Fall Prevention in Postacute Care: Best Practices Versus Documented Practices

PURPOSE: Value-based care is now being implemented in postacute care (PAC). As a result, providers must demonstrate their value using a predetermined set of interdisciplinary outcomes (e.g., falls). Thus, to demonstrate the value of occupational therapy (OT), practitioners must deliver best practices, document them, and demonstrate their relationship to these outcomes (Leland, Crum, Phipps, Roberts, & Gage, 2015). To begin this effort, we focused on a PAC population at high risk for falls—patients with hip fracture. The goal of this study was to identify stakeholder-driven best practices and ascertain the extent to which these practices were reflected in OT documentation within an episode of PAC.

DESIGN: This study used a mixed-methods convergent design (Creswell & Clark, 2011) and included two samples: a purposive national sample of interdisciplinary providers who cared for patients with a hip fracture (N = 88) to capture variation in geographic regions and discipline (e.g., geriatricians, nurses, occupational and physical therapy practitioners) and a retrospective electronic medical record (EMR) sample that included 2 yr of patient admissions (N = 22) to one of two PAC facilities located in different geographic regions to capture variations in documentation. Eligible EMR episodes included patients who (1) were discharged directly from an acute hospital with a diagnosis of a hip fracture, (2) underwent surgical repair, and (3) lived in the community at the time of the fracture.

METHOD: PAC providers participated in 1-hr focus groups or interviews to ascertain PAC fall prevention best practices and the role of each discipline in preventing this adverse event. Data included field notes from sessions and transcribed audio recordings. Documentation extraction was conducted using REDCap (Nashville, TN), a web-based data collection platform. Data were pulled from clinical notes within the EMR across the care team (e.g., nursing, occupational therapy) for the entire PAC stay. Variables included in the dataset were informed by current evidence-based literature and qualitative data (e.g., balance assessment; Cameron et al., 2012). Transcripts were analyzed independently of each other for familiarization, reviewed for potential patterns, and later analyzed for common themes by discipline and then collectively as a group. Candidate themes were developed, reviewed, and compared with selected quotes and the entirety of coded data. EMR data analysis included calculating the proportion of patients with documentation of each process. Data triangulation drew on field notes, themes, and proportions of documented care.

RESULTS: Assessing fear of falling, cognition, and home safety as well as examining habits, roles, and routines within the context of falls were themes that emerged as key OT contributions. Nursing identified all 22 patients to be a fall risk. Yet, OT documentation did not indicate fear of falling, and cognitive screens were completed. Cognitive screening was the only process to have a discrete field in the EMR. In the narrative section of the daily notes, a conversation about home safety (n = 2) and a discussion about fall prevention within the client’s routine at home (n = 1) were documented.

CONCLUSION: Across the interdisciplinary team, common themes described the contributions of OT in addressing fall risk in PAC. Yet, the EMR platforms did not capture all practices. Even when built into the EMR, the frequency of documented best practices was limited.

IMPACT STATEMENT: These findings suggest that there is a gap between best practice and current documented practice, which can inform quality improvement initiatives and refinement of EMRs. Thus, if OT is going to demonstrate its value, the profession needs to be able to deliver, document, quantify, and demonstrate the relationship of these practices to nationally prioritized patient outcomes.

References

Cameron, I. D., Gillespie, L. D., Robertson, M. C., Murray, G. R., Hill, K. D., Cumming, R. G., & Kerse, N. (2012). Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews, 2012, CD005465. https://doi.org/10.1002/14651858.CD005465.pub3

Creswell, J. W., & Clark, V. L. P. (2011). Designing and conducting mixed methods research (2nd ed.). Thousand Oaks, CA: Sage.

Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B. (2015). Advancing the value and quality of occupational therapy in health service delivery. American Journal of Occupational Therapy, 69, 6901090010. https://doi.org/10.5014/ajot.2015.691001