Fall Prevention Program Emphasizes Proactive Identification and Addressing of Risk Factors, Leading to Fewer Falls and Fall-Related Injuries Among Seniors Receiving Home Care

Problem Addressed

• Falls are common among community-dwelling seniors: According to the U.S. Centers for Disease Control and Prevention, more than one-third of all adults aged 65 years and older are injured in a fall each year;¹ approximately 30 percent of community-dwelling seniors fall each year.²
• Devastating, costly consequences: Falls are the leading cause of injury-related deaths and also the most common cause of nonfatal injuries and hospital admissions for trauma.¹ Furthermore, the risk of being injured from a fall increases with age: in 2001, an adult aged 85 years and older had a four to five times greater chance of being injured in a fall than did an adult aged 65 to 74 years.³ In 2005, 15,800 people aged 65 years and older died from fall-related injuries; about 1.8 million people in the same age category were treated in emergency departments for nonfatal injuries from falls, with more than 433,000 of these patients being hospitalized.¹ In 2000, the direct medical costs associated with nonfatal fall injuries totaled $19 billion, while the costs of fatal falls totaled $179 million.⁴
• Unfulfilled potential of home health agencies: Because so many seniors fall at home, home health agencies are uniquely positioned to identify and address risk factors for falls. However, most agencies use assessment tools that trigger interventions for only the highest-risk seniors, leaving many individuals who face a substantial risk of falling with little or no support.

Description of the Innovative Activity

• Comprehensive initial assessment and education: On admission to the home care program, a clinician (typically a nurse or physical therapist) performs a comprehensive assessment of the risk of falling and provides basic fall prevention education. 
  • Assessment: The Fall Risk Assessment Tool includes 12 elements, listed below:
    • Age older than 65 years
    • Multiple diagnoses
    • History of falls over the past 3 months
    • Incontinence
    • Vision impairment
    • Impaired functional mobility
    • Environmental hazards
    • Polypharmacy (four or more prescription medications)
    • Pain affecting level of function
    • Cognitive impairment
    • Postural hypotension
    • Fear of falling
  • General education: All enrollees, including those whose only risk factor is age, receive a booklet called Preventing Slips and Falls in the Home as well as general fall prevention education that covers the following five topics: eliminating hazards in the home, the benefits of physical activity and exercise, the need for annual vision examination, the need to review medications with a physician annually, and the importance of maintaining optimal hydration and nutrition.
• Risk-specific interventions: The clinician suggests additional interventions based on the particular risk factors identified. For example:
  • Patients with impaired physical mobility receive a referral for physical/occupational therapy. When indicated, physical therapists implement evidence-based therapeutic exercises, which have been shown to improve lower-extremity strength and balance and reduce the incidence of falls.
  • For those with cognitive impairment, the patient and/or caregiver receives education on how to simplify the daily routine and modify the environment. The patient may also receive a referral to occupational therapy.
  • Patients with incontinence may receive an intervention, such as instruction in timed voiding (training the bladder to hold fluids for incrementally longer time periods), timing of diuretics, or Kegel exercises to strengthen the pelvic floor muscles.
• Periodic medication assessment: Given the high association between medication use and falls in the senior population, the Visiting Nurse Association of Boston’s point-of-care electronic system automatically checks patient medications for adverse interactions and potential side effects. Clinicians use the system to check for drug-drug interactions when first admitting a patient to the agency and whenever a patient is started on a new medication.
• Risk reassessment: Ongoing fall assessment is embedded into the care process. For example, as prompted by the point-of-care documentation system, all clinicians must assess safety, environmental factors, and recent falls during every patient visit. Furthermore, the Fall Risk Assessment Tool is repeated for any patient who is hospitalized, with the reassessment being conducted on the patient’s return home.
• Documentation: Assessments and care needs are fully documented in preparation for submission for Medicare reimbursement, which is based on clinical findings and predicted care needs over a 60-day period.

References/Related Articles

Contact the Innovator

Results

• Significantly fewer falls and fall-related injuries: In 2005, before the implementation of the program, 2.9 percent of home care patients in the two pilot sites suffered an injury from a fall requiring emergent care. After program implementation in early 2006, that rate fell to 1.42 percent at the two sites and declined further to 1.2 percent at one site by year's end.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Task force: The organization’s preexisting task force was reorganized to become a multidisciplinary group that included physical therapists, occupational therapists, speech/language pathologists, nurses, nurse managers, and the vice president of quality and regulatory affairs.
• Information gathering: The task force reviewed current research to identify practical strategies that could serve as elements of a comprehensive fall prevention program. In addition, the developer of the agency's rehabilitation program attended a workshop based on the National Council on Aging’s Falls Free National Action Plan to gather information about successful fall prevention strategies.
• Redesign of assessment tool and triggers for intervention: The task force reworked the organization’s Fall Risk Assessment Tool. They based the new tool on the Missouri Alliance for Home Care’s Risk Assessment Form, which includes 10 core areas of risk, but added 2 additional elements (postural hypotension and fear of falling) based on research showing their link to fall risk. The task force also adopted the approach of the Connecticut Collaborative on Fall Prevention, which promotes intervention for every identified risk factor instead of quantifying a patient’s total risk and intervening only for those who reach a minimum threshold score.
• Clinician education: Members of the agency's fall prevention task force conducted classes for clinical staff that outlined the new program and described the revised assessment tool. They also presented research data emphasizing that falls can be prevented, a view that represented a paradigm shift away from the then current mindset that falls were inevitable in a senior population.
• Pilot sites: Visiting Nurse Association of Boston piloted the new system at two of its six sites for 1 year; selected sites exhibited the highest fall rates.
• Program expansion: Based on successful pilot test results, several aspects of the program were expanded to all six sites in February 2007, primarily related to rehabilitation clinicians assessing vital signs at every visit, completing the Timed Up & Go test for all ambulatory patients requiring physical therapy, implementing a standardized home environmental assessment checklist, and implementing evidence-based balance training and therapeutic exercise interventions. Other aspects of the program, including fall prevention education and medication management, will be expanded to all sites in the fall of 2008. 

Resources Used and Skills Needed

• Staffing: The ongoing operation of the program requires no new staff. The aforementioned task force spent time up front developing the program and its related tools.
• Costs: Program costs are minimal. Fall prevention efforts are reimbursable by Medicare, with reimbursement being based on clear documentation of the initial comprehensive assessment and predicted care needs over the next 60 days. 
  

Funding Sources

VNA of Boston

Tools and Other Resources

• Visiting Nurse Association of Boston Web site. Available at: www.bostonvna.org
• Visiting Nurse Association of Boston Fall Risk Assessment Tool and other forms and tools: contact the innovator.
• Home Health Quality Improvement National Campaign Web site. Available at: www.homehealthquality.org
• Missouri Alliance for Home Care: Home Care Fall Reduction Initiative. Best Practice Intervention Package (including a training video). Available at: http://www.homecaremissouri.org/projects/falls/index.php
• Connecticut Collaborative on Fall Prevention/Yale Program on Aging Web site. Available at: http://info.med.yale.edu/intmed/aging/

Getting Started with This Innovation

• Leverage available resources: Many resources that help to address fall prevention are available from governmental sources and professional societies.
• Change the mindset that falls are inevitable: Sharing data on the preventability of falls in seniors can help to teach clinicians that such falls are not inevitable and that this problem can be addressed.
• Use an interdisciplinary approach: Nurses and rehabilitation therapists can both work toward fall prevention within their own realms of responsibility.
• Attempt to standardize practices: Standardization can lead to better results, although it can be more difficult to standardize practices when physical therapists and other clinicians come from a multitude of agencies.

Sustaining This Innovation

• Develop a comprehensive program over time: Risk assessment tools are not sufficient to reduce falls on their own; instead, a comprehensive program is needed that identifies and addresses risks, including providing education, managing medications, and encouraging physical activity and appropriate exercise.
• Consider incorporating risk assessment into electronic systems: The risk assessment form can potentially be incorporated into existing electronic systems. Organizations that are planning to purchase a new electronic system might want to consider its ability to do this before purchase. Incorporating such tools into the point-of-care system can significantly reduce the documentation burden.