Training and Toolkit Resources to Support Implementation of a Community Pharmacy Fall Prevention Service

Experience and Hospital Context Influence Fall Prevention Practice by Physical Therapists: A Survey Study

BACKGROUND

Falls in and following hospitalization are common and problematic. Little is understood about the factors that impede or promote effective implementation of fall prevention practices.

PURPOSE AND RELEVANCE

Physical therapists are commonly consulted for acute care patients at risk for falling. The purpose of this study is to understand therapist perceptions of their effectiveness in fall prevention and to explore the impact of contextual factors on practice patterns to prevent falls surrounding hospitalization.

METHODS

Survey questions were tailored to the constructs of hospital culture, structural characteristics, networks and communications, and implementation climate, in addition to inquiries regarding practice patterns and attitudes/beliefs.

RESULTS

Overall, 179 surveys were analyzed. Most therapists (n = 135, 75.4%) affirmed their hospital prioritizes best practices for fall prevention, although fewer agreed that therapists other than themselves provide optimal fall prevention intervention (n = 105, 58.7%). Less practice experience was associated with greater odds of affirming that contextual factors influence fall prevention practice (odds ratio 3.90, p < .001). Respondents who agreed that their hospital system prioritizes best practices for fall prevention had 14 times the odds of believing that their system prioritizes making improvements ( p = .002).

CONCLUSIONS/IMPLICATIONS

As experience influences fall prevention practice, quality assurance and improvement initiatives should be used to ensure minimum specifications of practice.

A deprescribing medication program to evaluate falls in older adults: methods for a randomized pragmatic clinical trial

Background

Opioids and benzodiazepines (BZDs) are some of the most commonly prescribed medications that contribute to falls in older adults. These medications are challenging to appropriately prescribe and monitor, with little guidance on safe prescribing of these medications for older patients. Only a handful of small studies have evaluated whether reducing opioid and BZD use through deprescribing has a positive impact on outcomes. Leveraging the strengths of a large health system, we evaluated the impact of a targeted consultant pharmacist intervention to deprescribe opioids and BZDs for older adults seen in primary care practices in North Carolina.

Methods

We developed a toolkit and process for deprescribing opioids and BZDs in older adults based on a literature review and guidance from an interprofessional team of pharmacists, geriatricians, and investigators. A total of fifteen primary care practices have been randomized to receive the targeted consultant pharmacist service (n = 8) or usual care (n = 7). The intervention consists of several components: (1) weekly automated reports to identify chronic users of opioids and BZDs, (2) clinical pharmacist medication review, and (3) recommendations for deprescribing and/or alternate therapies routed to prescribers through the electronic health record. We will collect data for all patients presenting one of the primary care clinics who meet the criteria for chronic use of opioids and/or BZDs, based on their prescription order history. We will use the year prior to evaluate baseline medication exposures using morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs). In the year following the intervention, we will evaluate changes in medication exposures and medication discontinuations between control and intervention clinics. Incident falls will be evaluated as a secondary outcome. To date, the study has enrolled 914 chronic opioid users and 1048 chronic BZD users. We anticipate that we will have 80% power to detect a 30% reduction in MMEs or DMEs.

Discussion

This clinic randomized pragmatic trial will contribute valuable evidence regarding the impact of pharmacist interventions to reduce falls in older adults through deprescribing of opioids and BZDs in primary care settings.

Trial registration

Clinicaltrials.govNCT04272671. Registered on February 17, 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06164-5.

A qualitative study of older adults' facilitators, barriers, and cues to action to engage in falls prevention using health belief model constructs

BACKGROUND AND OBJECTIVES

Falls are the leading cause of fatal and nonfatal injuries among older adults. Decreasing falls is highly dependent on engagement in fall prevention activities. The Health Belief Model (HBM) theoretical framework was used to explore older adults' perceptions about falls prevention.

RESEARCH DESIGN AND METHODS

An informed grounded theory approach was applied. Four focus groups were conducted using semi-structured interview guides based on the HBM with 27 community-dwelling older adults (average age = 78 years). Deductive content analysis was used to apply constructs of the HBM to the data and explain the findings.

RESULTS

Potential reasons for not engaging in falls prevention included lack of self-perceived severity, susceptibility, and self-efficacy with a subtheme of lack of information about falls prevention from medical providers. Potential facilitators included older adults' knowledge and current engagement in falls prevention and socializing while engaging in falls prevention. Participants recommended cues to action to improve engagement in falls prevention from family, friends, physicians, pharmacists, and insurance companies; and using various modes to deliver cues to action, including print, audiovisual, online, and reminders.

DISCUSSION AND IMPLICATIONS

In this study, the HBM was used to understand older adults' potential barriers, facilitators, and cues to action to support engagement in falls prevention. Engagement in fall prevention behaviors could be improved by addressing barriers such as lack of knowledge, and lack of self-perceived severity and susceptibility to falls. Reinforcing the benefits of fall prevention, and promoting cues to action to engage in falls prevention may also support engagement.

Community pharmacists' perceptions on providing fall prevention services: a mixed-methods study

Background Pharmacists may contribute to fall prevention particularly by identifying and deprescribing fall risk-increasing drugs (FRIDs) in patients with high fall risk. Objective To assess community pharmacists’ perceptions on providing fall prevention services, and to identify their barriers and facilitators in offering these fall prevention services including deprescribing of FRIDs. Setting A mixed-methods study was conducted with Dutch pharmacists. Method Quantitative (ranking statements on a Likert scale, survey) and qualitative data (semi-structured interviews) were collected. Out of 466 pharmacists who were invited to participate, 313 Dutch pharmacists ranked statements, about providing fall prevention, that were presented during a lecture, and 205 completed a survey. To explore pharmacists’ perceptions in-depth, 16 were interviewed. Quantitative data were analysed using descriptive statistics. All interviews were audiotaped and transcribed verbatim. The capability opportunity motivation-behaviour model was applied to interpret and analyse the findings of qualitative data. Main outcome measure Community pharmacists’ views on providing fall prevention. Results Pharmacists stated that they were motivated to provide fall prevention. They believed they were capable of providing fall prevention by FRID deprescribing. They perceived limited opportunities to contribute. Major barriers included insufficient multidisciplinary collaboration, patient unwillingness to deprescribe FRIDs, and lack of time. Facilitators included goal-setting behaviour, financial compensation, and skilled communication. Conclusion Despite the complex decision-making process in medication-related fall prevention, community pharmacists are motivated and feel capable of providing fall prevention. Opportunities for pharmacists to provide fall prevention services should be enhanced, for example by implementing multidisciplinary agreements.

Screening for social determinants of health in community pharmacy: Identifying best practices, barriers, and strategies for success

The social determinants of health (SDOH) play a key role in patients' access to health care and medications. There exists an area of opportunity to leverage community pharmacists to make a large impact in identifying and incorporating an understanding of a patient's SDOH into their treatment plan. Community pharmacies are accessible and trusted avenues for health care interventions. With the advancement of appointment-based models as well as the increased training of support personnel, community pharmacies may be well suited for this public health task. However, there are major challenges such as paradigm shifts in workflow, reimbursement, and training that must be addressed to make this endeavor successful. This commentary explores the sparse literature related to community pharmacists conducting screening for social risk factors to identify best practices and barriers to implementation and outlines how screening for social needs aligns with the Pharmacists' Patient Care Process.

Using the Drug Burden Index to identify older adults at highest risk for medication-related falls

BACKGROUND

The Drug Burden Index (DBI) was developed to assess patient exposure to medications associated with an increased risk of falling. The objective of this study was to examine the association between the DBI and medication-related fall risk.

METHODS

The study used a retrospective cohort design, with a 1-year observation period. Participants (n = 1562) were identified from 31 community pharmacies. We examined the association between DBI scores and four outcomes. Our primary outcome, which was limited to participants who received a medication review, indexed whether the review resulted in at least one medication-related recommendation (e.g., discontinue medication) being communicated to the participant's health care provider. Secondary outcomes indexed whether participants in the full sample: (1) screened positive for fall risk, (2) reported 1+ falls in the past year, and (3) reported 1+ injurious falls in the past year. All outcome variables were dichotomous (yes/no).

RESULTS

Among those who received a medication review (n = 387), the percentage of patients receiving at least one medication-related recommendation ranged from 10.2% among those with DBI scores of 0 compared to 60.2% among those with DBI scores ≥1.0 (Chi-square (4)=42.4, p < 0.0001). Among those screened for fall risk (n = 1058), DBI scores were higher among those who screened positive compared to those who did not (Means = 0.98 (SD = 1.00) versus 0.59 (SD = 0.74), respectively, p < 0.0001).

CONCLUSION

Our findings suggest that the DBI is a useful tool that could be used to improve future research and practice by focusing limited resources on those individuals at greatest risk of medication-related falls.