Fall prevention implemented in primary healthcare

The objective of this study is to evaluate if the implementation of a systematic and targeted screening of fall risk among independently living frail older people in primary care will result in more referrals to existing evidence-based fall prevention interventions. This will be evaluated with help of the RE-AIM model of Glasgow et al (1999): Reach, Effectiveness, Adoption, Implementation and Maintenance. Evaluation will take place at the level of the primary care provider (implementation index) in Part 1 and the level of the patient (patient-related outcome measures) in Part 2 of this study.
In Part 1 of this research, the reach of the implementation strategy at the level of the primary care provider will be evaluated with the following outcome measures:
1. The percentage of vulnerable elderly screened for fall prevention care;
2. The percentage of screened vulnerable elderly eligible for a fall prevention program;
3. The percentage of eligible elderly for a fall prevention program that agreed with a referral to a fall prevention program
4. The percentage of vulnerable elderly that actually start the program
5. The percentage of vulnerable elderly that complete the program.

In Part 2 of this research, the effectiveness of the fall prevention implementation strategy on patient level will be assessed. In this part, based on the patient’s risk profile, patients are offered fall prevention interventions by their GP, practice nurse or home care provider like referral to an exercise program, treatment of urine incontinence, or perhaps an adjustment of medication. The group of patients who receive an exercise program are called group 1. The group of patients who are treated by their GP in example for urine incontinence or adjustment of medication, are called group 2. Patients from both groups can receive several fall prevention interventions, yet group 1 patients always receive an exercise program and group 2 patients do not. (see Figure 1. Overview procedures fall prevention implementation study, in the Protocol.) Patients from group 1 will be followed more intensively than patients from group 2. The outcome measures of patients from group 1 are assessed at baseline (T0), at the end of the intervention (T1) and after 12 months (T2). The following four physical tests, six short questionnaires and a falls-calendar will be conducted/provided by the GP, practice nurse, home care provider and the physio- or exercise therapist:
1. The Functional Reach Test (FRT): The patient is instructed to stand next to a wall, but not to touch it. The arm is positioned at 90 degrees of shoulder flexion with a closed fist. The started position is recorded at the third metacarpal head on the yardstick. The patient is asked to reach forward as far as possible, without taking a step. The difference between the start and the end position of the third metacarpal is used as score. Three trials are done and the average of the last two is noted (Weiner, 1992)
2. The Timed-Get-Up-and-Go-Test (TUG): This test will be used to assess patients’ mobility. The patient is asked to rise from a chair, walk three meters, turn around, walk back to the chair and sit down. The physio- or exercise therapist will measure the time required for this test with a stopwatch. Three trials are done and the average of the last two is noted (Podsiadlo, 1991)
3. Timed Chair Stand test (TCS): This test is used to assess the patient’s muscle strength. The patient is asked to sit and stand as quick as possible five times in a row from a chair without using their arms. The physio- or exercise therapist will measure the time required for this test with a stopwatch.
4. Tandem Stance test (TS): This test is used to assess the patient’s balance. The patients is asked to stand in three positions (that increase in difficulty) for 10 seconds. The physio- or exercise therapist will note the time and positions the patients was able to complete.
5. Fall history questionnaire: This questionnaire consists of five questions regarding the patient’s fall history, fall-related injuries and health.
6. Short Falls Efficacy Scale-International (Short FES-I): A questionnaire of 7 items to measure fear of falling and self-efficacy to manage daily situations (Kempen, 2007).
7. EQ-5D-5L: A standardised measure of health status developed by the EuroQol Group in order to provide a simple, generic measure of health for clinical and economic appraisal. The assessment consists of 5 multiple choice questions regarding mobility, self-care, usual activities, pain/discomfort and anxiety/depression. In addition it has a scale regarding once health on that day (Van Reenen & Janssen, 2015)
8. Impact Intervention Questionnaire: This questionnaire consists of 5 questions corresponding to the EQ-5D-5L standardised measure. These questions are about the patient feeling worse, the same or better regarding mobility, self-care, usual activity, pain/discomfort and anxiety/depression compared to before the intervention.
9. Activity Questionnaire: This questionnaire consists of 5 questions regarding living environment, mobility, free time and social contact.
10. Falls-calendar: All participants receive a falls-calendar on which they can write down on a day to day basis if they have had a fall or not. On this calendar they write down a ‘N’ for not fallen and an ‘F’ for fallen. After each month they can detach the page for that month and send it back to the research team. No patient details will be on the calendar. No stamp is necessary. In case the patient has fallen, the researcher will call the patient and ask him/her a few questions about the cause of the fall, related injuries and hospital admission.
11. Questionnaire Treatment Fall-risk: This questionnaire consists of three questions about which interventions the participant received regarding to their fall risk. The patients from group 2 will conduct one questionnaire at baseline and a questionnaire after 12 months. Furthermore they will be asked to keep track of their fall-incidence during these 12 months (T0-T2).

The following 2 questionnaires and falls-calendar will be conducted/provided by the GP, practice nurse or home care provider:
1. Fall history questionnaire: This questionnaire consists of five questions regarding the patient’s fall history, fall-related injuries and health.
2. Falls-calendar: All participants receive a Falls-calendar on which they can write down on a day to day basis if they have had a fall or not. On this calendar they write down a ‘N’ for not fallen and an ‘F’ for fallen. After each month they can detach the page for that month and send it back to the research team. No patient details will be on the calendar. No stamp is necessary. In case the patient has fallen, the researcher will call the patient and ask him/her a few questions about the cause of the fall, related injuries and hospital admission.
3. Questionnaire Treatment Fall-risk: This questionnaire consists of three questions about which interventions the participant received regarding to their fall risk.