M. K. Chung and J. M. Bartfield (2002). "Knowledge of prescription medications among elderly emergency department patients." Annals of Emergency Medicine 39(6): 605-08.

http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=abs&id=a122853&nav=abs

Study Objective: We determine how knowledgeable elderly (>65 years old) patients seen in the emergency department are of their prescription medications.

Methods: Patients older than 65 years who presented to the ED of an urban teaching hospital were interviewed concerning their prescription medications and the indications for their use. Medications and dosages were verified through the patients' pharmacies. Medication indications were assessed for accuracy by referencing the Physicians' Desk Reference.

Results: Data on 88 patients were collected over a period of 2 months. Eleven patients were excluded from the study because of logistics (9) and rescinding of consent (2). Patients averaged 5.9 prescription medications on presentation to the ED. Patients correctly identified 78.4% (359/458) of these medications. Thirty-three (42.8%) patients were able to correctly identify all of their prescription medications. Furthermore, patients correctly identified 65.5% (236/359) of dosages (25 [32.5%] patients named all dosages correctly), 91.4% (328/359) of dosing intervals (44 [57.1%] patients named all intervals correctly), and 83.3% (299/359) of indications (49 [63.3%] patients named all indications correctly).

Conclusion: Elderly patients presenting to the ED have only a fair knowledge of their prescription medications.

L. Day, B. Fildes, et al. (2002). "Randomised factorial trial of falls prevention among older people living in their own homes." British Medical Journal 325: 128.

http://bmj.com/cgi/content/abstract/325/7356/128

Objective: To test the effectiveness of, and explore interactions between, three interventions to prevent falls among older people.

Design: A randomised controlled trial with a full factorial design.

Setting: Urban community in Melbourne, Australia.

Participants: 1090 aged 70 years and over and living at home. Most were Australian born and rated their health as good to excellent; just over half lived alone.

Interventions: Three interventions (group based exercise, home hazard management, and vision improvement) delivered to eight groups defined by the presence or absence of each intervention.

Main outcome measure: Time to first fall ascertained by an 18 month falls calendar and analysed with survival analysis techniques. Changes to targeted risk factors were assessed by using measures of quadriceps strength, balance, vision, and number of hazards in the home.

Results: The rate ratio for exercise was 0.82 (95% confidence interval 0.70 to 0.97, P=0.02), and a significant effect (P<0.05) was observed for the combinations of interventions that involved exercise. Balance measures improved significantly among the exercise group. Neither home hazard management nor treatment of poor vision showed a significant effect. The strongest effect was observed for all three interventions combined (rate ratio 0.67 (0.51 to 0.88, P=0.004)), producing an estimated 14.0% reduction in the annual fall rate. The number of people needed to be treated to prevent one fall a year ranged from 32 for home hazard management to 7 for all three interventions combined.

Conclusions: Group based exercise was the most potent single intervention tested, and the reduction in falls among this group seems to have been associated with improved balance. Falls were further reduced by the addition of home hazard management or reduced vision management, or both of these. Cost effectiveness is yet to be examined. These findings are most applicable to Australian born adults aged 70-84 years living at home who rate their health as good.

Department of Health (2002). National service framework for older people supporting implementation intermediate care: Moving forward. London.

http://www.doh.gov.uk/intermediatecare/icmovingforward.htm

Executive Summary

1. Introduction
Intermediate care - a range of integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admission, support timely discharge and maximise independent living - is a vital component of the programme to improve the health and well being of older people and raise the quality of services they receive.

Intermediate care is not an optional extra - it is central to the modernisation agenda. It is about appropriateness and quality of care for individuals but also about making an impact on the health and social care system as a whole through more effective use of capacity and new ways of working. It is not the domain of any single profession, organisation or sector. Partnership is at the heart of intermediate care - professions and organisations working together to make person-centred care a reality.

This paper summarises the key points of a review of progress in intermediate care. It underlines the guiding principles, highlights 'success factors', based on good practice, available research evidence and current thinking, and explores some of the issues that excite debate and where action is needed.

2. Guiding Principles
The National Service Framework (NSF) for Older People is bound together by four principles, which should underpin planning and delivery of intermediate care:

Person-centred care - ensuring that older people are treated on the basis of their individual needs, circumstances and priorities. Must be supported by a robust assessment process and involvement of older people and their carers in decisions.

Whole system working. Older people's needs often include physical, mental and social dimensions and require responses that cut across organisational and professional boundaries. There must be partnership and shared responsibility for meeting those needs. Person-centred care will only be achieved when all groups and agencies involved agree to work within a single process for assessing needs and sharing information.

Timely access to specialist care. Older people benefit from high quality specialist care as much as anyone else and must not be denied access on the basis of age. Clear arrangements for accessing specialist assessment, diagnosis and treatment when needed are essential.

Promoting health and active life. Providing opportunities for older people to remain healthy and independent is a big challenge for health and social services, working with others in local government and in the independent sector. Intermediate care is a vital part of the strategy, helping older people to realise their full potential as well as regain health.

3. Success Factors
Local circumstances and models of intermediate care - how they are led professionally and organisationally, how they are structured and delivered - vary enormously but despite this variability, good practice and 'success' is generally underpinned by the same key factors:

Vision, drive and leadership. The ability to see beyond organisational boundaries, challenge orthodoxy and understand the changes needed for service redesign. Senior level commitment - support and empowerment - is essential.

Shared objectives. Clarity of purpose is important for any team, but is absolutely essential for a team working across organisational and professional boundaries.

Co-ordination - strategic and operational. Effective 'system' co-ordination to make the right organisational connections and to maximise impact but also day to day co-ordination to ensure that the service really is seamless. The role of intermediate care co-ordinators, as identified in the NSF, is vital.

Appreciation of potential and limitations. Challenging the boundaries of what is possible in delivering safe, appropriate care to promote independence, but realising that such services are not always appropriate. Depends on a shared understanding of where that boundary lies, a robust assessment process and a degree of confidence and trust between individuals, professions and organisations.

Clear professional accountability. Intermediate care often involves complex inter-professional and organisational relationships - there must be clear accountability for individuals at all times, safeguarding those individuals and providing a clear framework for those delivering care.

Practicalities - finance and logistics. Joint funding of services, with flexibility at the boundaries, is a very positive way of minimising potential disputes and giving practitioners freedom to meet individuals' needs. Practical arrangements such as a single point of contact and shared base shouldn't be underestimated - they make for easier access for service users and a greater sense of coherence for providers.

4. Evidence
There is growing evidence of the appropriateness of intermediate care as an alternative to traditional forms of care, in the right circumstances, and of the potential benefits for individuals and for the health and social care system as a whole. Local evaluations show that in areas with mature, established services there is evidence for reduced acute hospital admissions and fewer residential/nursing home placements. More robust evaluations by randomised controlled trials have also been reported and several more are in progress. A review of research evidence is included in the main report.

5. Further development: some key issues
The guiding principles and success factors should inform the development of intermediate care. In addition, these are some of the issues considered at a recent Department of Health workshop and where further action is needed:
Mental Health. The origins of intermediate care lie primarily in treatment and rehabilitation related to physical problems, but people who also have mental health problems should not be excluded. The evidence is that they can benefit equally well and the health and social care system can also benefit by providing appropriate care and making appropriate use of resources.

Clinical governance is an essential part of maintaining and improving service quality and should be applied in intermediate care so that quality of care, appropriateness and patient/user safety can be demonstrated.

Medical assessment. Ensuring timely access to appropriate specialist care is a guiding principle. Medical input and assessment and, through that, access to specialist diagnostic and treatment services are a vital part of ensuring that the principle is translated into practice.

Housing. There is increasing awareness of the importance of housing to the health and social care agenda and the potential of housing provision and housing related services within a whole system approach to promoting independence. Ensuring that a person's home is well repaired and adapted to maximise independent living and to provide a safe environment is of critical importance.

Learning from good practice. We need effective ways of learning from good practice in intermediate care to accelerate the process of development across the country. This review is part of that process - there is a role for central initiatives - but it is also important that collaboratives, learning networks and support mechanisms, for example for intermediate care co-ordinators, are set up locally.

6. Conclusion
Intermediate care is central to the modernisation agenda and has made significant progress but must develop further if it is to be fully accepted and realise its potential to transform service delivery and the experiences of the people served. This review aims to support that process but local action is needed to:

Review existing and proposed services in the light of the principles, success factors and evidence presented in this review.

Ensure that intermediate care services are co-ordinated and fully integrated with the full range of other services

Address key issues in development, including those highlighted here.

Establish effective ways of learning from good practice and supporting professional development.
There is a role for central support and advice and for effective learning from good practice and evidence but, ultimately, there is no blueprint and no substitute for local dialogue and agreement between organisations and professions leading to delivery of effective local services.

P. Hagan and C. Cooper (1999). Some characteristics of hospital admissions and discharges: Older Australians. Canberra, Commonwealth Department of Health and Aged Care.

http://www.health.gov.au/pubs/hfsocc/ocpanew8.pdf

Based on Western Australian hospital data covering admissions and discharges during 1994-95 and 1995-96, this study focuses on the experiences of older Australians who were admitted to hospital: how they came to be admitted and why; and where they went afterwards (including the proportion who went into a nursing home). This is only a partial picture of older Australians use of health services because it is restricted to hospital
admissions and discharges. The admission patterns of older people are very similar to other age groups except for the very oldest age groups (over 90 years of age). For the oldest age groups, suffering a medical emergency overtakes being referred by a medical practitioner as the most common reason for admission to hospital. Being admitted to hospital from a nursing home is not common, even among the elderly.

Discharges from hospital do not exhibit quite the same consistent pattern across age groups. Although most people are discharged home, there is a distinct change in the separation type with age: whereas under 50 year olds almost exclusively go home from hospital, an increasing number of older people are transferred to another hospital, a nursing home or die in hospital. Perhaps the most surprising finding of this study is the relatively small number of older Australians who move between nursing homes and hospital and vice versa - a pattern which only ceases to hold true for most elderly.

Queensland Health (2002). Statewide action plan. Falls prevention in older people 2002-2006. Brisbane, Queensland Government.

http://www.health.qld.gov.au/phs/Documents/shpu/13693.pdf

Indicative Extract from Foreword (No abstract available)

The Statewide Action Plan: Falls Prevention in Older People 2002-2006 is a significant
achievement for Queensland. It represents the first co-ordinated statewide framework for action to reduce falls and their consequences in older people.

WHY IS THIS IMPORTANT?
o It has been estimated that one in three older Australians will fall each year, with between 5% and 10% of these falls causing an injury serious enough to require medical attention.
o Falls in older people account for the largest proportion of all injury-related deaths and
hospitalisations.
o In Queensland, the total lifetime cost for these falls-related injuries is expected to reach $1 billion by 2021, which will be more than twice the expected cost of transport-related injuries.
o Most falls are preventable and predictable.

OUR CHANGING POPULATION
In line with national trends, the older population in Queensland is growing in absolute terms and becoming an increasing proportion of the population as a whole. This changing profile for Queensland indicates the number of older people aged 65 years or more is increasing at nearly 20,000 persons per year, and within 40 years one in every five people
living in Queensland will be aged 65 years and over.

PARTNERSHIPS AND SETTINGS
A holistic view of health recognises the dynamic interactions between the creation of safe and healthy communities, and effective injury prevention strategies. The Action Plan rests on the basic assumption there must be partnerships with other
stakeholders, government and non-government, to enable better co-ordination, effective strategies and on-going collaboration within priority settings. In this Action Plan, a settings approach has been adopted for the home, community, acute care facilities and residential aged care facilities and focuses on:
o promotion of optimal health
o prevention of falls-related risk factors
o management and contingency planning for
older people at risk of falls.

It incorporates the Queensland Health strategic approach to integrated risk management, as falls are recognised as a significant risk to the health and wellbeing of older Queenslanders. It directly supports the Queensland Health Aged Care
Strategy along with the Quality Improvement and Enhancement Program (Falls Prevention in Public Hospitals and State Government Residential Aged
Care Facilities Project).

Queensland Health delivers a range of services, which contribute to the whole-of-government policy priority of providing safer and more supportive communities. By taking a proactive stance now, and focussing on good practice interventions to address falls prevention, it is expected that the health of our older Queenslanders will improve significantly. The Statewide Action Plan: Falls Prevention in Older People 2002-2006 provides an important step towards achieving better health and wellbeing, and sets the stage for a sustainable and coordinated approach to falls prevention in older people.

S. Zimmerman, J. M. Chandler, et al. (2002). "Effect of fracture on the health care use of nursing home residents." Archives of Internal Medicine 162(13): 1502-08.

http://archinte.ama-assn.org/issues/v162n13/abs/ioi00863.html

Background
Osteoporotic fractures result in increased health care use. Care following fracture has been characterized for community dwellers but not for nursing home residents, whose fracture rates are as much as 11 times higher than those of age-matched community dwellers. Knowing the amount of care following fracture may help determine the effects of fracture prevention on use and costs in this population.

Methods
A prospective cohort study was conducted, with 18 months of follow-up, of 1427 randomly selected white, female nursing home residents 65 years and older from 47 randomly selected nursing homes in Maryland.

Results
After controlling for age, comorbidities, and mobility, nursing home residents who experienced a fracture were hospitalized more than 15 times as often as those who did not in the month following the fracture (relative rate, 15.35; 95% confidence interval, 12.27-19.21) and at a higher rate from 3 through 12 months postfracture. Rates in the first month were higher for persons with a hip fracture (relative rate, 31.01; 95% confidence interval, 26.52-36.24). Rates of emergency department use and contacts with physicians and therapists were increased, the latter two for 12 months following fracture. Also, before the fracture, patients who experienced a fracture visited the emergency department and had more physician contacts; for those with a hip fracture, there were fewer prefracture hospitalizations.

Conclusions
Health care use remained elevated through 1 year postfracture. Comparisons with community patients suggest that this care may be less than what would be provided in other settings. For patients who fractured a hip, higher use decreased after 6 months, similar to community cohorts. Nursing home residents who visit the emergency department may warrant special screening for a fracture.