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Table 1 The iSOLVE intervention: planned active ingredients of iSOLVE components

From: Integrated solutions for sustainable fall prevention in primary care, the iSOLVE project: a type 2 hybrid effectiveness-implementation design

Active ingredients Description
Component 1. Identifying and managing fall risk in general practice: knowledge translation and synthesis
1.1 Individual face-to-face training sessions An individual face-to-face training session is used to educate GPs in the various components of the iSOLVE intervention including decision support tools, evidence-based interventions, potential referral pathways and fall prevention strategies. The training is based on academic detailing which is characterized by principles such as involvement of a “peer” to enable rapport and credibility, concise graphic print materials and applies social marketing principles to facilitate behavior change [58, 59].
1.2 Decision support tools and fall management tailoring. GP resources (e.g., background information/evidence, case studies, Medicare reimbursement options) Decision support tools and fall management tailoring introduced in the GP training session. These decision making tools enable fall risk assessment and management and are part of a practice resource package for the GP. The decision tool and resources are adapted from a primary care resource for falls prevention, developed by the Centers for Disease Control in the USA [60]. A working group who were experts in fall prevention research, (LC, CS, ATi) drawing from the US resource and using evidence from systematic review meta-analyses of interventions [1] and of risk factors [61], developed the iSOLVE risk assessment/fall management algorithm and decision tools. The US Stay Independent Patient Check List and the GP Fall Risk Assessment chart were updated based on the iSOLVE algorithm. A new chart, Tailoring Interventions to Fall Risk, was developed which maps risk factors and risk factor profiles to appropriate interventions. This was based on the intervention evidence (e.g., medication review; balance, and strength training) and additionally, where intervention evidence did not exist, was based on modifiable risk factor evidence which strongly supported a guideline for practice (e.g., postural dizziness). Other iSOLVE resources include background information supporting the evidence for interventions; five case studies which each illustrate the algorithm and tailoring options and were validated by a local expert group; a detailed summary of known medications to be a risk of falling; Medicare reimbursement options for GPs; and, examples of “how to talk with patients about falls.” A summary of local allied health professionals who offer fall prevention services and who attended the workshops is provided for each GP with contact details.
1.3 GP computer systems GP computer systems supports: The decision tools can be embedded into the GP systems and software by a fall prevention add-on developed for the practice software supported by the SNHN. Embedded decision tools in practice software recognize the barriers to GPs adoption of new practices and the need for speed and efficiency. The software add-on automatically creates the iSOLVE decision support tools. Once the GP completes the Fall Risk Assessment, the program produces the recommended, individualized, and tailored interventions that match their fall risk. Sample referral forms are provided. There are hard copies of all these documents, so that the whole process can be manually done if the GP chooses to or if the practice is not computerized.
1.4 Fall or fall risk alert to GP Fall or fall risk alert to GP: People who report a fall in the past year or report “yes” to one of the risk questions on the Stay Independent Fall Check list will indicate an alert to the GP who then starts the process of assessment and management. Where practices agree a tablet device will be given to people 65 years and over by the practice nurse in the waiting room and the fall screen completed to assist in determining risk factors. If the tablet is used, this automatically sends the fall risk information to the GP’s software to speed up the process.
1.5 GP managing patient fall risk GP managing patient fall risk: The GP uses the patient check list, conducts a risk assessment, and determines a tailored management plan. The management plan is generated automatically if the computer system is used. The GP may review medications and check cataracts or postural hypotension where clinically indicated. The GP also initiates appropriate referrals to local fall services (e.g., allied health and/or community exercise and/or medication review) which specify “fall prevention”.
1.6 Identifying eligible older people Identifying eligible older people: People aged 65 years and over who have had a fall and or have a fall risk are identified by several processes: opportunistic presentation to the GP practice and complete Stay Independent Patient check list (or tablet) in the waiting room and/or are asked about falls by their GP; or, identify a fall during a 75+ annual health checks. Additionally, the falls prevention computer program initiates an annual review of fall status. These strategies are intended as routine and ongoing identification of older people who have fallen or are at risk of falling. Marketing poster and brochures are also provided for the waiting room. (Note that these approaches differ from the recruitment strategy used for patients to the trial which was adapted to ensure blinding of research assistants.)
1.7 Medication reviews Medication reviews. Drawing on successful methods for reducing falls by medication review conducted by GPs in the trial conducted by Pit et al. [62]. GPs are provided with information regarding both the evidence base for reduction or ceasing medications to prevent falls and detailed lists of medications with specific fall risks. Medication reviews may also be requested using the Medicare funded Home Medicines Review by accredited pharmacists and this option is included in the Tailoring Interventions to Fall Risk Chart.
Component 2. Knowledge translation, education and up-skilling the allied health local workforce
2.1 Evidence-based interactive fall prevention workshops Educational approaches are effective in facilitating knowledge translation by AHPs [56], but active training and planning for change are needed for effective implementation and sustainability [18, 20]. Evidence-based fall prevention education workshops are offered to allied health professionals and service providers within the SNHN. These have been developed by experts within their fields and include Home Hazard and Environment interventions (LC, LM) [3]; Exercise interventions (ATi, CS) [63] and the LiFE exercise program (LC) [64], Medication Management (SH), and Foot and Ankle interventions [65].
2.2 Active planning for fall prevention implementation and sustainability These interactive workshops comprise knowledge and skill development as well as a planning session for implementation and sustainability. Planning strategies documented by participants in each workshop form part of a developing working document shared to all workshop participants.
2.3 Linking AHPs with GPs to facilitate referrals There is also the opportunity for AHPs to opt to be linked to GPs, thus further enhancing pathways and implementation.
Component 3. Establishing referral pathways in primary care
3.1 Decision support tools and fall management plans The decision support tools and fall management plans assist in determining the best option/s for the older person. Depending on risk assessment, this can include one or more approaches: medication review, postural hypotension assessment, referral for cataract removal, home safety assessment, community exercise programs, home-based exercise programs for higher risk patients, group-based fall exercise programs, tai chi, a community-based multifaceted fall prevention program Stepping On [66], or referral to a falls clinic.
3.2 Referral pathway facilitation Pathway facilitation. We use a range of options to facilitate the pathway to local fall service providers, including but not limited to, the use of the Enhanced Primary Care service to encourage referral to private therapists and facilitating evidence-based fall-specific services to be provided in health and other potential care services. The aim is to provide education and knowledge translation that will up-skill and increase the fall prevention work force across the SNPHN.
3.3 Referrals to fall prevention services Referrals to fall prevention services: The health network (SNPHN) and the workshops have been central to mapping local health professionals who can engage in specific interventions.
3.4 Links with ambulance services Ambulance services. Fifty eight percent of older people seen by the ambulance service for a fall and not transported to hospital will fall again in the next 6 months [67]. During the development phase of the project, we will determine a process to initiate referral to GPs for fall management and follow-up. Barriers to engaging ambulance services have been investigated [68], and we will explore local options through consultation.
3.5 Network communication strategies Communication. A website provides information about the project, education options, and links to state fall prevention initiatives such as Stepping On and the Active & Healthy website (a state directory of evidence-based fall prevention exercise options suitable for older people).
Component 4. Diffusion and dissemination of the iSOLVE model
4.1 Development of a guiding strategy document “The aim is to facilitate sustained implementation of evidence-based fall prevention interventions by GPs and allied health workforce. Theoretically, informed models of sustainable education and support (such as the potential for train the trainer) will be developed drawing on data gained from workshops, interviews, and observations. The Conditions for Sustainability Theory [69] and Behaviour Change Wheel Framework [30] will be used to guide this process.
A guiding strategy document will be developed which outlines the Integrated Solutions for Sustainable Fall Prevention (iSOLVE) approach as a model of care for supporting regional health networks, GP practices, ambulance services, allied health, and community pharmacists to engage in integrated pathways and evidence-based effective practices to protect older people from falling. This will be developed by the investigators in collaboration with the partner representatives. It will be subject to extensive consultation with the key stakeholders and the Project Advisory Group.