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Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.) College of Public Health

2017

Bridging Public Health and Clinical Practice: A Pilot of the CDC’s Bridging Public Health and Clinical Practice: A Pilot of the CDC’s

Stopping Elderly Accidents, Deaths, and Injuries (STEADI) Fall Risk Stopping Elderly Accidents, Deaths, and Injuries (STEADI) Fall Risk

Screening and Prevention Program in an Academic Medical Screening and Prevention Program in an Academic Medical

Center Family and Community Medicine Clinic Center Family and Community Medicine Clinic

Carolyn C. Shammas University of Kentucky, cc.shammas@uky.edu

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Recommended Citation Recommended Citation Shammas, Carolyn C., "Bridging Public Health and Clinical Practice: A Pilot of the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) Fall Risk Screening and Prevention Program in an Academic Medical Center Family and Community Medicine Clinic" (2017). Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.). 162. https://uknowledge.uky.edu/cph_etds/162

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The document mentioned above has been reviewed and accepted by the student’s advisor, on

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Carolyn C. Shammas, Student

Sarah B. Wackerbarth, PhD, Committee Chair

Corrine Williams, ScD, MS, Director of Graduate Studies

BridgingPublicHealthandClinicalPractice:APilotoftheCDC’sStopping

ElderlyAccidents,Deaths,andInjuries(STEADI)FallRiskScreeningand

PreventionPrograminanAcademicMedicalCenterFamilyand

CommunityMedicineClinic

CAPSTONEPROJECTPAPER

Apapersubmittedinpartialfulfillmentofthe

Requirementsforthedegreeof

MasterofPublicHealthinthe

UniversityofKentuckyCollegeofPublicHealth

By

CarolynC.Shammas,M.D.,J.D.

Lexington,KentuckyApril19,2017

CapstoneCommittee:

SarahB.Wackerbarth,Ph.D.(Chair)

JonathanR.Ballard,M.D.,M.P.H.,M.Phil.(CommitteeMember)

RichardC.Ingram,Ph.D.(CommitteeMember)

2

Acknowledgments

IwouldliketothankthemembersoftheCapstoneCommittee,Dr.Wackerbarth,Dr.

BallardandDr.Ingram,fortheirinvaluableguidanceandencouragementthroughout

thisprocess.Theyhavecontributedtremendouslytomyeducationalandprofessional

growth.IamalsoindebtedtoDr.Ballardforhisinvaluablementorshipandwithout

whomthefallpreventionqualityimprovementprojectwhichformedthebasisforthe

capstonewouldnothavebeenpossible.Mythanksalsotothemembersofthefall

preventionworkgroupandtothestaffoftheUniversityofKentuckyFamilyand

CommunityMedicineClinicwhowerekeytothedevelopmentandrolloutofthepilot.I

wouldalsoliketoexpressmysincereappreciationtotheUniversityofKentucky

PreventiveMedicineProgramDirector,Dr.TishaJohnson,whosesupportandleadership

havecontributedsomuchtomyoutstandingresidencyexperience.

IamalsogratefultoallofthehighlysupportiveandknowledgeablestaffoftheKentucky

DepartmentforPublicHealth,particularlyDr.ConnieWhite,Mr.DustinFalls,Ms.Rebel

Baker-Chreste,Mr.GaryKupchinskyandMs.JoyMills;andtheKentuckyInjury

PreventionandResearchCenter,particularlyMr.CharlesSparrowandMs.Jeanne

Harris,forinspiringandfacilitatingmypassionforfallprevention.

Finally,mydeepestgratitudetoS.Ramanath;mysonanddaughter;andparticularlymy

parents,whohaveneverwaiveredintheirsupportandwithoutwhomthisjourney

couldnothavebeenundertakenorcompleted.

3

Abstract

Background:Fall-relatedmorbidityandmortalityintheolderadultpopulationis

apressingpublichealthproblembothnationallyandinKentucky,whichhasafallrate

abovethenationalaverage.ImplementationoftheCDC’sStoppingElderlyAccidents,

Deaths,andInjuries(STEADI)fallpreventionprogram,offersanopportunityto

effectivelyreducefalls,fall-relatedinjuriesandassociatedcosts.Theimplementation

processalsoservestofostercooperativeinterdisciplinaryandinterdepartmental

relationshipswithinhealthcaresystems,andbridgepublichealthandclinicalpractice.

Purpose:ThecapstonedescribesandevaluatesapilotofSTEADIatthe

UniversityofKentucky’sFamilyandCommunityMedicine(UKFCM)Clinic.Itfocuseson

pilotdevelopmentbyaninterdisciplinary/interdepartmentalworkgroupandpartnership

withotherkeystakeholders,suchastheKentuckyDepartmentforPublicHealth(KDPH).

Itpresentslessonslearned,recommendationsforimprovementandnextstepsin

STEADIimplementation.ItalsoreviewstheliteratureonSTEADIpilotprogramsand

facilitatorsandbarrierstoimplementation.

Methods:Thefive-daypilotwasconductedattheUKFamilyandCommunity

MedicineClinic.Patientsage65yearsandolderwerescreenedandevaluatedforfall

riskusingapaperformbasedontheSTEADIalgorithm.Thepilotwasevaluatedusing

theeight-stepKottermodelfororganizationalchange.

Results:Sixty-fourpatients(fiftypercent)ofpatientsage65andolderwere

screened,ofwhomforty-fourpercentscreenedpositiveforincreasedfallrisk.

MeaningfulstatisticsregardingothercomponentsofSTEADIweregenerallynot

4

obtainableduetoambiguitiesinthedesignoftheform.Thepilotevaluation

demonstratedseveralstepsintheKotterframeworkthatwereparticularlysuccessful:

creatingasenseofurgency;buildingaguidingcoalition;andgeneratingshort-term

gains.Lessonslearnedandrecommendationsincludedclarificationoftheassessment

andinterventionsectionsofthetemplatebeforeincorporationintotheambulatory

electronichealthrecord(AEHR);additionaltrainingofprovidersandstaff;andgreater

attentiontoworkflow.

Implications:STEADIpresentsanopportunitytobridgepublichealthandclinical

practiceandifbroadlyimplemented,promisestoreducetheCommonwealth’shighrate

ofolderadultfall-relatedmorbidityandmortality,aswellasassociatedcosts.

5

TableofContents

ListofAbbreviations

I. Introduction.…………………………………………………………………………………………………….…7

EpidemiologyandImpactofFalls.………………………………………………………………….....7

StoppingElderlyAccidents,Deaths,andInjuries(STEADI)………………………………11

ReimbursementandOtherIncentives……………………………………………………………..14

II. LiteratureReview.…………………………………………………………………………………………….17

NewYork……………………………………………………………………………………………….………..18

Oregon……………………………………………………………………………………………………………..20

Ohio………………………………………………………………………………………………………………….21

ImplementationfromaDepartmentofPublicHealthPerspective………………….22

OtherPilots………………………………………………………………………………………………………23

Conclusion………………………………………………………………………………………………………24

III. CapstoneProject…………………………………………………………………………………………….25

Methods…………………………………………………………………………………………………………..25

Background………………………………………………………………………………………………………26

PilotDevelopmentandRollout………………………………………………………………………..27

Results………………………………………………………………………………………………….............32

Evaluation………………………………………………………………………………………………………..33

LessonsLearned……………………………………………………………………………………………….40

Recommendations/NextSteps………………………………………………………………………..43

IV. Conclusion………………………………………………………………………………………………………45

References……………………………………………………………………………………………………….48

Appendix………………………………………………………………………………………………………….52

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ListofAbbreviations

ACA AffordableCareActAEHR AmbulatoryElectronicHealthRecordAWV AnnualWellnessVisitCDC CentersforDiseaseControlandPreventionCEE ClinicalEngagementandTrainingCMS CentersforMedicare&MedicaidServicesCPT CurrentProceduralTerminologyCST ClinicalServiceTechnicianEHR ElectronicHealthRecordKDPH KentuckyDepartmentforPublicHealthKIPRC KentuckyInjuryandPreventionResearchCenterKSAC KentuckySafeAgingCoalitionKSPAN KentuckySafetyandPreventionAlignmentNetworkKVIPP KentuckyViolenceandInjuryPreventionProgramLPN LicensedPracticalNurseMACRA MedicareAccessandCHIPReauthorizationActMIPS Merit-basedIncentivePaymentSystemMOC MaintenanceofCertificationODH OhioDepartmentofHealthOHSU OregonHealth&ScienceUniversityPACT PatientAlignedCareTeamSFPP StateFallsPreventionProjectSTEADI StoppingElderlyAccidents,Death,andInjuriesTJC TheJointCommissionTUG TimedUpandGoUHS UnitedHealthServicesUKFCM UniversityofKentuckyFamilyandCommunityMedicineUKHC UniversityofKentuckyHealthCareUSPSTF UnitedStatesPreventiveServicesTaskForceVA VeteransAdministrationVIPP ViolenceInjuryandPreventionCenter(VIPP)

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Introduction:

EpidemiologyandImpactofFalls

Fallsaretheleadingcauseofunintentionalinjuryandinjury-relateddeathin

adultsage65andolder(Bergen,Stevens,&Burns,2016).TheCDCestimatesthatin

2014,28.7percentofolderadultslivinginthecommunityreportedfallingwithinthe

pastyear,resultingin7millioninjuriesand27,000deaths(Bergenetal.,2016).In

Kentucky,thestatisticsareevenmorecompelling,with32.1percentofolderadults

havingreportedafallwithinthepastyear(Bergenetal.,2016).Thereareanumberof

riskfactorsforfalls,includingage;historyoffalls;lowerbodyweakness;gaitorbalance

impairment;psychoactiveandothermedications;chronicdiseasessuchasdiabetesand

arthritis;andhomehazards(Stevens,2005).Fearoffalling,resultingindecreased

physicalactivity,isalsoariskfactor(Phelan,Mahoney,Voit&Stevens,2015).According

toonestudy,theriskoffallingwas19percentwithoneriskfactor,butalmost

quadrupledwhenfourormoreriskfactorswerepresent(Tinetti,Speechley,&Ginter,

1988).Womenaremorelikelytofallandtosufferafall-relatedinjury,butmenare

morelikelytodieasaresultofafall(Peel,20).AccordingtotheWorldHealth

Organization,socioeconomicriskfactorsforfallsincludelowincomeandeducational

levels,inadequatehousing,lackofsocialinteractions,limitedaccesstohealthandsocial

servicesandlackofcommunityresources(WHO,2007).

ItisunclearwhyKentucky’sfallrateexceedsthatofotherstates,socioeconomic

factorsandhighratesofchronicdiseasessuchasarthritisanddiabetes,mayplayarole.

Asisthecasenationwide(Baldwin,Breiding,&Sleet,2016),fallsrepresenttheleading

8

causeoftraumaticbraininjuryintheolderadultpopulationinKentucky(KSPAN,2009-

2014).Thestate’s11.9percentfall-relatedinjuryrateexceedsthe10.7percentnational

average(Bergenetal.,2016).Ithasthedubiousdistinctionofbeingoneofthetopten

statesforbothpercentageofolderadultsreportingfallsandfall-relatedinjurieswithin

thepastyear(Bergenetal.,2016)asshowninFigure1below.

Figure1:Percentagesoffallsandfallinjuriesinthepreceding12monthsreportedbyadultsaged³65years(N=147,319)–BehavioralRiskFactorSurveillanceSystem,UnitedStates,2014

Therateofemergencydepartmentvisitsandinpatientdischargesforfall-related

injuriesvariesbycounty(Figure2andFigure3).TheUniversityofKentuckyHealthCare

(UKHC)system,locatedinFayetteCounty,servesanumberofcountiesthathavehigh

ratesofemergencydepartmentvisitsandinpatientdischargesforinjuresduetofalls.

UKFMCsees50,000patientsperyear,primarilyfromFayetteandsurroundingcounties;

Source: Bergen et al, 2016

9

approximately8percentofpatientsarecoveredbyMedicare(J.Ballard,personal

communication,April12,2017andApril18,2017).AccordingtoU.S.CensusBureau

estimates(2015),12.0percentofFayetteCounty’sand15.2percentofKentucky’s

populationareage65orolder,comparedtotheU.S.averageof14.9percent.

Figure2:EDVisitstoKentuckyhospitalsforunintentionalfalls(2008-2012)

Retrieved April 19, 207from Kentucky Injury Prevention and Research Center (a bona fide agent of the KY Department for Public Health), KY-IBIS site: https://kyibis.mc.uky.edu/kiprc; http://www.safekentucky.org/images/Data/falls-by-county-maps/ED_falls.jpg

10

Figure3:Inpatienthospitaldischargerateforunintentionalfalls(2010-2014)

Fallsnotonlytakeatollintermsofhumansuffering,butareassociatedwith

staggeringdirectandindirectmedicalcosts.Fall-relatedMedicareexpendituresare

estimatedatmorethan$31billion,andareexpectedtogrowto$100billionby2030

(Burnsetal.,2016).InKentucky,totalhospitalchargesamountedtocloseto$366.5

millionin2014(KentuckyInjuryandPreventionandResearchCenter,2017).Total

inpatienthospitalchargesmorethantripledfrom2005to2014(KentuckyInjuryand

PreventionResearchCenter,2017).Althoughnotallrelatedtofalls,thefinancialburden

ofhospitalizationinKentuckyislargeandgrowing.

Retrieved April 19, 2017 from Kentucky Injury Prevention and Research Center (a bona fide agent of the KY Department for Public Health), KY-IBIS site: https://kyibis.mc.uky.edu/kiprc; http://www.safekentucky.org/images/Data/falls-by-county-maps/ED_falls.jpg

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Fallsalsoresultinincreasednursinghomeplacement,lossofindependenceand

decreasedqualityoflife(Stevens&Burns,2015).Thereisagrowingimperativeto

addresstheproblemoffall-relatedinjury,deathandcostnationallyandinKentucky,

particularlygivenaprojectedincreaseof55percentintheU.S.populationage65and

olderby2030,accompaniedbyariseinthenumberoffallstoalmost49million,with12

millioninjuries(Bergenetal.,2016).

StoppingElderlyAccidents,Deaths,andInjuries(STEADI)

TheCentersforDiseaseControlandPrevention(CDC)hassoughttoreducefalls

throughtheevidence-basedStoppingElderlyAccidents,Deaths,andInjuries(STEADI)

initiative.TheSTEADItoolkitwasdesignedtoimprovefallsriskscreeningandprevention

ratesinprimarycaresettings(Caseyetal.,2016).TheSTEADIalgorithmandeducational

materialsincludedinthetoolkit,facilitatefallpreventionawarenessandcommunication

betweenprovidersandpatients.

Surprisingly,lessthanhalfofolderadultswilldisclosehavinghadafalltoa

healthcareprovider(CDC,2015).Reluctancetotalktoaprovideraboutfallsisduetoa

numberoffactors,includingembarrassment,fearoflossofautonomy,beingoverly

optimisticaboutcapabilities,andthemistakenassumptionthatfallsareanormalpart

ofaging(Childetal.2012;Moylan&Binder,2007;Stevens&Burns,2015;Yardley,

Donovan-Hall,Francis,&Todd,2006).Moreover,physiciansoftenfailtoinquireabout

fallsforanumberofreasons,includingunclearrolesamongmembersoftheprimary

careteam;unclearorchangingclinicalrecommendations;andlackoffamiliaritywithfall

12

interventionsandresources(Caseyetal.,2016;Jones,Ghosh,Horn,Smith,&Vogt,

2011;Landis&Galvin,2014;Stevens&Phelan,2013).

Whilethereissubstantialevidencetosupporttheeffectivenessoffallsscreening

andmultidimensionalinterventionstoreducerisk(Gillespieetal.,2012),itisestimated

thatphysiciansonlyaskwhetherapatienthasfallenaboutone-thirdofthetime(Jones

etal.,2011).Anumberofbarrierstoproviderscreeninghavebeencited:lackofrole

clarityamongprimarycareteammembers;unclearorchangingfallsriskreduction

recommendations;complicatedandfragmentedfinancialandqualityincentives;lackof

awarenessandknowledgeaboutfallpreventioninterventionsandresources(Caseyet

al.,2016;Childetal.,2012;Chouetal.,2006;Jonesetal.,2011;Landis&Galvin,2014;

Stevens&Phelan,2013).

STEADIwasdevelopedtoaddresstheseissuesandassistprimarycareproviders

inscreeningolderadultpatientsforfallriskandlinkingthemtoappropriate

interventions.TheSTEADIalgorithm(Figure4)isbasedonthe2010AmericanGeriatric

SocietyandBritishGeriatricSocietyClinicalPracticeGuidelines,aswellinputfrom

providers(Stevens&Phelan,2013).Itincludesscreening(askingthreekeyquestions

relatedtofallrisk,suchasnumberoffallsinthepastyear);evaluationofgait/balance;

assessmentofriskfactors(e.g.medicationsandcognitiveimpairment);and

interventions(e.g.acommunity-basedexerciseorfallpreventionprogram)(CDC,2016).

Theeffectivenessoffallinterventions,includingseveralcommunity-basedgroup

exerciseprograms,wasdemonstratedina2012CochraneReviewofalmost160

randomizedcontrolledtrials,withatotalofmorethan179,000participants(Gillespieet

13

al.,2012;Kaniewski,2015).Evaluationbyaclinician,andtreatmentofriskfactorsresult

ina24reductioninfallrate(Gillespieetal.,2012).Community-basedprogramsmay

alsoachievesubstantialcostsavings;theSteppingOnprogram,forinstance,hasbeen

showntohaveareturnoninvestmentof64percent(Houryetal.,2016).

Optimally,thealgorithminitsentiretywouldbeimplementedinallprimarycare

practices,asmultidimensionalinterventions,particularlythosethatincludegait,balance

andstrengthtraining,havethegreatestimpactonreducingfalls(Stevens&Burns,

2015).Recognizingthatthealgorithmmaynotbeperformedinitsentiretyduetotime

andotherconstraints(seebarrierstoimplementationbelow),providersareaskedto

Figure4:AlgorithmforFallRiskAssessment&Interventions

CDC, 2016

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focusonthreekeyactions:1)screening;2)reviewingmedicationstoreduce/eliminate

thosethatincreasefallrisk;and3)prescribingVitaminDtoimprovemusculoskeletal

health(Bergenetal.,2016).Inadditiontotheclinicaldecisionsupportalgorithm,the

CDChasdevelopedaSTEADItoolkitwithresourcesforproviders,suchastrainingvideos

andpatienteducationalmaterials(CDC,2016).

TheCDC(2015)projectsthatforevery5,000providerswhoimplementSTEADI

overa5-yearperiod,morethan6millionolderadultscouldbescreened;1millionfalls

prevented;and$3.5billionindirectmedicalcostssaved.

ReimbursementandOtherIncentives

FallriskscreeningandevaluationispartoftheWelcometoMedicareVisitand

AnnualMedicareVisit,andthereforeareanavenueofreimbursementforfall-related

providerservices.Fallriskscreening,however,isonlyoneofanumberofevaluationsto

beperformedduringthevisit,anddoesnotincluderobustassessmentorintervention.

Inaddition,itshouldbenotedthatMedicareWellnessAnnualvisitsareunderutilized,

withautilizationrateof12.8percentinKentucky,andonly17.7percentnationally

(CMS,2015).

HealthcareprovidersandsystemsaregivenincentivestoimplementSTEADIfall

preventionthroughtheMedicareAccessandCHIPReauthorizationAct(MACRA’s)

Merit-basedIncentivePaymentSystem(MIPS).LandisandGalvin(2015),studiedfall-

relatedmeasuresinCMS’PhysicianQualityReportingSystem(PQRS),thepredecessor

toMIPS,withagoalofreducingfall-relatedinjuriesandcostsby10percent.Four

15

primarycarepractices,locatedinwesternNorthCarolina(aregionofthestatewitha

highfallrate),withovertwothousandolderadultpatients,participatedinthequality

improvementproject.Almost70percentofeligiblepatientswerescreened.Ofthose

withreportedfalls,closeto90percentwereassessed.Alittleunderaquarterofthose

patientshadadocumentedplanofcare.Disappointingly,thestudyfailedto

demonstrateasignificantreductioninfall-relatedhospitalizationsorcosts,whichthe

authorssuggestmayhavebeendueto“inadequateimplementationofthe

managementcomponentoftheprogram.”(LandisandGalvin,2015,p.2413)

AninitiativebytheCDC,throughacooperativeagreementwiththeAmerican

CollegeofPreventiveMedicine(ACPM),isaimedatgainingCMSapproval,alengthyand

arduousprocess,fornewfall-relatedCPTcodeswhichareneededinordertobillfor

theseservices(ACPM,n.d.).Professionalmaintenanceofcertification(MOC)credits,as

wellasqualityimprovementrecognitionofferedbyhealthcaresystemsandinsurers

havealsobeenusedtoincentivizeSTEADIimplementation(Caseyetal.,2016;Gearon,

2015).

AchangeinUnitedStatesPreventiveServicesTaskForce(USPSTF)

recommendations,whichguideprimaryphysicianpractice,wouldlikelypromotefall

screeningandpreventionuptake(Tinetti&Brach,2012).Multidimensionalfallrisk

assessmentisnotcurrentlyrecommendedforallcommunity-dwellingolderadults,but

onlyforselectedindividualsbasedontheircircumstances(USPSTFCrecommendation)

(Moyer,2012).ThisUSPSTFrecommendationis,however,underreview(USPSTF,2017),

andifchangedfromaGradeCtoaGradeAorBrecommendation,wouldinfluence

16

reimbursement,particularlygiventhattheAffordableCareAct(ACA)mandates

Medicarecoverageforpreventiveservices(Tinetti&Brach,2012).

17

LiteratureReview:

AliteraturereviewofSTEADIimplementationwasconductedinPubMed,Webof

ScienceandAgeLineusingthefollowingterms:PubMed:”STEADI”AND"Accidental

Falls/preventionandcontrol"[majr]AND"Aged"[mesh]Filters:Review,5years,English;

WebofScienceusingonlykeywords;AgeLineusingthefollowingsearchterms:(DE

"Falls")OR(DE"AccidentPrevention").Theliteraturewassupplementedbyonline

resourcesandinformationprovidedbytheOhioDepartmentofHealth.

ShortlyfollowingthedevelopmentoftheSTEADIdecisionsupporttoolin2011,

theCDC’sStateFallsPreventionProject(SFPP)providedfundingtohealthdepartments

inColorado,NewYorkandOregon,todevelopfallpreventionstrategiesinclinical

practices,healthcaresystemsandcommunityorganizations(Casey,Parker,Winkler,

Liu,Lambert,&Eckstrom,2016;Shubert,Smith,Schneider,Wilson&Ory,2016;Stevens

&Phelan,2013).Thesethreestateshavejustrecentlycompletedthefive-year

implementationperiod(Shubertetal.,2016).Todate,neitherColoradonorNewYork

havepublishedadescriptionorevaluationofSTEADIimplementationintheirrespective

states.ResultsoftheNewYorkprogramhavebeenreportedinthepopularpressand

variouswebsites.Additionally,asmallstudyoffallprevention-relatedproviderattitudes

andpracticeswaspublishedin2015(Smith,Stevens,EhrenreichWilson,Schuster,

Cherry&Ory,2015).

TheOhioDepartmentofHealth,withtheassistanceofaconsultingfirm,hasalso

recentlycompleteda6-monthevaluationofapilotprojectinoneoftheirlargehealth

caresystems(RAMA,2015;RAMA,2016).Allofthesestate-initiatedprogramsidentify

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importantcomponentsofsuccessfulimplementationandidentifybarriers.The

foundationfortheUKFCMpilotanalysis,however,istheKotter-basedevaluationofthe

STEADIinitiativeinOregon.Importantly,thereisapaucityofpublicationsdescribing

STEADIqualityimprovementprojects,initiatedbyprimarycarepracticesoutsideofthe

CDC-fundedpilots.TheUKFMCpilotmayrepresentoneofthefirstclinicalpracticesto

collaboratewithpublichealthentitiestoimplementSTEADIintheabsenceofa

categoricalCDCgrant.Additionally,theincorporationofafallpreventiontoolintothe

AllscriptsEHR,thesystemusedinthispilot,hasnotheretoforebeendescribed.

NewYork

NewYork’sSTEADIprogramwasapartnershipbetweenaregionalhealth

system,UnitedHealthServices(UHS),BroomeCountyHealthDepartment,Broome

CountyOfficeforAgingandtheNewYorkStateDepartmentofHealth(Smith,2015;

UHS,2013;Gearon,2015).BroomeCountywasselectedfortheprogrambecause

approximately17percentofitsresidentsare65yearsorolder(UHS,2013),andfall

preventionwasatoppriorityinthecounty(Gearon,2015).Theinitialpilot,championed

byaninternalmedicinephysicianandanursemanager(UHS,2013),wasconducted

usingapaperform,followedbythedevelopmentofanEHRtemplate.Aswasthecase

inOregon,thealgorithmandworkflowweresimplifiedandadaptedtomeettheneeds

ofthepractice.

Thesuccessoftheinitialpilotledtoexpansiontomorethanfifteenclinicsites,

whichreportedascreeningrateofover85percent(“Dr.Floyd;”2014).Accordingtoa

19

2015U.S.News&WorldReport(2015)article,thehealthsystemreportedhaving

screened17,500patientsandthecounty’sfallratehasdeclinedby25percentbetween

2010and2013.Importantly,inthe18monthsafterimplementation,therewasa12

percentreductionincountyhospitalizationsandemergencydepartmentforfractures

relatedtofalls(Gearon,2015).

AstudybySmithetal.(2015),conductedaspartoftheCDCgrant,examined

primarycareproviderbeliefs,knowledgeandfall-relatedactivitiespriortoreceivinga

one-hour,physicianchampion-led,ClinicalEngagementandEducation(CEE)training

session.TheCEE’saimwastoassistcliniciansinidentifyingwaystointegrateSTEADI

intopractice.Thesessionbroughttogetherthirty-eightprovidersandstaff,representing

elevenpractices,todiscusstheproblemoffallsandtocollectivelydevelopwaysto

incorporatefallpreventionintoclinicalpractice(Smithetal.,2015).Resultsindicated

thatfallswererankedasalowerprioritythandiabetesandseveralotherchronic

diseases;andwerenotroutinelyscreenedfororintervenedupon(Smithetal.,2015).

Unfortunately,thisstudywasunable,duetoinadequatepost-trainingdata,toassess

theimpactofSTEADItrainingonproviderattitudes(Smithetal.,2015).Itdid,however,

givemeaningfulfeedbacktotheCDCregardingphysiciantimeconstraints,andledto

theCDC’sfocusonthreekeyscreeningquestions(hasthepatientfalleninthepastyear,

dotheyhaveafearoffalling,and/orunsteadinessinstandingorwalking)andtwokey

interventions(vitaminDsupplementationandmedicationreview)(Gearon,2015).

20

Oregon

STEADIwasimplementedinOregonthroughapartnershipbetweentheOregon

HealthAuthority(OHA)andtheOregonHealth&ScienceUniversity(OHSU)(Caseyet

al.,2016).Thefirststepinsystem-wideimplementation,wasthedevelopmentofapilot

involvinggeriatrics-trainedprovidersintheInternalMedicine&GeriatricsClinic.These

clinicchampionsrefinedclinicworkflowandtheelectronichealthrecordtool.Thepilot,

conductedoverseveralmonths,screenedfifty-sixpatientsage75patientsorolder.Fall

riskwasdeterminedusingthequestionscontainedintheSTEADItoolkit’sStay

Independentbrochure(AppendixA)whichincludethethreekeyquestionsinthe

algorithmaswellasquestionstargetedtoadditionalriskfactors.Ofthe80percentof

patientswhohadrecordedriskscores,56percentweredeterminedtobeathighrisk.

Ofthoseathighrisk,92percentwerefullyevaluatedattheinitialvisit.Impressively,

over90percenthadadocumentedvisionassessment,vitaminDlevelandfall-related

careplan.TheSTEADIworkflowandEHRwererevisedanumberoftimesbeforebeing

fullyimplementation.Duringthefirst18monthsofimplementation,45percentof

eligiblepatientswerescreened,35percentofwhomwereidentifiedasbeinghighrisk

(Caseyetal.,2016).

TheOHSUteamsurveyedhealthcareteammemberstoidentifyfacilitatorsand

barriersandusedsurveyresultstochangehowtheprogramwasimplemented.

Facilitatorsincluded:aclinicculturethatwassupportiveofnewprotocolssuchas

STEADI;theopportunityforproviderstoreceiveMaintenanceofCertification(MOC)

credits;theavailabilityofclinicchampionstoassistinimplementation;well-prepared

21

clinicstaff;anEHRSTEADItoolthatwaseasytouse;patientreceptivitytoscreening;

strongevidencetosupportfallsscreening;anduseofSTEADItostreamlinethe

screeningprocessandpreventfalls.Timeconstraints,competingmedicalinterestsand

thecomplexityofscreeningwereidentifiedasbarriers(Caseyetal.,2016).Notably,

poorreimbursementwasnotidentifiedasabarriertoimplementation(Caseyetal.,

2016).

InanalyzingthesuccessoftheOHSUprogram,theauthorsidentifiedfour

importantprocesses:developmentofworkflowthatdidnotdisturbthedailypractice

routine;incorporationofSTEADIintotheEHR;pilotingofworkflowandtheEHR

templatebyclinicchampionspriortoimplementation;andtrainingofpersonnelonuse

oftheEHRtool,workflowandfallprevention.Theyalsonotedtheimportanceofearly

buy-infromalllevelsoftheorganization,partnershipwiththestatehealthdepartment

andlinkagetocommunityinterventions(Caseyetal.,2016).

Ohio

TheOhioDepartmentofHealth(ODH)ViolenceInjuryandPreventionCenter(VIPP),

whilenotoneoftheoriginalCDCgrantrecipients,beganencouragingproviderstouse

STEADIin2013(RAMA,2015).Inordertofacilitateuptakeoftheprogram,ithas

recentlyembarkedonaninitiativetoimplementSTEADI.Thestate,withtheassistance

ofRAMAConsulting,embarkedonacollaborativeprojectwiththeOhioHealthsystem,

toamongotherthings,developastatewideworkgroup;pilotSTEADIinfiveOhioHealth

settings;identifybestpractices;assessbarrierstoimplementation;developpromotional

22

materials;andevaluatethepilot.Thefivepilotsiteswerechosenbasedonhavingan

olderadultpatientbase,adequatestaffandfacilitiesandtheuseoftheEpicEHR.

ConsistentwithOregon’sfindings,theextensivereportnotedtheimportanceof

aphysicianchampion,organizationalbuy-in,integrationofSTEADIintotheEHR,

incremental,tailoredanditerativeimplementation,trainingandtechnicalsupport,

attentiontoworkflowandlinkagetocommunityinterventions.Moreover,anadequate

reimbursementmechanismandotherincentiveshelpedtoensuresustainability(RAMA,

2015;RAMA,2016).

The6-monthquantitativeandqualitativeevaluation,basedondatacollected

fromavarietyofsources,includingtheEHRandfocusgroups,showedthatalmost450

patientshadbeenscreened,althoughduetodatacollectiondifficultiestheinitialreport

wasnotabletodeterminethepercentageofeligiblepatientsscreened(RAMA,2016).

Notsurprisingly,themostfrequentlyreportedbarrierwaslackofstafftimeor

availability(RAMA,2016).

ImplementationfromaDepartmentofPublicHealthPerspective

Anumberoflessonshavebeenlearnedbystatehealthdepartmentgrantees

chargedwithimplementingSTEADI.AnarticlebyThoreson,Shields,Dowler&Baer

(2015),eachofwhomisfromoneofthegranteestates,summarizedthekeyelements

insuccessfulfallpreventionprogramimplementation,suchasbuildinganinfrastructure

andensuringsustainability.Shubertetal.(2016)identifiednineimportantchallenges

departmentsofpublichealthfaceinimplementingSTEADI:1)changingphysician

23

practice,whichnecessitatesfinding“meaningfulvaluepropositions”forpracticingand

buildingrelationships;2)limitedknowledgeonthepartofprovidersandsystems

regardingthevalueandavailabilityofcommunity-basedinterventions;3)alarge

numberofcompetingeffortstoimproveefficiency;4)lackofuniformityofmotivators

amonghealthcaresystems;5)lackofacomprehensiveandcentralizedsystemfor

community-basedinterventionsandresources;6)lackofbidirectionalreferralsystems;

7)theneedtocreatedemandforcommunityservicesthroughproviderreferralwhile

havinganadequatesupplyofcommunityprograms;8)findingappropriatepartners;and

9)sustainability.Whilemanyoftheseissuesmustbesolvedbyhealthcaresystems,

cliniciansandcommunityorganizationspublichealthentitiescanbringstakeholders

together,provideeducationandfacilitateproblem-solving.

OtherPilots

ApilotstudyattheTampaJamesA.HaleyVA,testedwhetherSTEADIcouldbe

adaptedforusebythePatientAlignedCareTeam(PACT)(Ferguson,Friedman&Bulat,

2016).ThePACTwascomprisedofaphysician,nurseandclerk(Ferguson,2016).Lack

ofrobustleadershipsupport,difficultyinintegrationintotheworkflowandduplication

ofaspectsoftheexistingVAfallpreventionprogram,wereamongthebarriers

identified.Morepositively,pilotparticipantsreportedincreasedfallprevention

awarenessanduseoftoolkiteducationalmaterials.

24

Conclusion

TheliteratureonSTEADIpilotstudiesidentifiesanumberofelementsneeded

forsuccessfulimplementation.Aphysicianchampion,buy-infromhealthsystem

leadership,incorporationofthedecisionsupporttoolintotheEHR,andcollaboration

withhealthdepartmentandcommunityorganizations,facilitateasuccessfulprogram.

Timeconstraints,competingclinicaldemandsandintegrationintotheclinicworkflow

continuetorepresentsignificantchallengesandnecessitateaniterativeprocess.The

UKFMCpilot,discussedbelow,wascharacterizedbyanumberofthefactorsneededfor

successfulimplementation,butwillrequirefurtherrevisionsinordertobefully

integratedintotheclinicandthroughoutUKHC.

25

CapstoneProject:Thepurposeofthisprojectwastodescribeandevaluate,usingtheKottermodel,apilot

oftheSTEADIpreventionprogram.Thepilotwasdevelopedbyan

interdisciplinary/interdepartmentalworkgroupandfacilitatedthroughpartnershipwith

otherkeystakeholders.

Methods

ThecapstoneprojectwasbasedonaUKFamilyandCommunityMedicinefall

preventionqualityimprovementprojectusingtheCDC’sSTEADItoolkit.Itwas

developedbyaninterdisciplinaryandinterdepartmentalworkgroup,incooperation

withtheKentuckyDepartmentforPublicHealth.Thepilotdevelopmentprocessand

pilotdesignaredescribedmorefullyinthebackgroundsection.Descriptivestatistics

wereusedintheanalysisofpilotresults.ThepilotwasevaluatedusingtheKotter

LeadingChangemodel(Kotter,1995)whichiscomprisedofeightsteps:1)creatinga

senseofurgency;2)buildingaguidingcoalition;3)formingastrategicvisionand

initiatives;4)enlistingavolunteerarmy;5)enablingactionbyremovingbarriers;6)

generatingshort-termwins;7)sustainingacceleration;and8)institutingchange.

ThisprojectwasreviewedbytheUniversityofKentuckyInstitutionalReview

Boardandaswasdeterminedtomeetfederalcriteriatoqualifyasanexemptstudy.

26

Background

UniversityofKentuckyHealthCare(UKHC),anacademicmedicalcenteranda

leaderinhealthcareinthestate,seeksto“offercarethatispatient-centered,multi-

disciplinaryandcollaborative”(StrategicPlan,2016,p.4)andiscommittedtoevidence-

basedcareandcontinuousqualityimprovement(StrategicPlan,2016,p.40).Atthe

timethattheUniversityofKentuckyFamilyandCommunityMedicine(UKFCM)quality

improvementprojectcommenced,UKHCalreadyhadaninpatientfallscreening,

assessmentandpreventionprograminplace.Ithadalsoimplementedascreening

programtoidentifypatientsatriskoffallingwhileattendingmedicalappointmentsin

UKHCclinics.UKFCMrecognizedtheopportunitytoexpandtheorganization’sexisting

fallpreventioneffortsthroughpilotingSTEADI,andlaterincorporatingthealgorithm

intoitsenterprise-wideambulatoryelectronicrecord.

Thefallpreventionqualityimprovementprojectpresentedauniqueopportunity

topartnerwiththeKentuckyDepartmentforPublicHealth(KDPH).KDPH,

understandingthesignificantpublichealthproblemthatfallsandfall-relateddeathsand

injuriespresent,hasbeeninvolvedinavarietyofeffortstoreducefallsinthestate,and

hassoughttocollaboratewithhealthcareprovidersandothercommunitystakeholders

toimplementSTEADI.Thehealthdepartment,aswellastheKentuckyInjuryPrevention

andResearchCenter(KIPRC),apartnershipbetweenKDPHandtheUniversityof

KentuckyCollegeofPublicHealth,haveengagedinanumberofactivitiesthatsupport

fallsprevention.KIPRC’sKentuckyViolenceandInjuryPreventionProgram(KVIPP),

tracksandreportsstateandcountyfall-relatedinjurydata(C.S.Sparrow,personal

27

communication,April4,2017).Foroverfiveyears,theKentuckySafeAgingCoalition

(KSAC),asubcommitteeoftheKentuckySafetyandPreventionAlignmentNetwork

(KSPAN),hashostedanannualFallsSummit(D.Falls,personalcommunication,April4,

2017).TheSummit,attendedbymembersofthehealthcareandpublichealth

community,hasincludedinformationonSTEADI(KSPAN,2009-2014).Datacollectionis

fundedthroughtheCDCCoreStateViolenceandInjuryPreventionProgramGrant.

SupportfortheSummithasbeenprovidedbytheosteoporosisprogram,aspartofthe

CDCPreventiveHealthandHealthServicesBlockGrant,andKentuckyViolenceand

InjuryPreventionProgram(KVIPP)(D.Falls,personalcommunication,April5,2017;C.S.

Sparrow,personalcommunication,April4,2017).Giventhedemonstratedcommitment

ofUKHC,UKFCMandthestatehealthdepartmenttofallprevention,thequality

improvementpilotpresentedaclearopportunitytointroduceSTEADIintoclinical

practice.

PilotDevelopmentandRollout

Thefallpreventionpilotworkgroupwasledbytwophysicianchampions–the

UKFCMclinicdirector,Dr.JonathanBallard,andthisauthor,aresidentphysician.The

clinicdirectorhadextensiveexperienceinqualityimprovementandhadstrongworking

relationshipswithprojectpartnerswithintheUKHCorganization.Thisauthorhadbeen

involvedinfallpreventionprojectsatKIPRCandKDPH.Itwasrecognizedthatinorderto

besuccessful,theprojectworkgroupshouldbeinterdisciplinaryandinterdepartmental.

Aworkgroupwasestablishedandincludedaninformaticist;practicemanager;assistant

28

chiefnurseexecutive;familypracticepatientservicescoordinator(senior);physical

therapistfromUKHC’sKentuckyClinicOutpatientTherapy;andanurseclinicalmanager

fromthetheKentuckyNeuroscienceInstitute.Valuableinputwasalsoprovidedbythe

UKHCTraumaInjuryandPreventionOutreachCoordinator,whowasinvolvedinleading

anenterprise-wideefforttoprovidefallpreventioneducationandlinkstocommunity

resources,suchastheCountyExtensionService’sevidence-basedAMatterofBalance

program,toallolderadultsadmittedtoUKHealthCare.Laterworkgroupmeetingswere

alsoattendedbyrepresentativesfromKIPRCandKDPH.

Workgroupmeetingswereheldovera3-monthperiodpriortothepilotrollout

andmetaftertheconclusionofthepilottodiscussresults.Onedaypriortotherollout,

thepilotwaspresentedatthemonthlyUKFCMpractice-widemeeting,whichwas

attendedbyhealthcareproviders,clinicalservicetechnicians(CSTs),LicensedPractical

Nurses(LPNs)andotheradministrativestaff.KDPHrepresentativeswerealsopresent,

asobservers,duringtheFamily&CommunityMedicinepractice-widemeeting

introducingthepilot,andbroughtwiththemSTEADIeducationalmaterials.

The5-daypilotwasoriginallydesignedtoincludeonlytwoclinicteams,soasnot

tooverburdenandpossiblydisruptclinicworkflow,butwaslaterextendedtoincludeall

fiveteams.Residentphysicianswerepresentatthemonthlypracticemeetingandthey

alsoparticipatedintherollout.Aspartoftheinitialqualityimprovementpilot,apaper

versionoftheSTEADIambulatoryscreeningandassessmenttool(Figure5),ratherthan

anelectronicversion,wasused.TheCDC’sSTEADIalgorithmwasprintedonthebackof

theformforprovidersforreference.Theinformaticistlaterdevelopedmock-upsof

29

proposedchangestotheexistingAmbulatoryElectronicHealthRecord(AEHR)(Figure6)

includingmodificationofthefallriskscreeningquestions(Figure7).Itwasalso

proposedthattheassessmentandinterventionssectionsbeaddedtotheAEHR,

followingfurtherrevisionstoresolveambiguities.ThepresentationtotheAEHRUser

Group,whichmustapproveallchangestotheAEHR,wasmadethreemonthsfollowing

pilotcompletion.

30

Figure5:AmbulatoryFallRiskScreeningToolforPatientsAge65andOlder

31

Figure6:FallRiskScreeninginAEHRatTimeofPilot

Figure7:ProposedAEHRFallRiskScreeningChanges

32

Results

Therewere129patientsage65orolderseenintheUKFCMclinicduringthefive-

daypilot.Ofthose,64,or49.61percent,werescreenedforfallrisk.Ofthosescreened,

28answeredyestooneorbothofthefirsttwoscreeningquestions.Basedonapositive

responsetoatleastoneofthesequestions,44percentweredeterminedtohave

screenedpositive.Thirteenofthe64screened(20.31percent)hadfalleninthepast

year,and21ofthe64(32.81percent)wereworriedaboutfallingorfeltunsteadywhile

walkingorstanding.Thequestion“wasprotocolimplemented”referredtothepre-

existingfallsprotocolinplacetopreventapatientfromfallingwhileintheclinic.While

thiswasexplainedbrieflyintheclinicpracticemeeting,itmayhaveneededfurther

clarification,asitwasoftenleftblank.

Completionoftheproviderriskassessmentwasrelativelylow,with25percent

ofprovidersnotrespondingeitheryesornotomedicationreview,and32percentwith

noresponseregardingvitaminDsupplementation.Thequestionregardingmedication

review(psychoactive/anticholinergic/sedating,includingOTCmedications)appearsto

havebeensubjecttodifferentinterpretations.A“Yes”responsemayhavemeant

medicationswerereviewedorthattheywerereviewedandcontainedoneofthehigh-

riskmedications.Anegativeresponsemayhaveindicatedthatmedicationreviewwas

notconductedorthatmedicationswerereviewedandthepatientwasnottakinghigh

riskmedications.TherewasasimilarlackofclarityregardingtheVitaminD

supplementationquestion.Possibleinterpretationsincluded:VitaminDwasprescribed

33

atthisvisit;thepatientwasalreadytakingVitaminD;thepatientdidnotneeda

supplementbasedontestresultsorotherfactors;ortheproviderhadnotaddressed

theissue.

Someoftheformshadthescreeningquestionscompleted,butlackedanyother

responses,makingitunclearwhethertheCST/LPNdidnotgivetheformtotheprovider,

ortheproviderfailedtocompletetheassessment.Duetotheaforementioned

ambiguitiesintheform,reliablestatisticscannotbereportedregardingprovider

assessmentsandinterventions.

Evaluation

TheKotter8-stepprocessfororganizationalchange(Kotter,1995)providesthe

frameworkforevaluationoftheUKFCMpilot.TheKottermodelwasselectedfollowing

completionoftheUKFCMpilot.While,inretrospect,itwouldhavebeenvaluablehadit

beenusedprospectivelytoguidethedevelopmentandexecutionofthepilot,itis

nonethelessusefulforevaluativepurposesandcanhelptoguidefurther

implementation.

Step1:Createasenseofurgency

Thefirststepintheprocessofeffectivechangeisto“createasenseofurgency

amongrelevantpeople”(Kotter,1995;Kotter&Cohen,2002,p.3).Asenseofurgency

forthepilotwaseffectivelyconveyedthroughconnectingwithaudiencesinavisually

andemotionallycompellingmanner(KotterandCohen,2002p.22)andwasconsistent

34

withKotter’sobservationthat:“Peoplechangewhattheydolessbecausetheyaregiven

analysisthatshiftstheirthinkingthanbecausetheyareshownatruththatinfluences

theirfeelings.”(Kotter&Cohen,2002p.1).

Emotionhelpedtocreateasenseofurgencyatseveralpointsinthe

developmentoftheUKFCMproject.Workgroupmembers,aswellasclinicproviders

andstaff,couldrelatepersonallyaswellasprofessionallytotheproblemoffallsinolder

adults.Manyhadfamilymemberswhohadfallenand/orhadtreatedpatientswhohad

sufferedfall-relatedinjuries.Thepractice-widemeetingduringwhichthepilotwas

introduced,openedwiththepresenter,aphysicianchampion,askingattendeestoraise

theirhandiftheyhadaparent,grandparent,otherfamilymemberorneighborwhohad

beenimpactedbyafall.Theproblemoffallswasdemonstratedvisuallywithpicturesof

anolderadultinahospitalbedandanx-rayofahipfracture,whilethepresenter

relatedapersonalstoryofherolderadultparentswhohadfallen.

Asenseofurgencywasenhancedbythetimelinessofthequalityimprovement

project.ACDCarticleonfallsprevention,publishedseveralweekspriortothe

presentation,includedamapwithKentuckyhighlightedasoneofthestateswiththe

highestratesofreportedfalls(Bergenetal.,2016).Mapsoffall-relatedhospitaland

emergencyroomadmissionsbycounty,createdbyKIPRC,werealsoincludedinthe

presentation.Enthusiasmtoplayaroleinchangingthosemapswaspotentiatedby

presentingCDCestimatesofhowmanyfallscouldbepreventedbyimplementing

STEADI.Thepresentation,modifiedtoincludepilotresults,wasalsomadetotheAEHR

35

UserGroupwhenrequestingthattheSTEADItoolbeincorporatedintotheelectronic

healthrecord.

Asenseofurgencywasalsocontributedtobytheinvolvementofseveral

workgroupmembersinotherprojectsthatdove-tailedwiththepilot.UKHChadrecently

achievedprestigiousMagnetStatus,thehighestawardforinstitutionalnursing

excellence.Qualityimprovementandinterdisciplinaryrelationshipsareimportantin

beinggrantedthisrecognition(ANCC,2011);thepilotrepresentedanopportunityto

supportthisrequirement.Othermembersoftheworkgrouphadparticipatedinafall

preventioninitiativeundertakeninanotherdepartmentwhichhadnotbeenfully

implementedduetobarrierssuchastimeconstraints.Workgroupmembersfromthis

departmentwishedtolearnwhethertheUKFCMclinicencounteredthesame

difficultiesand,ifso,howtheycouldbeovercome.Anadditionalincentivewastheuse

oftheprogramtomeetMIPSandTheJointCommission(TJC)reportingrequirements.

Publichealthpractitionersinvolvedintheproject,inadditiontofurtheringthe

implementationofSTEADIinthestate,werealsointerestedingaininginsightsinto

clinicalpracticeandqualityimprovementprocesses.

Step2:Buildaguidingcoalition

Organizationalchangeisledbyaguidingteamorcoalition,“withthecredibility,

skills,connections,reputationandformalauthorityrequiredtoprovidechange

leadership”(Kotter&Cohen,2002,p.4).Theworkgroupteampossessedthe“titles,

informationandexpertise,reputationsandrelationships”(Kotter,1995)neededto

36

movetheprojectforward.Thepilotproject,guidedbyphysicianchampions,brought

togetherkeystakeholders,fromvariousdepartmentsanddisciplineswithinUKHC,and

formedvaluablerelationshipsbetweentheUKhealthcaresystemandrepresentatives

fromKIPRCandKDPH,allofwhombroughttheiruniqueperspectivetoandroleinfall

prevention.

Step3:Formastrategicvisionandinitiatives

Theguidingteamorcoalitionischargedwithdeveloping“sensible,clear,simple,

upliftingvisionsandsetsofstrategies”(Kotter&Cohen,2002,p.4).Thefallprevention

workgroupwasguidedbyandbuiltuponthevisionoftheCDC’sandstatepublichealth

entitiestoreducefall-relatedratedmorbidity,mortalityandassociatedcosts.Thegroup

wasalsodrivenbytheorganizationalvisionofcontinuousqualityimprovementand

patient-centeredcare.Thisorganizationalvisionwascarriedoutthroughongoing

qualityimprovementprojectswithintheUKFCMpracticeandtheclinicdirectorhad

substantialexperienceleadingoroverseeingqualityimprovementteams.TheNursing

DepartmentexecutiveintheworkgrouphadbeeninvolvedinachievingMagnetStatus

andcontinuousqualityimprovementintheambulatoryspace.Theinitiativeto

incorporatethetemplateintotheAEHR,andthepotentialtogatherdataon

performancemeasuresandoutcomeswasavisionsharedbytheworkgroup,andwould

nothavebeenpossiblewithouttheearly,activeinvolvementandexpertiseofthe

informaticist.

37

Step4:Enlistavolunteerarmy

Thepilotwasdevelopedprimarilybyvolunteers.Thepilotrolloutinvolvedallclinic

providersandstaff,ratherthanonlyvolunteerswhoofferedtoparticipate.Nextstepsin

enterprise-wideSTEADIimplementationmayincludeenlistingvolunteerstopilotthe

programintheirrespectiveclinics,participateinothereffortstoimplementthe

programandincorporatereferralloopsforcommunity-basedfallprevention

interventions.

Step5:Enableactionbyremovingbarriers

Anassessmentoffacilitatorsandbarrierswasnotpartoftheinitialpilot,butis

animportantnextphaseinSTEADIimplementation.TheliteratureonSTEADI,aswellas

fallsscreeningpre-datingSTEADI,hasidentifiedanumberofbarriers,suchastimeand

competingclinicaldemands,whichlikelyimpactedthepilot.Whileanswerstothe

STEADIscreeningquestionsregardingfallhistoryandfearoffallingorunsteadiness,

completedbyaCSTorLPN,hadaresponserecordedonallofthe64forms,the

responseratewasnotasrobustfortheotherquestionswhichwereassessedby

providers.MedicationreviewandvitaminDquestionshavingresponseratesof25

percentand32percent,respectively.Asdiscussedintheresultssection,TUGtestand

otherriskfactorassessmentshadlowresponserates,asdidinterventions.Designflaws

inthetoolresultedinambiguousresponsesandsuboptimaldataanalysis.

Improvements,reflectingfeedbackfromprovidersandstaff,willneedtobe

madepriortoincorporationintotheAEHR,andmayrequireseveraliterationsbecoming

38

anoptimallyeffectivetemplateanddatasource.Likewise,barriersrelatedtoworkflow,

whichreceivedlittleattentionduringthepilotrollout,will,aswasdescribedinthe

Oregonreport,requirefurtherstudyandrefinement.

Gapsincommunicationrepresentedabarrierinpilotimplementation.The

overallgoalofreducingfallsthroughSTEADIwascommunicatedduringthemonthly

practice-widemeetingwhichtookplaceonedaypriortothestartofthepilot.While

informationregardingthepilotstartdateandtheroleofclinicteammembersin

completingtheforms,wasprovidedduringthemeeting,thiswasinadequatetoensure

thatthepilotransmoothly.Thepilotwasinitiallyintendedtoincludeonlythreeofthe

fivepracticeteams,butaftertwodays,onlyfourformshadbeencompleted,prompting

theexpansionofthepilottoincludeallfiveteams.Whensomestaffwereaskedifthey

hadbeenscreeningpatients,itwaslearnedthatthesestaffmemberswerenotawareof

thepilot,asthepractice-widemeetinghadbeenheldontheirdayoff.Therewasalso

lackofcommunicationwhenoneofthestaffwasabsentandanotheremployee,who

hadnotattendedthemeeting,wascalledintoassumethatemployee’sduties.Anemail

withdetailedpilotinformationcouldhavebeensenttophysiciansandotherproviders,

however,CSTsandnursingstaffdidnotroutinelyutilizeemailforcliniccommunication.

Conveningabriefdailyteamhuddlewouldhavehelpedtoensureallmembersofeach

teamwereawareofthepilotandtheirrespectiveroles.

39

Step6:Generateshort-termwins

Theoverallsuccessofthepilotwasusedtomovetheprojectforwardtowards

enterprise-wideimplementation.Resultsofthepilot,particularlythepercentageof

patientsscreenedandthepercentageofpositivescreens,wascommunicatedtothe

teamandtheAEHRUserGroup.PresentationtotheAEHRUserGroupresultedin

modificationstotheAEHRfallsscreeningtemplatetoincludetheSTEADIscreening

questions(Figure6andFigure7).Theassessmentandinterventionsportionofthetool

werereferredtotheAEHRUserGroupteaminchargeofscreeningtemplates,for

furtherrevisiontoeliminateambiguities,priortoinclusionintheAEHR.

Step7:Sustainacceleration

Short-termwinsarebuiltuponinordertogainmomentumand“createwaveafterwave

ofchangeuntilthevisionisareality.”(Kotter&Cohen,2002,p.5).Therewas

substantialmomentumfromthepointofinceptionthroughpilotrolloutand

presentationtotheAEHRUserGroup.Thechallengewillbetosustainaccelerationand

takethestepsneededtosuccessfullyimplementSTEADI,includingtrainingstaff;

identifyingbarriers;improvingworkflow;optimizingtheAEHRtemplate;facilitatingand

monitoringuptakeinotherprimarycareclinics;andgatheringdataforquality

performancereporting.Continuedcooperationwithpublichealthentitieswillfacilitate

themonitoringoffallratereductionandothermetrics.Coordinationwithuniversity

andcommunityresources,suchastheExtensionService,willbeneededtoensurethat

40

momentumisnotlostinlinkingpatientstocommunityresources,andclosingtheloop

throughAEHRinterventionandoutcomedocumentation.

Step8:Institutechange

Thefinalstepintheprocessoforganizationalchangeis“tomakechangestickby

nurturinganewculture”(Kotter&Cohen,2002,p.5).Therecurrentlyexistsastrong

cultureofqualityimprovementwithinUKHC.TheSTEADIinitiativeappearedtobewell-

receivedbybothclinicstaff,providersandtheAEHRUserGroup,butitistooearlyto

knowwhethertheSTEADIpilotwillresultinfullimplementationintheUKFCMclinicand

inotherprimarycarethroughouttheUKhealthcaresystem.

Basedonthepilotplanningprocess,rolloutandevaluation,anumberoflessonslearned

wereidentified.

LessonsLearned

LessonslearnedduringthedevelopmentandrolloutoftheUKFCMpilotincluded:

• Communication--Themonthlypractice-widemeetingwasaneffective

foruminwhichtopresentthepilot;nonethelesssomeprovidersandstaff

wereabsentduetotheirindividualschedules.Emailswithkeypointsofthe

pilot,sentpriortoandafterthemeeting,wouldatleastinpartaddressed

thisproblem.Thesekeypointscouldalsohavebeenreviewedandreinforced

attheweeklyteammeetingandteamhuddlesheldimmediatelypriortothe

startofclinic.

41

• STEADIformdesign–Afterthepilotwasconducteditbecameclearthat

therewereanumberofambiguitiesintheassessmentandintervention

portionsofthepaperform,whichwouldhavebeenapparenthaditbeen

testedpriortouse.Theassessmentandinterventionsectionsoftheformwill

needtoberevisedbytheAEHRUserGroupcommitteeoverseeingscreening

templates,priortoincorporationintotheAEHR.

• Divisionoftasks–Duringthedevelopmentprocessitwasdecidedthatthe

TUGtest,whichincludesanassessmentofpatientgaitandbalance,was

outsideoftheCST’sscopeofpractice.Hadthetestbeenlimitedtorecording

thetimeittookforthepatienttocompletetheTUG,itcouldhavebeen

performedbytheCST,therebyreducingtheburdenontheproviderand

likelyincreasingthenumberoftestsdoneduringthepilot.

• Training–TherewerenoformalSTEADItrainingsessionsconductedaspart

ofthepilot.ATUGtestvideowasnotshownduringthepracticemeetingdue

totechnicaldifficulties.Alinktothevideowasemailedtoproviders,but

giventhatthepracticemeetingandemailoccurredthedaybeforethepilot

commenced,providersmayhavenothadenoughtimetoviewthevideo.

• Referralstofallpreventionprograms–Therewerenoreferralsmadeto

communityoruniversity-affiliatedfallpreventionorexerciseprograms,

whichmayhavebeenattributabletolackofproviderfamiliaritywiththese

programs.AshasbeennotedintheSTEADIliterature,processesthat

seamlesslylinkpatientstofallpreventionprogramsareneededinorderto

42

ensurethatpatientsreceiveevidence-basedinterventionsandthat

participationandcompletionoftheinterventionisdocumentedinthe

patient’selectronichealthrecord.

• Interdisciplinary,interdepartmentalcooperation–Collaborationamong

differentdisciplinesanddepartmentswaskeytothepilot’ssuccess.The

experiencesofworkgroupmemberswhohadparticipatedinfall-related

projectsinotherdepartments,theinpatientsettingandinitialambulatory

screeningprojecthelpedguidepilotdevelopment.Interdepartmental

collaborationwas,andwillcontinuetobeinstrumentalintheintegrationof

theSTEADItoolintotheenterprise-wideAEHRpreventivehealthnoteform.

• Theroleofpublichealth–BothUKFCMandpublichealthentitiesbenefited

bytheSTEADIpilotpartnership.UKFCMwasabletoimprovethequalityof

careitprovidestoolderadultpatientsthroughtheuseofaclinicaldecision

supporttooldevelopedbytheCDCandpromotedthroughthestatehealth

department.ItwasabletoprovidepatientswithCDCeducationalmaterials

suppliedbyKDPH.KDPHgainedinsightsintothechallengesfacedby

cliniciansandhealthcaresystemsinSTEADIimplementation,whichwill

informitsstatewideimplementationefforts.

43

Recommendations/NextSteps

• Asurveyand/ormeetingsshouldbeconductedinordertosolicitfeedbackfrom

providersandstaffwhoparticipatedinthepilot.Facilitatorsandbarriers,aswell

aspotentialsolutionstochallengesshouldbeidentifiedandincorporatedinto

theAEHRtoolandenterprise-wideSTEADIimplementation.

• TheAEHRtemplateshouldberevisedtoeliminate/reduceambiguitiesthatwere

presentinthepaperform.Providersshouldtestthetoolpriortointegrationinto

theAEHR.Thescreeningquestions,medicationreviewandvitaminD

supplementation(ifappropriate)shouldbefeaturedprominently.

• TheAEHRtoolshouldbelinkedtoreimbursementforMedicareannualwellness

visits,whichincludefallriskscreening.Thismayalsoservetoincreaseutilization

ratesforthesevisits,whichareonly12.8%inKentucky,and17.7%nationally

(CMS,2015).

• STEADItoolkittrainingsessionsshouldbeconducted,preferablyinsmallgroup

sessions,aswasdoneintheOregonpilot(Caseyetal.,2016).KDPHcould

participateinthetrainingofcliniciansandstaff,asthismodelhasbeenused

successfullyinotherSTEADIimplementationprojects.OnlineCDCSTEADI

training,forwhichcontinuingeducationcreditsaregranted,shouldalsobe

encouraged.

• Workflowandtaskallocationamongteammembersshouldbeformallyassessed

andrefinedbasedonproviderandstafffeedback.Inaddition,engagingother

UKHCprofessionals,suchasPharmacists,whocouldcontributeexpertisein

44

medicationmanagementandreducetheburdenonproviders.TheCDChas

recentlylaunchedonlineSTEADItrainingandcontinuingeducationcreditsfor

pharmacists(CDC,2017).ThePhysicalTherapydepartmentshouldcontinueto

beinvolved,andcouldassistinperforminggaitandbalanceassessments.

• Providersandstaffshouldreceiveadditionalinformationandeducationon

evidence-baseduniversityandcommunityfallpreventioninterventions,suchas

Stepping-OnandTaiChi:MovingforBetterBalance.

• Referralstocommunity-basedprogramsshouldbedocumented,withfollowup

regardingwhetherthepatientparticipatedinandcompletedtheprogram.The

referralprocesswouldideallybeincorporatedintotheAEHR.

• Relationshipswithcommunityorganizationsandpublichealthentitiesshouldbe

continuedandstrengthened.KDPH’scontinuedinvolvement,particularlyinthe

areaoftraining,willbeimportantinsuccessfulimplementationbothwithinthe

UKHCsystemandstatewide.Asastatehealthdepartment,KDPHcanactasa

“connector”byprovidingforumsinwhichUKHCcanshareitsmodelwithother

stakeholders(Shubertetal.,2016).

45

Conclusion:

TheSTEADIalgorithmandtoolkitpromisetoreducefallsinolderadults

nationallyandinKentucky.UKFMCembarkedonthefirststepinimplementingSTEADI

inamajorhealthcaresystemintheCommonwealth.Thefive-daypilotresultedin

screeningalmost50percentofeligiblepatients.Thepilotdevelopmentandrollout

containedmanyofKotter’selementsforsuccessfulorganizationalchange.Thethreekey

strengthswhichhelpedtoensurethepilot’ssuccesswere:1)creatingasenseof

urgencythroughcouplingcompellingepidemiologicaldataregardingthehighrateof

fallsinKentucky,totheemotionalandpersonalimpactoffallsonindividualsandtheir

families;2)buildingaguidingcoalitionofstakeholders,includingthe

interdisciplinary/interdepartmentalworkgroupandKDPH;and3)generatingshortterm

winsbycompletingapilotthatachievedascreeningrateofclosetohalfofallalleligible

patientsandadvocatingforintegrationofSTEADIintotheAEHR.Challengesincluded

effectivecommunicationwithclinicstaffandambiguitiesinthepaperSTEADIform

whichhinderedpilotdataanalysis.Nextstepsintheimplementationprocessinclude

formalassessmentofworkflowandbarriers,suchascost,time,staffingandresources.

FurtherrevisionoftheAEHRtemplatewillbeneededinordertooptimizeuptakeand

enablethecollectionandanalysisofdataforreimbursementandreportingofquality

measures.Reimbursementandotherincentiveswillalsoberequiredtobuildabusiness

caseandachievebuy-infromhealthcaresystemleadership.

46

ImplementationofSTEADIthroughoutUKHC,aswellasstatewidecommunity-

basedprimarycarepracticeswhopartnerwithUKHC,willbeincrementalandtailored

totheuniqueneedsandenvironmentofeachclinicalsite.Optimally,thealgorithminits

entiretywouldbeimplemented,asmultidimensionalinterventions,particularlythose

thatincludegait,balanceandstrengthtraining,havethegreatestimpactonreducing

falls(Stevens&Burns,2015).Amorelimitedapproach,focusingonthreekeyactions:

screening,reviewingmedicationstoreduce/eliminatethosethatincreasefallriskand

prescribingVitaminD,toimprovemusculoskeletalhealth(Bergenetal.,2016)mayalso

beconsideredinordertopromotebetteruptake.

Finally,continuedpartnershipwithkeystakeholders,oneofthestrengthsofthe

UKFCMpilot,willbeneededtoassurethatSTEADI’saimofreducingfallratesinolder

adultisachieved.Publichealthentitiesandothercommunitypartnerswillbecriticalin

providingtraining,evidence-basedinterventionsandoutreachtovulnerableand

underservedolderadults.Strongcollaborativerelationshipswillneedtobeforged

betweenhealthcareprovidersandcommunityorganizationstocreateaseamless

referralprocess.

Injuryanddeathresultingfromfallsisasignificantpublichealthproblemin

Kentucky,whichhasreportedratesabovethenationalaverage.Furtherresearch

regardingtheetiologyofthestate’shighratesoffallsandfall-relatedinjuriesisneeded

inordertodeveloptargetedsolutions.Fallsandfall-relatedinjurieswillhaveagrowing

impactasthepopulationages.TheUKFCMSTEADIpilotrepresentsanimportantfirst

47

stepinreducingtherateofinjuries,deaths,aswellasthecosts,attributabletofallsin

theolderpopulationinKentucky.

48

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AppendixA:StayIndependentBrochure

CDC,2016