven- tions implemented (z=2.0, p<0.05). Examination of the individual interventions implemented by the OT did not result in statistical significance (p>0.05).

Year 3 Medical record reviews included a total of 13 providers (medicine = 2, PT = 7, OT or OT assistant = 4) who collectively encountered 85 post-fall patients during T1, 87 during T2, and 65 during T3. The PTs and OTs did not show any statistically significant prac- tice improvements related to assessment (p>0.05). The PTs also did not show any statistically signifi- cant practice improvements related to the cumulative number of implemented AGS/BGS interventions, and examination of the individual interventions imple- mented by the PTs similarly did not reveal any statisti- cally significant changes (p>0.05). The OTs did not show a statistically significant practice improvement in the cumulative number of implemented EBP interven- tions (p>0.05), but an examination of individual inter- ventions revealed a 6.8% improvement in the imple- mentation of home modifications between baseline and T2 that was statistically significant (z=2.0, p<0.05). This improvement was not sustained into T3 (p>0.05).

Assessment and Intervention Practice Changes for All Post-Fall PT and OT Patient Encounters

Year 1 The PTs demonstrated a robust practice improvement (37.5%) from T1 to T2 in documented fall causes (z=3.5, p<0.001). This improvement was sus- tained at T3 (z=3.1, p<0.005). No statistically significant practice improvements in recommendations for the implementation of AGS/BGS interventions were revealed (p>0.05).

Year 2 There were no statistically significant practice changes related to any of the assessment measures. This was primarily a consequence of the small number of patients encountered by the providers. The PT encoun- tered 3 patients at T1 and 5 at T2, while OT encoun- tered only a single patient at T1 and the increase at T2 was merely one more. As a consequence, no statistical testing was feasible for the OT. The PT demonstrated a 66.7% practice improvement in the number of imple- mented EBP interventions from T1 to T2 (z=2.1,

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TABLE 4. OT Practice Change Outcomes for All Post-Fall Patient Encounters

TABLE 3. PT Practice Change Outcomes for All Post-Fall Patient Encounters

* p <0.05, †p <0.005, ‡ p <0.001.

* p <0.05.

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z

1.8

0.2

1.2

1.1

0.9

0.2

0.3

1.3

 

T1 to T3

T3 = 65

%

15.4

–0.9

5.6

8.8

7.6

–2.4

2.4

10.1

Year 3

T3, n

z

36

1.4

4

0.7

9

0.7

21

0.0

34

0.1

29

0.0

13

0.0

28

1.1

 

T1 to T2

T1 = 85 T2 = 87

%

10.6

3.3

3.3

0.6

–1.0

0.1

0.7

8.4

 

T1/T2, n

34/44

6/9

7/10

20/21

38/38

40/41

15/16

28/36

Z

 

T1 to T3

T3 = 0

%

Year 2

T3, n

z

1.5

1.3

0.9

0.8

0.9

0.6

1.2

 

T1 to T2

T1 = 33 T2 = 43

%

14.5

7.7

2.9

20.0

2.9

5.9

10.6

0.0

 

T1/T2, n

1/5

0/2

1/2

0/1

1/2

2/4

1/4

2/4

z

4.2‡

3.2‡

0.8

2.8†

 

T1 to T3

T3 = 35

%

50.6

38.8

–6.7

33.1

Year 1

T3, n

z

23

4.7‡

21

4.0‡

4

0.0

19

3.0†

 

T1 to T2

T1 = 33 T2 = 43

%

54.6

46.2

0.4

34.6

 

T1/T2, n

5/30

7/29

6/8

7/24

Total patient count, n

Intervention outcome

AGS/BGS intervention(s) implemented

Home modification(s) Individually tailored exercise Patient/family education Documented fall causes Fall circumstances EBP interventions recommended Assessed risk factors

   

z

0.6

0.0

0.8

0.5

1.0

0.4

1.0

0.5

 

T1 to T3

T3 = 65

%

–1.6

–0.8

–1.2

0.36

2.3

0.7

–3.2

–1.6

Year 3

T3, n

z

2

1.4

1

2.0*

0

0.9

1

0.5

3

1.6

2

1.6

1

1.2

2

1.5

 

T1 to T2

T1 = 85 T2 = 87

%

6.8

6.8

–1.2

1.1

4.5

4.5

5.6

5.7

 

T1/T2, n

4/10

2/8

1/0

1/2

2/6

2/6

4/9

3/8

Z

 

T1 to T3

T3 = 0

%

Year 2

T3, n

z

2.0*

0.9

0.8

1.3

0.9

0.9

0.4

0.4

 

T1 to T2

T1 = 33 T2 = 43

%

22.2

3.9

6.8

7.7

3.9

3.9

2.9

7.7

 

T1/T2, n

1/7

0/1

1/2

0/2

0/1

0/1

1/2

0/2

z

 

T1 to T3

T3 = 35

%

Year 1

T3, n

z

1.1

1.1

1.1

 

T1 to T2

T1 = 33 T2 = 43

%

–3.0

–3.0

–3.0

 

T1/T2, n

0/0

1/0

1/0

1/0

Total patient count, n

Intervention outcome

AGS/BGS intervention(s) implemented

Home modification(s) Individually tailored exercise Patient/family education Documented fall causes Fall circumstances EBP interventions recommended Assessed risk factors

WHEELER ET AL., Practice Improvement with Falls Prevention Training

TABLE 6. OT Practice Change Outcomes for All Post-Fall OT Patient Encounters

TABLE 5. PT Practice Change Outcomes for All Post-Fall PT Patient Encounters

*p <0.05, † p <0.005, ‡ p <0.001.

   

z

3.4‡

0.3

1.2

1.4

1.7*

0.5

1.1

1.8*

 

T1 to T3

T3 = 36

%

27.7

–1.7

10.1

15.8

13.6

–4.6

11.8

18.2

Year 3

T3, n

z

36

3.1†

4

0.9

9

0.9

21

0.3

34

0.3

29

0.6

32

0.6

28

1.9*

 

T1 to T2

T1 = 47 T2 = 46

%

23.3

6.8

6.9

3.1

1.76

4.0

–7.5

18.7

 

T1/T2, n

34/44

6/9

7/10

20/21

38/38

40/41

25/26

28/36

Z

 

T1 to T3

T3 = 0

%

Year 2

T3, n

z

2.1*

1.3

0.9

0.2

0.4

1.3

0.4

 

T1 to T2

T1 = 3 T2 = 5

%

66.7

40.0

0.0

3.8

6.7

13.3

46.7

13.3

 

T1/T2, n

1/5

0/2

1/2

0/1

1/2

2/4

1/4

2/4

z

3.1‡

1.0

3.0

.03

 

T1 to T3

T3 = 23

%

37.5

3.8

–57.6

–4.9

Year 1

T3, n

z

23

3.5‡

21

1.0

4

2.5

19

0.5

 

T1 to T2

T1 = 8 T2 = 30

%

37.5

9.17

–48.3

–7.5

 

T1/T2, n

5/30

7/29

6/8

7/24

Total patient count, n

Intervention outcome

AGS/BGS intervention(s) implemented

Home modification(s) Individually tailored exercise Patient/family education Documented fall causes Fall circumstances EBP interventions recommended Assessed risk factors

Journal of Allied Health, Spring 2018, Vol 47, No 1

   

z

0.2

0.4

0.9

0.2

1.4

0.4

1.1

0.2

 

T1 to T3

T3 = 3

%

–8.3

–17.0

–25.0

8.3

50.0

16.7

–33.3

–8.3

Year 3

T3, n

z

2

0.9

1

0.6

0

1.8

1

0.4

3

1.0

2

0.0

1

1.1

2

0.3

 

T1 to T2

T1 = 4 T2 = 12

%

–16.7

16.7

–25.0

–8.3

0.0

0.0

–25.0

–8.3

 

T1/T2, n

4/12

2/8

1/0

1/2

2/6

2/6

4/9

3/8

Z

 

T1 to T3

T3 = 0

%

Year 2

T3, n

z

 

T1 to T2

T1 = 1 T2 = 2

%

155.0

50.0

0.0

100.0

50.0

50.0

0.00

100.0

 

T1/T2, n

1/7

0/1

1/2

0/2

0/1

0/1

1/2

0/2

z

 

T1 to T3

T3 = 0

%

Year 1

T3, n

z

 

T1 to T2

T1 = 1 T2 = 0

%

 

T1/T2, n

0/0

1/0

1/0

1/0

Total patient count, n

Intervention outcome

AGS/BGS intervention(s) implemented

Home modification(s) Individually tailored exercise Patient/family education Documented fall causes Fall circumstances EBP interventions recommended Assessed risk factors

15

p<0.05). OT also demonstrated a drastic practice improvement in this regard (155%), but a z statistic could not be computed for this result (p>0.05) because of the small number of patient encounters.

Year 3 The PTs documentation of risk factors assessed increased by 18.7% from T1 to T2 (z=1.9, p<0.05), and this improvement was maintained into T3 (18.2%; z=1.8, p<0.05). The PTs demonstrated a 23.3% practice improvement in the cumulative number of AGS/BGS interventions implemented from T1 to T2 (z=3.1, p<0.005). By T3, a recommended intervention was implemented 36 times among the 36 post-fall patients encountered (z=3.4, p<0.001). The recom- mended interventions were predominantly education and information (15.8%) and individually tailored exer- cise (10.1%); however, the effects for these individual interventions did not reach the level of statistical signif- icance (p>0.05). No statistically significant practice improvements were uncovered for OT (p>0.05).

Discussion

This study demonstrated that interprofessional EBP assessment and intervention training modules for falls prevention and management seem to have had a signif- icant effect on PT and OT practice. Specifically, PTs increased documentation of fall causes, fall circum- stances, and fall assessment. OTs increased interven- tions provided and home modification recommenda- tions. Patients received more fall risk assessments and a higher volume of evidence-based interventions pro- vided by PT and OT post-training. PT assessment of risk factors as well as both the cir- cumstances and causes of falls improved during year 1 and was sustained over time. This may be a result of better internalization of practice guidelines and prioriti- zation of the need for documentation of fall risk criteria because of enhanced understanding post-training. However, it could also reflect the increase in the number of patients seen by PT from T1 to T2 in “all post-fall patient encounters.” Although site personnel limitations did not allow us to observe practice improvements for OT during train- ing year 1, during training year 2, OT adopted increased implementation of EBP recommended interventions. The number of PT and OT “all post-fall patient encoun- ters” for training year 2 was small for both PT and OT and may explain why the documented assessment and intervention changes did not reach significance. Both PT and OT showed improvements in interventions from T1 to T2 during training year 3; however, practice changes for OT did not reach statistical significance at T3 due to extremely small patient encounter numbers compounded by small numbers of OTs. Again, in addi- tion to the relatively smaller number of therapeutic encounters by OT during T3 in relation to T2, another

16

possible explanation for the lack of change in practice is time and resource constraints. These constraints may have allowed OTs to revert to previous behavior. It is also possible that practice changes may have continued without being explicitly documented. The assessment module content for both PT and OT provided an evidence-based strategy to identify elders at greatest risk of falling, which may have increased the OT home safety. Chase et al. 22 challenged OTs to con- duct research evaluating the impact of home modifica- tions on preventing falls and to produce outcome meas- ures that include activities of daily living (ADL) and instrumental activities of daily living (IADL). OTs play an important role on interprofessional teams by addressing the multifactorial impact of falls, including fear of falling, environmental hazards, cognition, depression, anxiety, personal interests, and visual acuity on fall risk. 8 The systematic review by Chase et al. 22 reported moderate evidence that individually implemented physical activity and home modification interventions reduce falls and impact ADL and IADL performance. OT reflected similar practice implementa- tion in our study demonstrated by a significant improvement in home modification interventions. More comprehensive evidence-based curricula to better educate healthcare providers on fall prevention guidelines could help improve compliance. Implementa- tion of such a curriculum has been shown to significantly increase learning and produce practice changes. 23 Our study also engaged a broad range of healthcare practition- ers and employed an interprofessional training approach to inform them about fall prevention guidelines. Chart review data demonstrated an increased adoption of these guidelines with patients. This approach could be repli- cated in the future to improve healthcare providers’ adherence to fall prevention guidelines. Following the success of the initial EBP training pro- gram, the medical director recognized the advantages of expanding the training systemwide. With the goal of more widely enhancing team care communication and facilitating quality improvement, the Virginia Geriatric Education Center Consortium (VGEC) made the 24- hour training series simultaneously available to all five PACE programs in the health system during the third year. The value of this training, however, could have been underreported in this study by the data collection process used to describe change. The challenges of delivering the curriculum remotely may partly explain why the assessment changes at these training sites were less robust. The remote nature lead to inconsistent attendance, and there were different profes- sionals represented each time as the expectation for atten- dance was lower than for face-to-face sessions. Technical difficulties with sound and video also impacted the receipt of module information and led to decreased com- munication and interaction between participants.

WHEELER ET AL., Practice Improvement with Falls Prevention Training

Limitations

There were several limitations to this study. Medical records may or may not truly reflect some of the details about what happened. Documentation may not differ- entiate subtle overlaps of assessment and intervention. For example, home modifications are typically addressed once identified. They were coded as a recom- mended need when identified, as a planned interven- tion when there was a stated intention to address the need, and then as an implemented AGS/BGS inter- vention once accomplished. Additionally, some changes in PT and OT behavior, such as spending more time discussing fall risk factors, may have been viewed as educational or elementary and not specifically docu- mented in the chart. Thus, adherence to practice guide- lines may be better than actual chart documentation. Therefore, we would recommend future researchers perform direct observation of practitioners, conduct pre and post practitioner interviews on all training par- ticipants, including those who do not document in the medical record, and employ outside observers to meas- ure team communication. Qualitative measures of prac- tice change and knowledge gains may not have been captured by medical chart reviews. Another limitation related to our constrained eval- uation method, which did not include a determination of whether the interventions and assessments chosen by PT and OT were the most appropriate. The data collection process counted the frequency of interven- tions without judgment of quality or appropriateness of chosen interventions. For example, PT may have prioritized ambulation over balance retraining or OT may have prioritized adaptations to self-care routines over home modifications. Appropriate prioritization of targeted interventions is most effective for decreas- ing fall risk. 6 The EBP instruction provided could have helped PT and OT select better interventions without them necessarily doing more interventions, and this would not have been coded as a positive change in practice. The development and delivery of interprofessional training modules in this study as well as the method- ological approach for chart reviews were time intensive. This may limit opportunities to replicate the study. This study trained health providers in PACE settings only. It would be interesting to see if such training improves adherence to published guidelines in other settings. Poor documentation of risk factors may limit the recommendations provided to the patient. Further investigation needs to focus on the development of easy-to-use checklists and more efficient ways to docu- ment fall risk factors and recommendations. This could lead to improved chart reviews and better under- standing of assessment and interventions delivered to the patient.

Journal of Allied Health, Spring 2018, Vol 47, No 1

Conclusion

This study demonstrates that PT and OT provide more fall risk assessments and interventions after robust EBP fall prevention training. Increased knowledge of fall prevention guidelines and recommendations translate to PT and OT’s increased identification and documen- tation of risk factors and interventions. Educational programs that emphasize best practice recommenda- tions for fall prevention, like the one outlined in this paper, show potential to improve PT and OT adher- ence to published guidelines and thus improve their skills in caring for older adults.

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WHEELER ET AL., Practice Improvement with Falls Prevention Training

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