Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation
BMJ 2021; 375 doi: https://doi.org/10.1136/bmj-2021-066991 (Published 07 December 2021) Cite this as: BMJ 2021;375:e066991Linked Editorial
Preventing falls in residential care
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Dear Editor
This trial shows that training of care home staff with a written plan for falls prevention has a short lived effect on falls in care homes. A persistent effect can only be achieved by nurturing and sustaining care home staff over the long term. The approach mirrors FallSafe, a trial to prevent inpatient hospital falls, in which a care bundle was given to staff to implement, and ward staff were trained in falls prevention. It was successful because of the work of the paid falls champions on the wards and the team of people interested in falls they enthused, not because of the care bundle and the initial training.
This paper says little about the falls champions and what support they received. Just knowing that falls are being monitored in a care home, and that they are part of a big study will result in changes in behaviour that are unlikely to be replicated outside the setting of a clinical trial. The paper tells us little about what the frequency and intensity of input was of trial staff, and it is possible that this input, rather than the document and the training, was the active intervention in this trial.
We tried this approach, with written information and training for care home staff in Oxfordshire in 2006, and it had a short term impact of increasing falls reporting but did not create a sustained change of behaviour of care staff towards falls prevention. Staff training was difficult. We translated the information into the most prevalent foreign language (we found 34 first languages among care home staff, with many having poor language skills having recently arrived in the UK). Time to attend training for staff was a problem, and often pre-arranged training sessions might attract only one person. There was a high turnover of care staff.
Without regular reminding, falls became just one of many priorities the care homes faced, and the written materials were used little. However, as part of that trial, a multi factorial falls assessment by our falls specialist nurses of all residents that had experienced a fall showed significant reductions in falls and fractures over a 9 to 12 month period.
A service supporting falls prevention in care homes can be justified financially on the money saved from fall related admissions. But, as one care home manager out it, once health staff are going into care homes, “why do they have to throw themselves on the floor before you will see them”.
Inspired by the work of Dr Tony Vernon in Manchester, the outcome was the formation of the Oxfordshire Care Home Support Service in 2010, with 22 wte staff led by a Consultant Geriatrician, consisting of Physical Health Nurses and Support workers, physios and OTs together with Mental Health Nurses and OTs, and a small admin team who support all 128 Oxfordshire care homes to manage their complex residents, including falls prevention, dementia management, end of life support, drug reviews, manual handling, mobility and positioning advice, hydration and nutrition, and the ability to access rapid input from psychiatry and other specialties, and to signpost to other services.
Prior to the pandemic, this led to Oxfordshire performing well compared to surrounding counties on any metrics concerning care homes - mortality, hospital admissions, days spent in hospital, falls and fractures. It also contributed to a fundamental re-organisation of medical care to care homes and the closure of the worst homes. The service more than pays for itself in health economic terms, even before taking into account the improved quality of life for residents. The service is now part of the regular healthcare landscape of Oxfordshire.
Dr Adam Darowski MD FRCP
Consultant Physician,
John Radcliffe Hospital, Oxford
Mrs Antoinette Broad RGN
Advanced Clinical Practitioner, Community Services
Mrs Kristel Silvester RGN
Clinical Lead, Oxfordshire Care Home Support Service
Mrs Paula Hughes RGN
Falls Specialist, Oxfordshire Care Home Support Service
Oxford Health NHS Foundation Trust
Competing interests: No competing interests
Dear Editor
As a final year medical student, I found the ‘Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation’ (1) to be highly insightful. I would like to express my gratitude to the authors’ for highlighting such an important topic within a demographic that needs to be researched further.
The authors emphasised the high rate of falls in the elderly population, as well as the proportion of falls that occur in care homes. I would like to point out, however, how limited the research on falls prevention in care homes is. There are currently no systematic reviews addressing falls prevention in care homes in the UK, with only one systematic review conducted in the United States (2). Furthermore, in the public health guidance, the only systematic review evidenced was conducted within the community (3). The National Falls Prevention Coordination Groups have raised public awareness about the need of preventing falls in the elderly and coping with the consequences of falls in the community and in hospitals (4). However, establishing programmes in care homes has received little attention.
Additionally, it is important to note the limited training care home staff receive on falls. Many falls that occur are preventable and require simple assessments of their gait, visual impairments and other factors (4). When providing carers with education on how to prevent falls with programmes such as the GtACH illustrated in this article, this can play a major role in reducing the number of falls while maintaining their mobility and independence. As a result, I strongly agree with the authors that a suitable multifactorial and multicomponent intervention, should be considered for implementation as mandatory training for all care home workers across the UK.
1. Logan PA, Horne JC, Gladman JR, Gordon AL, Sach T, Clark A, Robinson K, Armstrong S, Stirling S, Leighton P, Darby J. Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation. bmj. 2021 Dec 7;375.
2. Vlaeyen E, Stas J, Leysens G, Van der Elst E, Janssens E, Dejaeger E, Dobbels F, Milisen K. Implementation of fall prevention in residential care facilities: A systematic review of barriers and facilitators. International journal of nursing studies. 2017 May 1;70:110-21.
3. Hopewell S, Adedire O, Copsey BJ, Boniface GJ, Sherrington C, Clemson L, Close JC, Lamb SE. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 2018(7).
4. Falls: applying All Our Health [Internet]. GOV.UK. 2021 [cited 23 December 2021]. Available from: https://www.gov.uk/government/publications/falls-applying-all-our-health...
Competing interests: No competing interests
Maintaining and promoting health in care homes
Dear Editor
The prevention of falls is an important public health issue for care homes but a fairly recent Cochrane review found that the benefits of interventions were uncertain for care home residents.(1) So it is very positive that a high quality RCT of a complex intervention was associated with a significant reduction in the incidence of falls among older adults living in long term care.(2) The authors also investigated health economic outcomes and found the intervention to be cost effective.
It is of note that this multifactorial falls prevention programme was co-designed with care home staff and residents.(2) The study has a number of strengths including the involvement and empowerment of care home staff, large sample size and the measures taken to avoid contamination. We hope that policy makers and care home providers will take note of the findings of this robust intervention and use the lessons learnt to tackle this important public health area.
Falls prevention is just one of the many health issues that care home staff have to deal with. Individuals who move into care homes are usually those who are unable to live at home even with complex care support. Admission may be due to impairments in activities of day-to-day living and although the health status of residents will vary these individuals may be frail, have multi-morbidity and dementia-related symptoms.
Additionally, when people move into residential care homes, they may experience loneliness and social isolation. In Essex, an intervention involving participatory arts was used to tackle these issues.(3) Reminiscence arts, seated dance, and orchestral music participation enabled older people to express themselves creatively, and make meaningful contributions to their social relationships.(3) Similarly, in the East Midlands creative writing groups were used in care homes and found to be beneficial in terms of self-expression and wellbeing.(4) Although time limited and using external arts groups, these studies do add to the evidence base on linking arts to positive health and wellbeing.(5,6)
Despite these promising interventions, the care home sector has wider long-standing problems that need to be urgently addressed. These include under-investment, under-staffing, poor employment conditions, and difficulty recruiting and retaining staff.(7-9) The covid-19 pandemic has exacerbated these issues and has had a detrimental influence on the health of many staff, as well as residents. We firmly believe that care home staff play vital roles in the care of vulnerable people, and are invaluable members of society, employed in complex environments and have recently been working under extreme pressure in unprecedented times.
Institutional settings such as care homes can affect health either negatively or positively.(10) However, they provide good opportunities for promoting the health of all those who live and work there. This requires attention to the design of the spaces as well as the activities taking place within them. For example, the dining experience can be a focal point for participants’ broader experiences of residing in a care home, including making social interaction and connection with other residents, familiarity and routine.(11) Care home staff should be afforded the same opportunities around food.
Internal space needs to provide both communal areas as well as smaller quiet areas. Easy access to outdoors offering potential for varied activities as well as relaxation is also essential. Links with the surrounding community and opportunities for involvement are also important.
As a workplace setting, care homes need to address both occupational health issues of the staff and general health promotion including mental health, healthy eating, physical activity, and support for quitting smoking.(12-15) Similar topics are of course also important for the residents. However, in spite of good practice in some areas of the country more support would be needed to maximise the focus on promoting all aspects of health. This could be facilitated by public health specialists if they were provided with sufficient resources.(16-17) Also needed internally would be sound leadership, training and management support to provide clear direction and guidance.(7)
We recommend that in the future the health of care home staff is prioritised with the aim of maintaining and promoting their health alongside promoting all aspects of residents’ health. Healthy staff are more likely to look for opportunities to promote the health of residents rather than keeping the focus just on the important and immediate areas of care. In the long term we would like to see “health promoting care homes” established, empowering and firmly promoting the health of residents and all the staff.(10,18)
References
1) Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev2018;9:CD005465. . doi:10.1002/14651858.CD005465.pub4 pmid:30191554
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005465.pub4/...
2) Logan P A, Horne J C, Gladman J R F, Gordon A L, Sach T, Clark A et al. Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation. BMJ 2021; 375 :e066991 doi:10.1136/bmj-2021-066991
https://www.bmj.com/content/375/bmj-2021-066991
3) Dadswell A, Bungay H, Wilson C, Munn-Giddings C. The impact of participatory arts in promoting social relationships for older people within care homes. Perspectives in Public Health. 2020;140(5):286-293. doi:10.1177/1757913920921204
https://journals.sagepub.com/doi/10.1177/1757913920921204?url_ver=Z39.88...
4) Stickley T, Watson M C, Hui A, Bosco A, French B, and Hussain B. “The Elder Tree”: An evaluation of Creative Writing Groups for Older People. Nordic Journal of Arts, Culture and Health. 2021;Nov: 48–62. https://doi.org/10.18261/issn.2535-7913-2021-01-
https://www.idunn.no/doi/10.18261/issn.2535-7913-2021-01-02-05
5) All-Party Parliamentary Group on Arts, Health and Wellbeing. All-Party Parliamentary Group on Arts, Health and Wellbeing Inquiry Report Creative Health: The Arts for Health and Wellbeing. London: All-Party Parliamentary Group on Arts, Health and Wellbeing, 2017.
https://www.culturehealthandwellbeing.org.uk/appg-inquiry/
6) Jensen A, Torrissen W, and Stickley T. Arts and public mental health: exemplars from Scandinavia. Public Health Panorama, 2020;6(1): 193 – 210.
https://www.euro.who.int/en/publications/public-health-panorama/journal-...
7) McGilton K, Escrig-Pinol A, Gordon A, Chu C, Zúñiga F, Gea Sanchez M et al. Uncovering the Devaluation of Nursing Home Staff During COVID-19: Are We Fuelling the Next Health Care Crisis? JAMDA, 2020;21(7): 962-965.
https://www.jamda.com/article/S1525-8610(20)30492-8/fulltext
8) Heneghan C, Dietrich M, Brassey J, Jefferson T, Kay AJ. CG Report 6: Effects of COVID-19 in Care Homes - A Mixed Methods Review. Collateral Global. Version 1, 2021.
https://collateralglobal.org/article/effects-of-covid-19-in-care-homes
9) Care Quality Commission. The state of health care and adult social care in England 2020/21. Newcastle upon Tyne: Care Quality Commission, 2021.
https://www.cqc.org.uk/sites/default/files/20211021_stateofcare2021_prin...
10) Baybutt M, Kokko S, editors. A handbook on settings-based health promotion. New York: Springer, 2022; [forthcoming].
11) Watkins, R, Goodwin V, Abbott R, et al. Exploring residents’ experiences of mealtimes in care homes: A qualitative interview study. BMC Geriatrics, 2017;17:141.
https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-017-0540-2#...
12) Faculty of Public Health and the Faculty of Occupational Medicine. Creating a healthy workplace: A guide for occupational safety and health professionals and employers. London: Faculty of Public Health, 2006.
13) IOSH. Working well. Guidance on promoting health and wellbeing at work. Wigston: IOSH, 2015.
14) Royal College of Physicians of London. Work and wellbeing in the NHS: why staff health matters to patient care. 2015.
https://www.rcplondon.ac.uk/guidelines-policy/work-and-wellbeing-nhs-why...
15) National Institute for Health and Care Excellence. Workplace health: long-term sickness absence and capability to work. NICE guideline NG146. 2019.
https://www.nice.org.uk/guidance/ng146
16) BMA. Funding for ill-health prevention and public health in the UK. May 2017.
http://bit.ly/2quLN3K
17) Watson M C and Thompson S. Government must get serious about prevention. BMJ 2018;360:k1279.
https://www.bmj.com/content/360/bmj.k1279
18) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.
https://primarycare.imedpub.com/going-for-gold-the-health-promoting-gene...
Competing interests: No competing interests