The iSOLVE Project: Falls Prevention and the Role of General Practice

The iSOLVE project is a partnership between the University of Sydney, the NSW Clinical Excellence Commission and Sydney North Primary Health Network (SNPHN). The project aims to provide a whole primary care approach to falls prevention by helping general practices better identify older people at risk of falling and efficiently manage their fall risk.

The clinical decision tool provides GPs with tailored management plans for their older at-risk patients. The SNPHN also offers a directory of trained fall prevention service providers in the GPs local area to facilitate patient referral. I talked to Prof Lindy Clemson and her team of researchers to find out more about the work iSOLVE is doing and how the tool helps clinics.

How did you get started with iSOLVE?

“I’ve been researching falls prevention now for probably 25 years. My background is in occupational therapy. I started out looking at home safety and hazards around the home and people’s behaviours around falls. So, what kind of risks they take and what kind of things they could do to change those behaviours to make themselves safer.

“I did a group based program we called Stepping On. It’s a seven week program designed for people who are living at home and have experienced a fall or are concerned about falling. We ended up doing a randomised trial, which incorporated a practical set of exercises that were specifically designed to improve strength and balance.

“It also involves the older participants understanding their personal fall risk and engaging in relevant safety strategies to address a variety of falls-related topics, including vision, home hazards, medicines, bone health and footwear. In these programs I produced the manuals, which really helped with disseminating them and them being taken up.

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“Then, I did a study looking at the LIFE program, which stands for ‘Lifestyle Integrated Functional Exercises’ to reduce fall risk. It’s kind of an occupational therapy approach to exercise. So it’s about getting balance and strength in daily life. So, instead of doing something say, three times a week, you do it throughout the day and do things like standing up slowly, or standing on one leg, or changing your balance in different ways as you go about your daily routine. And that was really effective too.

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“I guess the iSOLVE project is kind of the culmination of all the years of work that I and others have done in falls prevention. I’ve always enjoyed working with older people, and falls is one of those things that if you reduce your risk of falling, then you’re doing things that are going to be good for your ability to keep doing stuff and getting around and being independent.”

What does iSOLVE do?

“iSOLVE is about GPs asking people if they’ve had a fall because we know that these early interventions reduce falls. We’ve got statistics that show how many people we can reach and reduce falls by, but the problem has been doing it on a bigger scale. That’s the challenge we’re trying to solve: how can we reach people before they’ve had that injurious fall, or a number of falls?

30% of people out there aged over 65 are going to have a fall this year. Can we reach more of these people before they have more falls or things start to deteriorate even more?

“We want to upskill the allied health in this area and work with the GPs and provide them with an efficient, easy system where they can understand how to better manage falls. GPs often see a fall as an injury because that’s what the person who talks about their fall has had — a bad injury. They don’t always see it as something they can manage. And that’s what we changed with a lot of the GPs in this program. We’re trying to change their practice about routinely asking older people if they’ve had a fall and helping them do something about it to prevent another fall.

Aside from reducing injury, what are some of the other benefits of fall prevention?

“Well, if it’s home safety, you’re more aware of your environment, so you’re more likely to see a hazard. If it’s the balance program, you’re improving your balance and leg strength. And the LIFE program for example has great functional outcomes because people are able to do more, stand up and put their trousers on, catch a bus, things like that.

“Then there is medication management. That’s another one of the interventions that we know can work. It means reducing people’s reliance on psychotropic medications or sleeping tablets. Sleeping tablets is one of the biggest things. It actually increases falls because it makes you sleepy during the day. So GPs can actively reduce side effects from medications and review their patient’s medications.

Is iSOLVE built specifically for GPs?

“It is the core part of it. We’ve been running iSOLVE training with GP practices throughout the Sydney North Primary Health Network, initially as part of a trial.

We’re currently running a cluster randomised trial collecting falls data from 560 patients at 27 GP practices to look at whether we can change fall prevention in GP practice

“We’re also working with The Sydney North Health Network, the Primary Health Network, using education to reduce falls post-hospitalisation. And we’ve been running evidence-based training for allied health practitioners, pharmacists, podiatrists, physiotherapists, OTs etc.

How does it work for GPs?

“For GPs it has to be something quick. We’ve got an algorithm that uses a short questionnaire, which the patient or the doctor fills out. It involves questions like, are you unsteady on your feet, how many medications do you take etc. There are 14 questions. The algorithm then tries to highlight some of the risk factors they might have and asks a few more questions specifically about vision and so on.

“We get the GP to say, ‘how many falls have you had, and what do you think causes your falls’. We want the GPs to routinely ask the F question for all their older patients – have you had a fall? From that we’ve worked out a process of tailoring solutions based on the evidence for what works. So the different interventions that work and what’s available to support the doctor and patient in the local area.

“Depending on what risks they tick, or the GP ticks, then it comes up with a small list of proposed interventions

“It might be they should have a physiotherapy assessment because their balance is really poor. If they’ve been recently hospitalised, it might encourage them to have an occupational therapy assessment, or look at home safety. If they’ve got cataracts, it might suggest they go and have their cataracts out as soon as possible, and so on. So it comes up with suggestions for how the GP might manage the person. It sounds quite simple, except it’s not of course.

How have trial practices responded?

“Really good. I mean, we’ve learnt a lot and there are things we’d do differently, but GPs have said it’s a really good training process. As well as the electronic system we have booklets for them and case studies and examples, we have information about how they can fit different things within their funding system, we have a lot of information on medications, we have snippets on what kind of exercise, why home safety works, why you should get your cataracts done. We have all these resources but we do it as efficiently as possible and they say they like what they’ve learnt.

“It’s kind of this mantra. By going through this process, GPs become kind of ingrained in the system. And the best result is that many have been able to move beyond just seeing the injury. They’ve been able to see that they can do something and manage falls, which is something that hadn’t been on their radar previously.”

How can doctors access iSOLVE’s GP Fall Risk Assessment Tool?

iSolve’s GP Fall Risk Assessment Tool and all the relevant resources are now available for doctors to use.  You can access the tool by clicking the link.  Prof Lindy Clemson and her team are also developing active learning modules and clinical audit activities for GPs that should be available on the website soon.

For more information, please email [email protected].

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