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Service Delivery Innovation Profile

Fall Prevention Education and Outreach Reduces Injuries and Use of Fall-Related Medical Services Among Community-Dwelling Seniors


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Snapshot

Summary

The Connecticut Collaboration for Fall Prevention is an initiative for clinicians and other individuals who work with seniors to incorporate assessment and management of the risk of falls into their everyday practices. A study comparing key metrics in a geographic area where clinicians were exposed to the initiative to those where clinicians were not indicates that the program reduced rates of serious, fall-related injuries and use of fall-related medical services. In addition, surveys of clinicians exposed to the initiative reveal high rates of adoption of fall prevention strategies.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes in two nonrandomized groups of providers, including rates of serious injuries related to falls and use of fall-related medical services.
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Developing Organizations

Yale University School of Medicine
New Haven, CTend do

Date First Implemented

2001
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

Falls are common and a major cause of injury, functional loss, and premature death among seniors, particularly those who live in the community. Primary care clinicians and staff at home health agencies, outpatient rehabilitation centers, and senior centers are in a unique position to reduce the risk of falling, but competing time demands and other factors may prevent these individuals from sharing fall prevention strategies with clients.
  • A common problem: 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 while approximately 30 percent of community-dwelling seniors fall each year.2 Twenty to 30 percent of people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas.
  • Devastating consequences: Fall-related injuries are an especially big problem for older individuals; in 2005, 15,800 people age 65 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 1996, the Connecticut Hospital Association conducted a statewide study which found that falling was the most common and serious cause of unintentional injury across all age ranges, with the problem being especially severe among older individuals.
  • Lack of focus on fall prevention among clinicians and facilities: Primary care physicians and staff at home health agencies, outpatient rehabilitation centers, and senior centers are uniquely positioned to identify and address risk factors for falls. However, most do not focus on fall prevention strategies for a variety of reasons, including competing time demands, a perceived lack of expertise, inadequate reimbursement, lack of knowledge about falling as a preventable event, and fragmentation of care.3

What They Did

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Description of the Innovative Activity

Through various outreach efforts, the Connecticut Collaboration for Fall Prevention initiative encourages community-based clinicians to incorporate a variety of fall prevention strategies into their everyday practices. To support efforts to identify and address risks, the initiative also developed a set of educational materials and practical tools for both clinicians and patients. Key elements of the program include the following:
  • Targeted clinicians: The initiative targets primary care physicians, home care nurses, physical therapists, occupational therapists, and emergency department physicians and nurse managers. Outreach is available to other clinical specialties if they express interest.
  • Educational outreach to clinicians: Collaborative representatives perform outreach to clinicians in the community:
    • Personal visits: Collaborative representatives make personal visits to clinicians and facilities to explain fall prevention practices. During these visits, the representatives discuss the rationale for incorporating fall risk assessment and management into care; provider-specific activities that can be adopted; how to address barriers to fall prevention activities; and information about reimbursement for fall prevention services. Repeated contacts to each provider are made to encourage adoption of fall prevention strategies.
    • Discipline-specific retreats: Periodically, 15 to 30 clinicians within a specific provider specialty meet to discuss progress, share best practices, offer suggestions for overcoming challenges, and suggest additional methods for encouraging fall risk assessment and management.
    • Educational sessions: The initiative offers continuing medical education courses and sponsors educational grand rounds at hospitals.
  • Educational workbook for clinicians: A workbook entitled the Guide for Clinicians is distributed during outreach activities. The workbook includes a summary of established risk factors for falling, simple tests for screening and assessing risk factors and suggested interventions for each individual risk factor, checklists and worksheets for specific disciplines to use in clinical practice, and a strategy for reviewing and reducing use of medications in patients with multiple health conditions, including practical steps that can reduce the likelihood of falls due to medication interactions.
  • Educational materials and tools for patients: The initiative developed a series of materials and practical tools that can be given to patients to support the conversation with their clinicians about fall risk assessment and management, including a self checklist for patients to identify their own risk factors for falling, brochures on topics like medication side effects and safe footwear, a medication record, a handout on home balance exercises, and a checklist to identify fall hazards in the home.
  • Additional activities to build awareness: Seniors, providers, and other community members are made aware of the importance of fall risk assessment and management through the media (e.g., television, radio, newspaper, billboards); letters from the county medical association (to providers); brochures and posters distributed in medical offices and other facilities; and a Web site (http://www.fallprevention.org).

Context of the Innovation

The Connecticut Collaboration for Fall Prevention was modeled after the Yale Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT), a randomized controlled trial funded by the National Institute on Aging in the early 1990s, that tested multiple strategies targeted toward an individual's specific risk factors on community-dwelling seniors. In addition, a 1996 study by the Connecticut Hospital Association found that falling was a common cause of serious injury among all ages, especially the elderly living in the community. These studies spurred the Yale researchers and other collaborators (including the Connecticut Hospital Association, the Connecticut Association for Home Care, Inc., Gaylord Rehabilitation Hospital, Qualidigm, and the University of Connecticut School of Medicine) to develop the initiative, which translates the Yale FICSIT program into protocols that can be easily adopted by physicians and other clinicians in community settings.

Did It Work?

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Results

A nonrandomized study comparing key metrics in a geographic area where clinicians were exposed to the initiative (the intervention region) with those where clinicians were not (the usual care region) suggests that the program reduced rates of serious, fall-related injuries and use of fall-related medical services. In addition, surveys of clinicians exposed to the initiative reveal high rates of adoption of fall prevention strategies.
  • Fewer serious, fall-related injuries: In 2001, before the intervention, the rates of serious, fall-related injuries per 1,000 person-years were similar in both regions (31.9 in the intervention region and 31.2 in the usual care region). After the intervention, this rate fell to 28.6 in the intervention region, but rose slightly to 31.4 in the usual care region.
  • Smaller rise in use of fall-related medical services: Between 2001 and the evaluation period (2004 to 2006), the use of fall-related medical services per 1,000 person-years rose from 70.7 to 74.2 in the intervention region, a much smaller increase than seen in the usual care region (68.1 to 83.3).
  • High, self-reported adoption of the initiative's fall assessment and prevention strategies: A cross-sectional survey of 94 physical therapy providers throughout north-central Connecticut (conducted between October 2002 and April 2003) found that 68 percent reported increased use of fall reduction strategies. In addition, a survey of nurses and rehabilitation therapists in 19 Connecticut home health agencies that were exposed to the initiative found that the vast majority (80 percent or more) had implemented specific strategies designed to address each of the major risk factors for falling (with the exception of postural hypotension, where the percentage of providers adopting strategies was lower).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes in two nonrandomized groups of providers, including rates of serious injuries related to falls and use of fall-related medical services.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Formation of core group: A multidisciplinary core group was formed to oversee the development and implementation of the initiative. Members of the core group included the original Yale FICSIT investigators.
  • Formation of working groups: Five disciplinary-specific working groups of 10 to 15 members each were formed to serve as a forum for planning, implementing, and evaluating the program. Working groups included representatives from the individual clinician groups targeted by the initiative.
  • Adaptation of FICSIT protocols: The FICSIT falls assessment and management protocols, which were implemented by researchers as part of the clinical trial, were adapted and simplified to increase their relevance and practicality in community-based settings.
  • Development of educational materials: The work groups developed the aforementioned workbook that describes strategies for addressing each risk factor; patient handouts for balance exercises, footwear, safe walking, and safe medication use; and one-page assessment and management forms for different provider groups.
  • Development and refining of referral protocols: The working groups established and/or refined referral protocols. Referral protocols clarified which patients should be referred for particular services, what types of providers should manage particular risk factors, and how the referral should be made. As part of this effort, the initiative developed sample patient cases and outlined appropriate referrals for those patients.
  • Clarification of reimbursement: The core group met with representatives from the Medicare peer review organization, the Centers for Medicare & Medicaid Services (CMS), and payers to identify the coverage policies relevant to fall risk factor assessment and management for each group of providers. Reimbursable services were identified along with the appropriate diagnostic and procedure billing codes. This information was provided to physicians, physical therapists, and occupational therapists.

Resources Used and Skills Needed

  • Staffing: The program did not require the hiring of new staff; rather, Yale researchers incorporated the program's development into their ongoing responsibilities.
  • Costs: The initial grant provided $3 million over 7 years, which covered the cost of public relation campaigns, preparation of educational materials, and stipends for working group and retreat participants.
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Funding Sources

Donaghue Foundation
The Patrick and Catherine Weldon Donaghue Medical Research Foundation, a private, Connecticut-based foundation, provided the initial 7-year grant, which ended in August 2008. The Connecticut Collaboration for Fall Prevention has also received some grant support from the National Institute on Aging. Going forward, activities will be funded by the state of Connecticut, grants from the National Administration on Aging, and nominal fees charged by the collaborative for materials. The collaborative is also developing a consulting program that will generate additional funds.end fs

Tools and Other Resources

A selection of Connecticut Collaboration for Fall Prevention fall prevention tools is available at http://www.fallprevention.org.

Adoption Considerations

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Getting Started with This Innovation

  • Form discipline-specific working groups: Clinicians are more likely to adopt new strategies if they are involved in their development. In addition, working group members can help disseminate the strategies among peers because of their ties to the local clinical community.
  • Make repeated contacts with providers: Talking to providers repeatedly helps to ensure a continued focus on fall prevention.
  • Focus initial efforts on early adopters and local opinion leaders: Along with working group members, these individuals can help disseminate the program throughout the provider community.
  • Consider how to expand or solidify referral patterns: Different disciplines and providers may not know when, how, and to whom to refer patients. For example, in Connecticut, many primary care physicians did not know they could refer patients with balance or walking problems to outpatient occupational and physical therapy, and many home care providers did not know that patients discharged from home care could continue with outpatient rehabilitation therapy.
  • Work with each group to identify incentives for fall prevention: Different provider groups may have different incentives for using the program. For example, fall assessment and management can be a new revenue stream for occupational and physical therapists. Leaders in overcrowded emergency departments may be attracted to the idea of reducing emergency department utilization due to fall-related injuries. Finally, primary care physicians may be attracted to the program because fall assessment is included in the CMS Physician Voluntary Reporting pay-for-performance initiative.

Sustaining This Innovation

  • Leverage patient demand: Clinicians are more likely to adopt new practices if patients request them.
  • Continue advertising efforts: Ensure that fall prevention strategies remain top-of-mind among providers and the general public.
  • Encourage clinician input: Regularly invite clinicians to suggest new ways to reach their colleagues and share best practices for assessing and managing risk factors for falls.
  • Ensure continued focus on fall prevention: Work with stakeholders such as State legislators and agencies, CMS, and national specialty organizations to identify how the occurrence of falls and fall injuries by older adults affects health care utilization, and how fall prevention programming can be embedded in the preventive, primary, acute, rehabilitation, and long-term care received by older adults.

More Information

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Contact the Innovator

Mary E. Tinetti, MD
Yale University School of Medicine
333 Cedar Street
PO Box 208025
New Haven, CT 06520
(203) 688-5238
E-mail: Mary.tinetti@yale.edu

Innovator Disclosures

Dr. Tinetti has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Tinetti ME, Baker DI, King M, et al. Effect of dissemination of evidence in reducing injuries from falls. N Engl J Med. 2008;359:252-61. [PubMed]

Baker DI, King MB, Fortinsky RH, et al. Dissemination of an evidence-based multicomponent fall risk-assessment and -management strategy throughout a geographic area. J Am Geriatr Soc. 2005;53:675-80. [PubMed]

Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331:821-7. [PubMed]

Brown CJ, Gottschalk M, Van Ness PH, et al. Changes in physical therapy providers' use of fall prevention strategies following a multicomponent behavioral change intervention. Phys Ther. 2005;85(5):394-403. [PubMed]

Fortinsky RH, Baker D, Gottschalk M, et al. Extent of implementation of evidence-based fall prevention practices for older patients in home health care. J Am Geriatr Soc. 2008;56(4):737-43. [PubMed]

Footnotes

1 U.S. Centers for Disease Control and Prevention. Falls among older adults: an overview. Page last updated September 16, 2011. Available at: http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html
2 Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331:821-7. [PubMed]
3 Tinetti ME, Baker DI, King M, et al. Effect of dissemination of evidence in reducing injuries from falls. N Engl J Med. 2008;359:252-61. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 27, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 11, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.