Improving the Care of Older Adults Full Report

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Improving the Care of Older Adultswith Common Geriatric Conditions

A Report from the HM O Workgroup on Care M anagement


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Improving the Care of Older Adultswith Common Geriatric Conditions

A Report from the HM O Workgroup on Care M anagement

February 2002

This report was written by the HM O Workgroup on C are M anagement. I t does not necessarily reflect the views of

the American A ssociation of Health Plans (A A HP) , the AA HP Foundation, or The Robert Wood Johnson Foundation.

This publication may be freely reproduced and redistributed without permission; however, neither the report nor i ts

contents may be resold. This report may be cited as: H M O Workgroup on Care M anagement, Improving the Care

of O lder Adults with C ommon G eriatric Conditions (A A HP Foundation, Washington, DC , February 2002).


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Improving the Care of Older Adults with Common Geriatric Conditions iii

Foreword

The HM O Workgroup on Care Management represents both health plans and group practices that are

capitated by health plans for a signif icant portion of revenues. H ealth plans and capitated provider

groups are referred to, collectively, as M anaged Care Organizations (M COs). Workgroup part icipants

hold senior medical and patient care management positions within their respective organizations, all of

which enroll significant numbers of older adults under M edicare capitation, known as M edicare+Choice,

contracts. The Workgroups activit ies are lodged at the AAHP Foundation, and AAHP staff members

provide invaluable support.

Over the past seven years, the HM O Workgroup on Care Management has met quarterly to discussways in which the delivery of care to M edicare beneficiaries can be improved. This report is the seventh

to be released. The six other reports released by the Workgroup are:

Identifying High-Risk M edicare HMO M embers

Planning Care for H igh-Risk Medicare HMO M embers

Essential Components of Geriatric Care Provided Through Health M aintenance Organizations

Establishing Relations with Community Resource Organizations: An Imperative For M anaged

Care Organizations Serving M edicare Beneficiaries

Geriatric Case Management: Challenges and Potential Solut ions in M anaged Care

Organizations

Risk Screening M edicare Members Revisited

We are deeply grateful to The Robert Wood Johnson Foundation for its financial and moral support.

The primary writer of this report was Eric A. Coleman, MD, MPH, University of Colorado Health

Sciences Center and Kaiser Permanente Colorado Region.

Peter D . Fox

Chair


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Improving the Care of Older Adults with Common Geriatric Condit ions v

*Served as scient i fic consultant

Served as Convener and Chair

Ellen Aliberti, BSN, MS, CCMRegional D irector, Care M anagement

HealthCare Partners

Los Angeles, Cal i fornia

Danielle Butin, MPH, OTRM anager of Health Promotion & Well ness

Oxford Health Plans

Whi te Plai ns, New York

Jan Clarke, MD, MPHIn-Pati ent Program

Advocate Health Centers

Chicago, I ll inois

*Eric A. Coleman, MD, MPHAssociate Professor of Geriatric M edicine

Uni versi ty of Colorado Healt h Sciences Center

and Clini cal Researcher

Kaiser Permanente Colorado Region

Denver, Colorado

Richard D. Della Penna, MDRegional Elder Care Coordinator

So. Cali forni a Kaiser Permanente

San D iego, Cali fornia

Joyce DubowSenior Policy Advi sor, Public Poli cy Insti tute

AARP

Washington, D.C.

Peter D. Fox, PhD

PresidentPDF, LLC

Chevy Chase, M aryland

Brian Hayes, MD, CMCESenior M edical D irector

Independence Blue Cross

Philadelphia, Pennsylv ania

Acknowledgments

The HMO Workgroup on Care Management:

Bonnie Hillegass, RN, MHAVi ce President , Medical M anagement

Sierra H ealth Services, I nc.

Las Vegas, Nevada

Christine Himes, MDDirector, Geriatr ics and Long Term Care

Group Healt h Cooperative

Seatt le, Washington

Joy Luque, RN, BSN, CCMDirector, Case M anagement

PacifiCare of Cali fornia

Cypress, Cali fornia

Paul Mendis, MDMedical D irector

Neighborhood H ealth Plan

Boston, M assachusetts

Robert J. Schreiber, MDMedical D irector of Geri atri c Services

Lahey Clinic

Burli ngton, M assachusetts

Ingrid Venohr, RN, PhDDirector, Senior Programs

Kaiser Permanente Colorado Region

Denver, Colorado

Nancy A. Whitelaw, PhDDirector, H ealt h and Aging Services Research

National Counci l on Aging

Washington, D.C., andAdjunct Investi gator

Center for Health Services Research

Henr y Ford Health System

Detroit , M ichigan


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Improving the Care of Older Adults with Common Geriatric Condit ions vii

Table of Contents

Section 1

Introduction 1

Section 2

Physical Inactivity 5

Section 3

Falls 13

Section 4

Medication-Related Complications 21

Section 5

Dementia 29

Section 6

Depression 41

Section 7

Undernutrition 53

Section 8

Urinary Incontinence 63

Appendix

Illustrative Process and Outcome Measures 69


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Improving the Care of Older Adults with Common Geriatric Condit ions 1

Section 1

Introduction

Recommendations for Managed Care Organizations

M COs should:

Conduct periodic screening and assessment for common geriatric conditions and have effective

interventions in place for positively identified older members.

Ensure that primary care practitioners have the tools, incentives, and resources to facilitate

identification and appropriate management of older members with common geriatric conditions. Establish partnerships with community agencies that provide complementary services for older

members with common geriatric conditions.

Recognize that geriatric conditions often confound treatment of other chronic illnesses.

Be open to innovations that are not currently part of their benefit structure but may have a positive

impact on quality of life for older members.

Traditionally, most of the focus of geriatric care in M anaged Care Organizations (M COs)1 has been

on identifying the relatively small number (3-5%) of older members who account for disproportionate

uti li zation. The main intervention M COs have offered these high-risk enrollees has been intense,comprehensive case management. M ore recently, and as will be described in this report, M COs are

beginning to recognize the advantages of broadening this focus to include older members at risk for

functional decline and subsequent frail health. These members may not need longitudinal case man-

agement but, rather, access to targeted, evidence-based interventions that address specific conditions.

The financial advantages of traditional uti lization management have largely been realized, and future

savings will likely accrue from investing in upstream approaches that prevent costly utilization altogether

(e.g., of the hospital or the emergency department). In order to provide excellent geriatric care and

simultaneously mitigate downstream cost, M COs need to establish expertise in improving functional

reserve in their older members. Functional reserve refers to the capacity of individuals to withstand a

threat to their health and functional status. Persons with limited functional reserve take longer to

recover, or may not recover, from their illness to the point that they can manage their care at home.

These persons may be frail or may be high-risk for becoming frail (i.e., the pre-frail).

1Managed care organizations (MCOs) include health maintenance organizations and other health plans with capitated contracts to serve Medicare beneficiaries.

They also include providers (e.g., hospitals or group practices) that are capitated by health plans.


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2 Section 1 Introduction

Functional decline and accompanying frailty is costly (1). Compared with their counterparts, whose

functional status worsened over time, direct costs of care for members who maintained high functional

status over the same time period were 62 percent lower (2). Further, many of the benefits with regard to

both outcomes and costs can be realized in the relatively short time horizon of 6-12 months (3-6).

Cost avoidance achieved from implementing interventions described in this report can be used to

further sustain such programs.

Reduced functional reserve is frequently multi-factorial, and different combinations of geriatric

condit ions may contribute to decline in a given individual. Although many conditions threaten functional

reserve in older members, seven treatable geriatric conditions serve as the focus of this report:

Physical Inactivity Depression

Falls Undernutrition

Medication-related Complications Urinary Incontinence

Dementia

These conditions represent common problems that adversely affect function and quality of life. They

are frequently underdiagnosed and therefore undertreated, and there are effective interventions available.

The seven condit ions should not be viewed in isolation since they may interact to potentially enhance

or confound treatment (7-10). For example, physical inactivity and urinary incontinence both increase

risk for falls; use of high-risk medications is a risk factor for both falls and cognitive dysfunction; and

social isolation is a risk factor for depression, undernutrition, and physical inactivity. Conversely, greater

physical activity has been shown to improve depressive symptoms and reduce the risk for falls.

The Workgroup envisions a tri-part ite relationship among the MCO, the primary care practitioner

(PCP),2 and the member. M COs can support the PCP and member towards achieving improved

functional outcomes. For example, the M CO can assure that brief and simple-to-use tools to manage

these conditions are readily available to PCPs. The MCO can also ensure that programs are availablefor referral, whether offered by the MCO or in partnership with relevant community-based organizations

(11). As discussed in a previous Workgroup report, MCOs can initiate periodic screening and assessment

of common geriatric conditions in both newly enrolled and existing members (12). They can also

facilitate the availabil ity of evidence-based care pathways for common geriatric conditions that can be

accessed by any member of the health care team, or alternatively, by the patient or an informal caregiver.

Primary care practitioners need to manage geriatric conditions. However, systems of care are often not

in place to provide them with the time, the tools, the incentives, and the support to consistently identify

and assess geriatric conditions. PCPs may be reluctant to address these conditions in the absence of

effective and accessible treatment programs for appropriate referral, particularly when they face immediate

pressures to attend to more acute medical problems. In contrast, M COs may have, or can develop, theinfrastructure for identification and assessment. M COs can be instrumental in making these programs

available and facilitating the referral process. Further, many of the conditions described in this report

2 Primary care practitioner broadly refers to the primary care physician, nurse practitioner, or a medical or surgical specialist to the extent they assume a primary

care role. Nurses, who provided asthma-related information, checked on symptoms, and provided assistance as needed. In addition, members in the program

could call these nurses at any time to ask questions or request help.


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can be managed by health professionals other than physicians and in locations other than the medical

office (e.g., senior centers, self-management groups, physical therapy, and organized incontinence or

exercise classes). In order to reduce the threat of care fragmentation, the PCP needs to be continually

apprised of the members progress.

M COs can encourage members to take a more active role in their care through ongoing monitoring

and positive reinforcement. Strategies to build self-efficacy and self-management skills have been shown

to have positive effects on a wide range of health outcomes, including geriatric conditions (13;14). The

member has a role in formulating the care plan and bringing in condition-specific materials to share

with practitioners. MCO-produced member educational or empowerment materials need to complement

M CO-produced PCP education and decision support materials. Thus, the MCO can provide greater

self-directed care and can simultaneously prepare PCPs to better manage geriatric conditions.

For example, members with urinary incontinence may be encouraged to play a more collaborative role

in their care by gathering condition-specific information prior to their visit (e.g., by completing symptom

diaries of incontinent episodes), key questions to ask about their condition (e.g., could my incontinence

be due to an infection or my medications?), and information regarding specif ic programs and treatments

about which to inquire (e.g., physical therapist or nurse-led incontinence self-management program).

Treatment of geriatric conditions often requires that older members change their health-related

behavior (15-17). Treatment regimens will more likely be followed when they are tailored to the members

personal goals, such as the abil ity to attend church, enjoy time with family, or return to work. Adherence

can be further enhanced through mechanisms that provide positive reinforcement and sustain attempts

at behavioral change. MCOs need to account for a members readiness to change when developing new

programs. PCPs also need to understand the members readiness to change and individual preferences

in order to establish meaningful and obtainable goals.

Increasingly, the Center for M edicare and M edicaid Services (CMS) has directed M COs to include

programs that enhance the health status and function of older members in their quali ty improvementefforts. Nearly all of the interventions for the geriatric conditions discussed in this report lend themselves

to continuous quality improvement initiatives such as those required by the National Committee for

Quality Assurance (NCQA) and the Quality Improvement Systems for Managed Care (QISM C)

regulations applying to M COs with M edicare and M edicaid enrollees.

The goal of this report is not to dictate the practice of medicine. Rather, it is to draw from a composite

of evidence-based literature, best practices, and professional judgment to demonstrate how M COs can

implement effective interventions that enhance functional status and quality of life for their older

members. Historically, older persons with multiple coexisting problems have been excluded from

therapeutic trials. Consequently, for some of the seven conditions, the evidence base is more developed

than for others. Many of the recommended interventions do not represent a large investment to theM CO and are not difficult to undertake. In many cases, the role of the MCO is to make it easy for the

clinician to do what is best for the member.


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4 Section 1 Introduction

Each condition is developed in a separate section that follows the same format: Clinical Vignette,

Recommendations for M COs, Nature of the Problem, Target Population and Risk Factors, Screening

and Assessment, Interventions, Implementation Barriers, Economic Impact, and Reference L ist.

Interactions between the condit ions are highlighted. Throughout this report, effective programs that

leading M COs have implemented will be featured for each of the seven geriatric conditions. Examples

are drawn from both Workgroup members and other MCOs to highlight that such programs are notonly possible but have already been successfully implemented and add value to the respective

organizations. The Workgroup acknowledges, however, that there is considerable activity in these areas

beyond what is reported herein.

Reference List

(1) National Institute on Aging. Physical frailty. 1991. N ational Institutesof Health.(2) Leveille S, LaCroix A , H echt J, G rothaus L, Wagner E. The cost of disability in older women and opportunities for prevention. Journal of

WomensH ealth 1992; 1(1):53-61.

(3) Leveille S, Wagner E, Davis C, G rothausL, Wallace J, et al. Preventing disability and managing chronic illnessin frail older adults: a randomized

trial of a community-based partnership wi th primary care. Journal of the American GeriatricsSociety 1998; 46(10):1191-1198.

(4) Burgio K, Locher J, G oode P, H ardin M , M cDowell B, et al. Behavioral vs. drug treatment for urge urinary incontinence in older women: a

randomized controlled trial. JA M A 1998; 280(23):1995-2000.

(5) StearnsS, Bernard S, Fasick S, Schwartz R, Konrad T, et al. The economic implicationsof self-care: the effect of lifestyle, functional adaptations,

and medical self-care among a nat ional sample of M edicare beneficiaries. A merican Journal of Public Health 2001; 90(10):1608-1612.

(6) Rizzo J, Baker D, M cA vay G , Ti netti M . The cost-effectivenessof a multifactorial targeted prevention program for fallsamong community

elderly persons. M edical Care 1996; 34(9):954-969.

(7) Tinetti M E, Inouye S, G ill TM , D oucette JT. Shared risk factorsfor falls, incontinence, and functional dependence: unifying the approach to

geriatric syndromes. JA M A 1995; 273(17):1348-1353.

(8) Singh N, ClementsK, Fiatrone M . A randomized controlled trial of progressive resistance training in depressed elders. Journal of G erontologyA Biological and M edical Sciences1997; 52A(1): M 27-M 35.

(9) Dugan E, Cohen S, Bland D , Preisser J, DavisC, et al. The association of depressive symptoms and urinary incontinence among older adults.

Journal of the American GeriatricsSociety 2000; 48(4) :413-416.

(10) Wolf SL, Barnhart HX, Kutner NG , M cNeely E, Coogler C, Xu T. Reducing frailty and fallsin older persons: an investigation of Tai Chi and

computerized balance training. Journal of the American GeriatricsSociety 1996; 44(5) :489-497.

(11) HM O Workgroup on Care M anagement. Establishing relationswith community resource organizations: an imperative for managed care

organizationsserving M edicare beneficiaries. 1-26. 1999. Washington D .C ., AA HP Foundation.

(12) The HM O Workgroup on Care M anagement. Risk screening M edicare membersrevisited. 1-37. 2000. Washington D. C. , A A HP Foundation.

(13) Lorig K , Sobel DS, Stewart A , Brown B, Bandura A , et al. Evidence suggesting that a chronic disease self-management program can improve

health status while reducing hospitalization. M edical Care 1999; 37(1) :5-14.

(14) Reuben D , Frank J, Hirsch S, M cGuigan K , M aly R. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled wi th

an intervention to i ncrease adherence to recommendations. Journal of the A merican G eriatricsSociety 1999; 47(3) :269-276.

(15) Nigg CR, Burbank PM , Padula C , D ufresne R, Rossi JS, et al. Stagesof change acrossten health risk behaviorsfor older adults. G erontologist

1999; 39(4):473-482.

(16) Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. A merican Journal of Health Promotion 1997; 12(1):38-48.

(17) Simons-M orton DG , M ullen PD, M ainsD A , Tabak ER, G reen LW. Characteristicsof controlled studiesof patient education and counseling

for preventive behaviors. Patient Education and Counseling 1992; 19(2):175-204.


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Section 2

Physical Inactivity

Clinical Vignette

In 1998, Group Health Cooperative was faced with becoming the highest priced Medicare+Choice

plan in Washington state. Recognizing an opportunity to combine a member retention strategy

with a clinical imperative for senior health, the health plan decided to add a covered physical

activity benefit, partnering with senior centers and local health clubs. The strategy has increased

member retention and decreased utilization. Those members who took advantage of the added

benefit experienced 1.5 fewer outpatient clinic visits over one year compared with those who did

not. Furthermore, the 14 percent of members currently using the benefit have become some of

the most loyal and most vocal advocates, praising Group Health Cooperative in the community.

Finally, Group Health Cooperative has received positive publicity fromthe local press with numerous

articles featuring their exercising seniors.


M COs should:

Promote physical activity for members irrespective of age, health, or functional status. Physical

activity is particularly important for members with chronic illness at high-risk for functional

dependence and those contemplating elective surgery, such as knee replacement.

Increase awareness of the benefi ts of physical activity among older members and encourage them to

discuss physical activity with their primary care practitioner.

Provide both practitioners and members with specific tools and guidance to promote regular physical

activity.

Establish partnerships with community-based agencies to ensure that physical activity programs

are available to their members. MCOs should also participate in state- or city-wide initiatives designedto promote physical activity.


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6 Section 2 Physical Inactivity

Nature of the Problem

Lack of regular physical activity3 is a major under-recognized risk factor for chronic health problems,

loss of functional reserve, and disability. Either alone or through its contribution to prevalent and

costly chronic illnesses, physical inactivity extols significant burden in terms of morbidi ty and mortali ty

(1). Physical deconditioning, through its adverse effect on physical function, is a contributing factor

for extended hospital length-of-stay and need for subsequent post-hospital care in skilled nursing

facilities (2-5).

Regular physical activity has been shown to extend life, reduce disability, and improve quality of life

in older adults (6-10). I t reduces risk for cardiovascular disease, osteoarthritis, osteoporosis, obesity,

diabetes, and insomnia. In addition, it significantly reduces risk for three of the conditions featured in

this report; falls, depression, and incontinence (6;8;11-19). Consequently, because of the high prevalence

of these conditions, older persons potentially have the most to gain from regular physical activity

(6;7;20;21).

Thus, if there is one thing that M COs can do to improve health outcomes in older memberswhether

they are robust and healthy or frail and immobileit is to encourage a program of regular physicalactivity. The Surgeon General recommends that nearly all persons should accumulate 30 minutes or

more of moderate intensity physical activity over the course of most days (6;22). Currently, however,

older adults are the most sedentary segment of the adult population (6). Fewer than half of men 70

years of age and older engage in physical activity three or more times per week. I n women, the

proportion is even lower with fewer than one-third participating in physical activity three or more

times per week (23).

Target Population and Risk Factors

M COs should promote physical activity for members irrespective of age, health, or functional status.

Traditionally, MCOs have focused their attention on healthier members and have placed considerably

less emphasis on reducing physical inactivity among older members with multiple chronic illnesses, the

pre-frail , or the frail .

Scientific evidence strongly supports implementation of programs that promote physical conditioning

for all members throughout the spectrum from healthy to frail (6-8;24-26). For example, recent studies

have demonstrated the value of strength training in frail 80- and 90-year-old nursing home residents

(20). Regular physical activity in older adults with chronic il lness can potentially reverse loss of mobili ty

(6). Older members with degenerative joint disease of the knees who undergo knee replacement can

improve their post-operative recovery through participation in a structured exercise program prior to

surgery (27). The minority of community-dwelling enrollees who have particularly high health carecosts are another important group for targeted programs that promote physical conditioning.

3 The following elements are aspects of physical activity: cardio respiratory (aerobic) endurance, muscle strength and endurance, balance, and stretching.

Physical activity is regular if activities are performed most days of the week (1).


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Screening and Assessment

Physical activity levels of new members can be determined by a mailed screening questionnaire. Taken

a step further, the assessment of physical activity can be considered an additional vital sign for all older

members, performed at each visit irrespective of health or functional status (1).

Consistent with the Surgeon Generals recommendations for promoting physical activity, a commonlyused screening question asks, H ow many days in the past week have you accumulated 30 minutes or

more of moderate exercise (for example, walking, gardening, cleaning)? (6). Two more elaborate tools

have been used within M CO populations (28). PASE, or the Physical Activity Scale for the Elderly,

measures total leisure and work activity through a weighted scoring of hours per activity in the previous

7 days (29). PACE, or Physician-based Assessment and Counseling for Exercise, measures attitudes

and behaviors related to physical activity (30).

In assessing older members for participation in a physical activity program, a question that often arises

is whether a medical evaluation is needed, such as exercise treadmill testing, to assess the likelihood of

adverse cardiac events. For older members who have no active cardiopulmonary symptoms embarking

on a moderate-intensity program (as opposed to a vigorous one that causes the person to breathe hardand sweat profusely), formal testing is generally not necessary and is not supported by the current

scientific evidence (8;31-34). Furthermore, recommending additional steps such as exercise treadmill

testing could deter participation by portraying physical activity as potentially hazardous, when in fact

just the opposite message needs to be conveyed. Nevertheless, formal instruments, such as the Physical

Activity Readiness Questionnaire (PAR-Q) have been developed to identify persons who may benefit

from exercise treadmill testing and ongoing physician monitoring (35). An evaluation by a physical or

occupational therapist prior to initiating a program of regular physical activity may be appropriate for

some older members, for example, those with impaired balance or mobility who are high-risk for falls.

InterventionsThe Surgeon Generals national goal for each person to accumulate 30 minutes or more of moderate

intensity physical activity during the course of most days can be achieved in multiple ways (6;22).4 In

this context, the emphasis is on physical activity rather than exercise per se. Physical activity is a broader

term that includes activities such as walking, climbing stairs, or regular gardening. A program may

emphasize strength, aerobic, balance, flexibility training, or it may be multifaceted. In general, however,

the recommendation is intended to convey the message that any type of physical activity is better than

none. The initial goal may be to move from no activity to minimal activity, followed by incremental

gains as tolerated.

An individual conditioning program should be tailored to the members abilities, preferences, andliving environment. An older member suffering from osteoarthritis of the knee may benefit most from

an emphasis on flexibility and strength training. In contrast, a frail older member with impaired

mobility and falls living in an assisted living environment may benefit from a balance program such as

4The activity or activities do not necessarily need to be performed continuously.


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group Tai Chi. This activity has been shown to reduce the risk of multiple falls, fear of falling, and

improve ability to perform activities of daily living (14;36). Informal walking programs offered at local

shopping malls are a good way to promote physical activity in environments where the weather may

not always be conducive.

Tailoring of a program of physical activity also entails deciding whether the physical activity is performed

individually or within a group, and whether it is based at home or in a community setting (32).

Participation in a structured group exercise program (e.g., at a healthcare facility or in a community

senior center) versus a home-based program is a matter of personal preference. Comparable results can

be achieved in either (12;37;38). The group setting, however, affords additional benefits by creating an

environment for peer support, self-efficacy, and increased socialization that can counteract the negative

effects of social isolation and associated depression (29;39;40). Also, members who exercise in a group

setting may feel a greater sense of personal safety that might reduce an additional barrier, namely fear

of injury. For members who prefer the convenience or privacy of a home-based program, protocols

have been developed that use resistance bands, light weights, stationary bicycles, or common household

objects such as a chair or a towel (37;41). The National Institute on Aging, among others, has produced

a low-cost ($7.00) self-guided home video that begins with 6 minutes of safety tips followed by 40minutes of balance, strength, and stretching exercises.5

M ult iple studies have shown that PCPs are an important source of moti vation for members

contemplating the initiation of a physical activity (42;43).6 Every clinical encounter represents an

opportunity to reinforce the benefits of regular physical activity. Thus, MCOs should provide both

PCPs and members with specif ic tools and guidance to promote regular physical activity. MCOs can

offer PCPs continuing medical education classes on physical activity counseling and prescription wri ting.

M COs can also establish partnerships with community programs to facilitate PCP referral of interested

members.7 For example, Oxford Health Plan gives physicians prescription pads that list Oxford-

sponsored community walking clubs and the name and phone number of the leader. M embers are also

encouraged to lead walking programs on their own by acting as a coach for peers in their neighborhood.

Similarly, M COs can encourage members to discuss physical activit y with their PCPs, provide

members with information about specific types of physical activity programs and their respective

benefits (e.g., strength, balance, aerobic), and direct them to available community resources (e.g.,

senior centers) where they can pursue such programs. For example, PacifiCare provides members with

information regarding the benefits of physical activity and an up-to-date listing of available

community physical activity programs on their web site.

Older members at Group H ealth Cooperative are asked yearly about their physical activity as one

component of the Lifetime Health Monitoring questionnaire.8 The underlying premise is that everyone

can benefit from regular physical activity, particularly persons with chronic illness or functional

5 The video can be obtained by calling 1-800-222-2225 or online at http://www.nih.gov/nia.

6 Although a discussion of physical activity counseling and motivation is beyond the scope of this report, the reader is referred to several excellent resources

(8;32;42-45).

7 Please see an earlier Workgroup report (46).

8 This annual questionnaire comprises an important component of a Group Health Cooperative members overall health promotion and disease prevention care plan.


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impairment. Primary care practitioners are encouraged to assess physical capacity, develop an

individualized written exercise prescription, and direct patients to either a communit y- or home-based

exercise program. One community-based program in part icular, the L ifetime Fi tness Program, began

in 1993 and is now offered in nearly 30 locations in the Seattle metropolitan area. It offers low-cost,

one-hour supervised classes that focus on strength training (with wrist and ankle weights), aerobics,

balance, and flexibility. Positive outcomes have included improved balance and flexibility as well asimproved overall functional status in members who attended at least two classes per week (12). I n

addition, Group Health Cooperative has contracted with health clubs throughout the Seattle area to

provide senior-oriented exercise classes. Out of approximately 60,000 older Group Health Cooperative

members, 9,513 have visited a network contract health club and 3,206 attend the facility at least twice

weekly. These classes are a covered benefit for Group Health Cooperative Medicare members.

Health Partners, a mixed group model and IPA M CO serving 800,000 members in M innesota,

encourages members to participate in a wide variety of programs tailored to their interest and motivation

for behavioral change. Programs include a mall walking program at the Mall of A merica (currently

5000 members are enrolled), reduced monthly fees for joining a contract local fitness club, a clinic-

based fitness program, and an innovative self-directed walking program entitled, 10,000 Steps. Nearly10,000 individuals have participated in the 10,000 Steps program. It is based on the premise that

inactive people take 2,000 to 4,000 steps per day, whereas active people take over 10,000 steps per day.

Inactive people need positive reinforcement to increase their level of activity in order to gain the same

health benefits. Participants in the program are issued a pedometer (i.e., step counter) that provides

positive reinforcement, a personal action planner designed to encourage them to initiate and sustain

part icipation, a log to keep track of steps, biweekly mailed motivational cards for eight weeks followed

by bimonthly cards for six months, and an opportunity to enter drawings and win prizes (47). This

program has been implemented in various settings, including primary care clinics, disease management

programs, worksites, and in community programs as part of a state-wide initiative sponsored by the

Department of H ealth.

Implementation Barriers

There are multiple barriers to improving physical activity levels in older members. Motivation and

adherence barriers can be counteracted through PCP encouragement, transportation, and exercising

with a partner (8;32;42-45). Further, a lack of knowledge regarding nearby community physical

activity programs is common. Fear of crime can deter participation in outdoor programs such as

walking. Because of the loss of a spouse, sibling, or friend (and associated social isolation), many older

members do not have a partner to participate in a regular conditioning program. Weather that is not

conducive to physical activity (e.g., excessive cold or heat) may also preclude regular outdoor exercise.

Finally, the myth of the need to take it easy in older age is far from eradicated in the minds of manyolder members.


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At the level of the M CO, the geographic distribution of a plans membership may complicate the

offering of M CO-developed and run physical activity programs. Instead, M COs may choose to partner

with community-based organizations (e.g., senior centers, parks and recreation, YM CA/YW CA). Few

PCPs have had formal training in prescribing and monitoring a physical activity program, especially

for their older members. Many PCPs feel that they lack the time, prescribing skills, and specific tools

that they need to encourage their patients to become more active (44;45;48). The MCO can play apivotal role in sensitizing PCPs to the central importance of physical activity in older adults, thereby

reducing the possibil ity that negative attitudes do not create barriers to counseling. MCOs can also

facilitate the PCPs role in promoting regular physical activity by providing them with a listing of

available community resources, tear-off sheets on exercise tips, and a prescription pad to assist their

patients in initiating an exercise program to prompt immediate referral.

Economic Impact

Deconditioning, through its adverse effect on physical function, is often a contributing factor to

prolonged hospital length of stay or post-hospitalization admission to a skilled care facility (2-5).

Alternatively, physical conditioning is one of the most effective strategies for building physiologicreserve (i.e., pre-hab), thereby proactively reducing hospital length-of-stay or obviating the need for

post-hospital ski lled care. In a study by Buchner and colleagues, older community-dwelling adults who

were randomized to receive a strength and endurance training intervention had fewer high cost

hospitalizations (more than $5,000) and outpatient visits compared with those who were randomized

to a comparison group (21). Older women who walk more than four hours per week reduce their risk

of hospitalization due to cardiovascular conditions (49).

Health Partners has examined the economic impact of encouraging sedentary members to become

physically active one day per week. Based on conservative analyses, they estimate a 4.7 percent reduc-

tion in annual costs for each member who achieves this modest increment (50). These findings have

been instrumental in decisions to expand their efforts to promote physical activity for members caredfor in primary care, disease management, weight management programs, and in community settings

such as walking programs offered in local shopping malls.

Enrollees who are candidates for elective joint replacement illustrate the potential economic benefits of

physical activity. A physical therapist-led strengthening program focusing on the quadriceps and

hamstring muscles in the legs has been shown to delay or prevent the need for subsequent elective knee

joint replacement surgery. The cost of the program is estimated around $500 to $1,000 for the physical

therapy visits, compared to the cost of knee replacement, estimated around $30,000 (27;51). 9

Cost savings due to the positive influence of physical activity on improved management of chronic

illnesses such as hypertension, diabetes, and osteoarthritis are difficult to quantify. For example, oldermembers with adult-onset diabetes who exercise regularly may no longer require pharmacologic therapy

or may have fewer complications requiring hospitalization. Hu and colleagues demonstrated that women

with diabetes who engaged in regular physical activity had fewer cases of heart disease and stroke (52).

9 These costs do not account for the complications associated with surgery.


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Reference List

(1) Robert Wood Johnson Foundation. National Blueprint for Increasing Physical Activity Among A dultsA ge 50 and O lder. 2000. Princeton,

New Jersey.

(2) StearnsS, Bernard S, Fasick S, Schwartz R, K onrad T, et al. The economic implicationsof self-care: the effect of lifestyle, functional adaptations,

and medical self-care among a national sample of M edicare beneficiaries. A merican Journal of Public Health 2001; 90(10):1608-1612.

(3) K ane R, Finch M , Blewett L, Chen Q , Burns R, M oskowitz M . U se of post-hospital care by M edicare patients. Journal of the American

G eriatricsSociety 1996; 44(5):242-250.

(4) Inouye S, W agner D, A campora D, Horowitz R, Cooney L, et al. A predictive index for functional decline in hospitalized elderly medical

patients. Journal of G eneral Internal M edicine 1993; 8:645-652.

(5) Hoenig H, Nusbaum N, Brummel-Smith K. G eriatric rehabilitation: state of the art Journal of the American Geriatrics Society 1997;

45(11):1371-1381.

(6) U. S. Department of Health and Human Services CDC . Physical activity and health: a report of the Surgeon General. Executive summary.

9-14. 1996.

(7) Buchner D. Preserving mobility in older adults. W estern Journal of M edicine 1997; 167(4):258-264.

(8) A merican C ollege of SportsM edicine. Exercise and physical activity for older adults. M edical Science SportsExercise 1998; 30(6):992-1008.

(9) G uralnik J, LaCroix AZ, A bbott R, Berkman L, Satterfield S, et al. M aintaining mobility in late life: I demographic characteristicsand chronic

conditions. American Journal of Epidemiology 1993; 137(8): 845-857.

(10) LaCroix A , G uralnik J, Berkman L, Wallace R, Satterfield S. M aintaining mobility in late life: II smoki ng, alcohol consumption, physical activity,and body massindex. A merican Journal of Epidemiology 1993; 137(8): 858-869.

(11) Singh N, C lementsK , Fiatrone M . A randomized controlled trial of progressive resistance training in depressed elders. Journal of Gerontology

A Biological and M edical Sciences1997; 52A (1):M 27-M 35.

(12) Wallace JI, Buchner DM , G rothaus L., Leveille S, Tyll L, et al. Im plementation and effectiveness of a community-based health promotion

program for older adults. Journal of Gerontology A Biological and M edical Sciences1998; 53A(4):M 301-M 306.

(13) G ardner M , Robinson C , Campbell J. Exercise in preventing fallsand fall related injuriesin older people: a review of randomised controlled

trials. Bri tish Journal of Sports M edicine 2000; 34:7-17.

(14) Wolf SL, Barnhart HX , K utner NG , M cNeely E, Coogler C, X u T. Reducing frailty and fallsin older persons: an investigation of Tai Chi and

computerized balance training. Journal of the American GeriatricsSociety 1996; 44(5) :489-497.

(15) Burgio K, Locher J, G oode P, H ardin M , M cDowell B, et al. Behavioral vs. drug treatment for urge urinary incontinence in older women: a

randomized controlled trial. JA M A 1998; 280(23):1995-2000.

(16) Camacho T, RobertsR, LazarusN, Kaplan G , Cohen R. Physical activity and depression: evidence from the A lameda County Study. A merican

Journal of Epidemiology 1991; 134(2):220-231.

(17) Farmer M E, Locke B, M oscicki E, D annenberg A , Larson D , Radloff LS. Physical activity and depressive symptoms: the NHA NES I epidemiologic

follow-up study. A merican Journal of Epidemiology 2001; 128(6):1340-1351.

(18) Ettinger Jr W, BurnsR, M essier S, A pplegate W, Rejeski W, M organ T et al. A randomized trial comparing aerobic exercise and resistance

exercise with a health education program in older adultswith knee osteoarthrit is. The FitnessA rthrit isand SeniorsTrial (FAST) . JAM A 1997;

277(1):25-31.

(19) Coleman EA, Buchner DM , C ressM E, Chan BKS, D eLateur B. The relationship of joint symptoms with exercise performance in older adults.

Journal of the American GeriatricsSociety 1996; 44(1) :14-21.

(20) Fiatrone M , M arksE, Ryan N, M eredith C , Lipsitz L, EvansW. High-intensity strength training in nonagenarians: effectson skeletal muscle.

JAM A 1990; 263(22):3029-3034.

(21) Buchner D, C ress M , D eLateur B, Esselman P, M argherita A , Price R et al. The effect of strength and endurance training on gait, balance,

fall risk, and health services use in community-living older adults. Journal of G erontology A Biolog ical and M edical Sciences 1997;

52(4):M 218-M 224.

(22) Pate R, Pratt M , Blair S, H askell W, M acera C, Bouchard C et al. Physical activity and public health: a recommendation from the centersfordisease control and prevention and the American College of Sports M edicine. JA M A 1995; 273(5):402-406.

(23) Crespo C, Keteyian S, Heath G , SemposC . Leisure-time physical activity among U.S. adults. A rchivesof Internal M edicine 1996; 156(1):93-98.

(24) Wagner EH. Preventing decline in function: evidence from randomized trials around the world. Western Journal of M edicine 1997;

167(4):295-298.

(25) Larson E. Exercise, functional decline and frailty. Journal of the A merican GeriatricsSociety 1991; 39:635-636.


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(26) Institute of M edicine. The second fifty years: promoting health and preventing disability. Berg R, CassellsJ, editors. 1990. Washington D .C .,

National Academy Press.

(27) Deyle G, Henderson N, M atekel R, Ryder M , G arber M , A llison S. Effectivenessof manual physical therapy and exercise in osteoarthritis of

the knee. A randomized, controlled trial. Annalsof Internal M edicine 2000; 132(3):173-181.

(28) Leveille S, Wagner E, DavisC , G rothausL, Wallace J, et al. Preventing disability and managing chronic illnessin frai l older adults: a randomized

trial of a community-based partnership with primary care. Journal of the American G eriatricsSociety 1998; 46(10):1191-1198.

(29) Washburn RA Smi th KW Jette AM , Janney CA . The physical activity scale for the elderly (PA SE): development and evaluation. Journal of

C linical Epidemiology 1993; 46(2):153-162.

(30) Cardiovascular Health Branch, editor. Project PA CE. Physician M anual. A tlanta, GA : C entersfor Disease Control, 1992.

(31) G ill T, D iPietro L, K rumholz H. Role of exercise stress testing and safety monitoring for older personsstarting an exercise program. JA M A

2000; 284(3):342-349.

(32) K ing A C , Rejeski WJ, Buchner DM . Physical activity interventionstargeting older adults. A critical review and recommendations. A merican

Journal of Preventive M edicine 1998; 15(4):316-333.

(33) Buchner DM , C oleman EA. Exercise considerationsfor older adults. Physical M edicine and Rehabilitation Clinicsof N orth A merica 1994; 5(2) .

(34) National Institute on Aging. Exercise: a guide from the National Institute on Aging. N IH 99-4258. 1999.

(35) Thomas S, Reading J, Shepherd RJ. Revision of the Physical Activity ReadinessQ uestionnaire (PAR-Q ). Canadian Journal of SportsScience

1992; 17(4):338-345.

(36) K utner N, Barnhart H, Wolf S, M cNeely E, Xu T. Self-report benefits of Tai C hi practice by older adults. Journal of Gerontology 1997;

52(5):P242-P246.

(37) K ing A , H askell W, Taylor C, K raemer H, DeBusk R . G roup vshome-based exercise training in healthy older men and women: a community-

based clinical trial. JAM A 1991; 266(11):1535-1542.

(38) Wagner EH, LaCroix A , G rothausL, Leveille SG , Hecht JA , et al. Preventing disability and fallsin older adults: a population-based randomized

trial. A merican Journal of Public Health 1994; 84(11):1800-1806.

(39) Lorig K , Sobel DS, Stewart A , Brown B, Bandura A , et al. Evidence suggesting that a chronic disease self-management program can improve

health status while reducing hospitalization. M edical Care 1999; 37(1) :5-14.

(40) Beck A , Scott J, W illiams P, Robertson B, Jackson D, et al. A randomized trial of group outpatient visits for chronically ill older HM O

members: the cooperative health care clinic. Journal of the American G eriatricsSociety 1997; 45(5):543-549.

(41) Jette A, Harris B, Sleeper L, Lachman M , Heislein D, et al. A home-based exercise program for nondisabled older adults. Journal of the

A merican GeriatricsSociety 1996; 44:644-649.

(42) A ndersen R, Blair S, Cheskin L, Barlett S. Encouraging patients to become more physically active: the physiciansrole. A nnals of Internal

M edicine 1997; 127(5):395-400.

(43) Christmas C, A ndersen R. Exercise and older patients: guidelines for the clinician. Journal of the Am erican G eriatrics Society 2000;

48(3):318-324.

(44) K ohrt W, Spina R, Holloszy J, Ehsani A . Prescribing exercise intensity for older women. Journal of the American G eriatrics Society 1998;

46:129-133.

(45) Eckstrom E, Hickam D , Lessler D, Buchner D. C hanging physician practice of physical activi ty counseling. Journal of G eneral Internal

M edicine 1999; 14(6): 376-378.

(46) HM O Workgroup on Care M anagement. Establishing relationswith community resource organizations: an imperative for managed care

organizationsserving M edicare beneficiaries. 1-26. 1999. Washington D .C ., AA HP Foundation.

(47) Lindberg R. Active living: on the road with the 10,000 stepsprogram. Journal of the American Dietetic Association 2000; 100(8):878-879.

(48) Pretrella R, Wight D . A n off ice-based instrument for exercise counseling and prescription in primary care. The step test exercise prescription

(STEP). A rchivesof Family M edicine 2000; 9(4):339-344.

(49) Leveille S, LaCroix A , H echt J, G rothaus L, Wagner E. T he cost of disability in older women and opportunities for prevention. Journal of

WomensH ealth 1992; 1(1):53-61.

(50) Pronk N, G oodman M , O C onnor P, M artison B. Relationship between modifiable health risks and short-term health care charges. JAM A1999; 282(23):2235-2239.

(51) K nee pain: early intervention can boost outcomes, cut costs. Senior Care M anagement M ay, 73-77. 2000.

(52) Hu FM , Stampfer J, Solomon C, Liu S, Colditz G , et al. Physical activity and risk for cardiovascular events in diabetic women. A nnals of

Internal M edicine 2001; 134(2):96-105.


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Section 3

Falls

Clinical Vignette

Mrs. D. is a 76-year-old woman with obesity, macular degeneration, Type II diabetes, asthma,

and degenerative joint disease who has experienced two non-injurious falls over the past six

months. During a telephone call initiated by an Oxford Health Plan outreach worker, Mrs. D.

reported feeling depressed over her inability to perform basic daily activities unassisted, such as

using the shower and toilet, doing laundry, and cooking. The outreach worker enrolled Mrs. D.

into Oxfords Activity and Safety Program, and both a physical and an occupational therapist

visited her. The therapists ordered adaptive equipment that included a tub bench, grab bars,

trolley walker, and a toilet safety frame. Mrs. D. was taught how to use the adaptive equipment,

and she subsequently expressed to the therapists that she has more energy, requires less frequent

use of her inhaled asthma medications, and relies less on her husband for help with household

chores. Approximately two months after enrollment into the program, Mrs. D. proudly reported

that, for the first time in two years, she was able to serve dinner to her family without help.

Since enrollment in the Activity and Safety Program, she has remained free of falls.


M COs should:

Adopt mechanisms to identify older members who have fallen in the past year or who are at high

risk for falls and associated injuries, given that over 30 percent of community dwelling older adults

fall at least once each year.

Heighten awareness among members and providers of the significance of falls and provide

interventions tailored to their level of risk.

Ensure that interventions are available that address the following four risk areas: high-risk

medications, deconditioning, home and environmental safety, and visual impairment.

Participate in state-wide initiatives aimed at reducing fall-related injuries.


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14 Section 3 Falls


More than 30 percent of community dwelling older adults fall at least once each year, 50 percent of whom

do so repeatedly (1-3). A fall in an older member often represents a sentinel event, heralding the begin-

ning of a decline in function. Mult iple falls are a marker of physical frailty since falls and associated fear

of falling frequently lead to reduced activity, social isolation, and, consequently, impaired function (1;2;4).

This downward spiral may ultimately lead to loss of independence and nursing home placement (4).

Not all falls result in injury and not all injuries result in healthcare uti li zation. However, because of the

large number of falls, the overall impact on utilization is substantial. Approximately 30-55 percent of

falls result in minor injury and about 5 percent of falls result in a fracture (1;5;6). Approximately eight

percent of persons older than age 70 seek emergency care for a fall-related injury and 30-40 percent of

these emergency visits result in hospitalization with an average length of stay ranging from 8-15 days

(2;7-9). The Lahey Clinic in M assachusetts closely examined emergency visits in members over age

65 and found that 45 percent of emergency visits were fall-related in 1997-8. Older patients with fall-

related injuries are also more likely to require continued skilled care in a nursing facility following

hospitalization (9-12). Further, complications caused by falls are the leading cause of death from injury

in persons over age 65 (2;13). Fortunately, proven interventions designed to reduce risk factors for falls

have been shown to be effective as well as cost-effective (14).


M ost falls are attributable to multiple factors and providers should search for more than one possible

etiology. Risks for falls are commonly categorized into (1) intrinsic factors, referring to characteristics

of the individual faller, and (2) extrinsic factors, referring to the individuals environment (1;13;15).

Intrinsic factors include physical deconditioning, gait disturbance, vestibular dysfunction, visual deficits,

and certain underlying medical conditions such as Parkinsons disease, dementia, stroke, macular

degeneration, and urinary incontinence. Extrinsic factors include high-risk medications, use of alcohol,environmental hazards (e.g., throw rugs, extension cords, poor lighting, and slippery floors), and lack

of sturdy shoes with good traction (16).

The most important risk factors on which a MCO should focus are muscle weakness (five-fold risk for

falls compared with those without such weakness), balance or gait deficits (three-fold risk), and vision

deficits (two and a half-fold risk) (4). Medications are an additional risk factor to consider (17). Classes

of medications that are associated with a particularly high risk for falling include: psychotropic drugs,10

associated with a 73 percent increased risk for falls; medications that suppress abnormal heart rhythms,

associated with a 59 percent increased risk; Digoxin, associated with a 22 percent increased risk; and

diuretics, associated with an eight percent increased risk (17). Diphenhydramine (Benadryl) and other

over-the-counter medications can also contribute to falls as a result of drowsiness, confusion, orinteraction with other medications. Finally, environmental factors, including poor lighting or the absence

of assistive devices such as grab bars in the bathroom are also important risk factors (16). Each of these

individual risk factors can have either additive or synergistic effects when combined (4).

10 This category includes anti-psychotics, tricyclic antidepressants, and benzodiazepines.


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Older persons who fall repeatedly are at highest risk for future falls and are most likely to benefit from

targeted intervention (4;18;19). H igh-risk members can be identified by questionnaires administered

either by mail or in the waiting room of a PCPs office. PCPs, specialists, and emergency department staff

are additional sources for identification of high-risk members (20). The most commonly employed screening

question for falls inquires about the number of falls in a six-month time interval (21).11

Administrative data are another way to identify older members who fall. For members enrolled in its

M edicare product, I ndependence Blue Cross monitors emergency department uti li zation that does

not result in a hospitalization. A case-manager telephones members to conduct a detailed assessment

to determine the next course of action. Determining the need for referral to a falls prevention program

is a particular focus of this assessment.

Further assessment after a positive screen often necessitates a gait evaluation. Although more

sophisticated tools exist, two simple assessments are adequate for most situations (22). The first one,

the timed Up & Go, is a test of functional mobility for older members (23). The PCP, nurse, or

medical assistant can administer it when the older member is called in from the waiting room, or thereceptionist can even administer it before the encounter. During this test, the patient is observed and

timed while rising from an armchair, walking 10 feet, turning, walking back, and sitting down again.

Patients who cannot perform the test within 20 seconds should be evaluated further (i.e., by a physical

therapist) to identify specific problems with gait and balance.

The second tool, functional reach, is a measure of balance that can identify persons who are likely to fall

(24). Functional reach, the maximal distance one can reach forward from a standing position without

stepping, is measured using a leveled yardstick secured to the wall at shoulder height. Patients who

cannot reach more than 10 inches are at increased risk of falling (25).

Other critical components of the assessment besides the gait evaluation include measuring the membersblood pressure and heart rate as they change positions from lying to sitting to standing and conducting

a comprehensive medication evaluation. The medication evaluation can be performed by the PCP or

by a clinical pharmacist. Part icular attention should be paid to medications associated with confusion

(e.g., benzodiazepines, Benadryl or diphenhydramine), those that inadvertently lower blood pressure

upon standing (e.g., antihypertensives, diureti cs, tri cyclic antidepressants such as Doxepin, and

Amitriptyline), and medications that suppress abnormal heart rhythms (e.g., Digoxin) (17). An evaluation

of alcohol consumption is an important component of the medication evaluation.

Environmental assessments focus on home safety. They are most commonly conducted by a nurse or

occupational therapist employed by a home care agency and are designed to reduce hazards and make

the home more suited to members functional level.

11 Longer time intervals are associated with reduced reporting accuracy.


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16 Section 3 Falls

Interventions

The falls intervention literature strongly supports the initiation of a multi-factorial falls reduction

program, particularly one that targets multiple risk factors in individuals who have experienced repeated

falls (19;26;27). Elements of a multi-factorial falls program may address strength and balance, home

safety modification, instruction in the use of a cane or walker, and high-risk medication reduction.

Although not all older members who fall have correctable contributing factors, a significant number

do. Interventions to reduce falls can be categorized into physical activity, environmental interventions,

assistive devices, and medication review.

Although physical activity programs designed to build physiologic reserve are the cornerstone of any

falls reduction program, they are most effective when they are part of a multi-component risk reduction

approach (19;28;29). Physical activity programs, particularly those emphasizing balance and lower

extremity strengthening, are associated with a 10-20 percent reduction in falls (30). These programs

may be conducted in either a group or individual format. Older adults with repeated falls may require

supervision by a physical therapist or trained exercise leader.

Environmental interventions usually entail a home safety assessment, commonly conducted by a nurse,or a physical or occupational therapist from a home care agency. The assessment focuses on reducing

hazards such as throw rugs, extension cords, poor lighting, dangerous stairwells and shoes that increase

the risk of falling. It also attempts to make the home more suited to the members functional level, such

as installation of a raised toilet seat, a shower chair, or grab bars near the toilet and tub. With a home

self-assessment guide and access to durable medical equipment, some members and their families can

improve the safety of their home without the need for a visit from a healthcare professional. In either

case, the involvement of a concerned family member or friend can help ensure that the safety recom-

mendations are followed. Through partnerships with community agencies, M COs can help members

identify low-cost installers of equipment to promote home safety (e.g., grab bars in the bathroom).

Environmental safety can also be promoted among older adults population-wide. For example, thestate of M innesota has initiated a state-wide campaign aimed at reducing fall-related injury. MCOs

can enhance their efforts through partnering with relevant state and local agencies.

Referral to physical and occupational therapy is often the most efficient way for members to obtain and

learn how to use assistive devices, such as a single-point cane, a four-point cane, or a walker. Assistive

devices can help the older member compensate for a gait or balance disturbance. M ore appropriate

footwear may also be prescribed. The member may also need training from a therapist to learn how to

get up safely once a fall has occurred.

Sierra H ealth Services in Nevada has designed and implemented an extended physical therapy benefit

to improve balance, gait and function. Services include a continuum of different levels of supervisedtherapy. Examples of services include customized individual physical therapy provided in the home,

individualized therapy offered in an outpatient facility, supervised group exercise classes, and supervised

pool exercise classes. Evaluation of members function before and after participation has revealed significant

improvements in balance, gait stability, and physical function.


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For older persons living alone who are frail or otherwise could not get back up after a fall, a home alert

lifeline necklace may be life saving. One push of the button on the necklace can summon help and

reduce some of the complications of falls. These devices are available from home health agencies for a

monthly fee. PCP encouragement can be instrumental in assuring that members obtain this device and

wear it on a regular basis.

Either the PCP or a clinical pharmacist can conduct a comprehensive medication review. To prevent

fall-related complications, the overall goal is to reduce use of high-risk medications and to reduce the

risk for osteoporosis using proven treatment such as calcium and vitamin D replacement, estrogens,

and bisphosphanates (e.g., Alendronate). Sierra Health Services, the Lahey Clinic, Group Health

Cooperative, and Kaiser Permanente, Colorado Region, have all invested in clinical pharmacists to

assist practitioners and members in their efforts to reduce high-risk medication use.

M any M COs have adopted strategies to reduce falls among their older members. I n collaboration with

researchers from Yale, Oxford Health Plan is evaluating the effectiveness of a multi-component risk

reduction demonstration program in selected boroughs of New York Ci ty. In accordance with the

protocol, screened members are identified to participate if they report having fallen over the past six

months or if they are worried about falling (i.e., fear of falling). M embers identif ied using this approach

receive an in-home comprehensive assessment from an occupational therapist and a physical therapist.

The goals for these visits are to improve gait, balance, and strength, and to teach compensatory strategies

for any functional impairment. M embers are also counseled how to access vision and podiatry services.

A registered nurse may conduct an in-home falls risk assessment if the member is 1) currently prescribed

a targeted high-risk medication; 2) has a history of falls associated with dizziness; or 3) the members

blood pressure has been observed to drop upon standing. Results from this study are expected in

December 2002.

The Lahey Clinic in Massachusetts offers high-risk members a mult idisciplinary fall r isk prevention

clinic. This clinic is staffed by a geriatrician, a physiatrist (a physician who specializes in rehabil itativemedicine), and a physical therapist. Following an evaluation by the physical therapist, the team works

with primary care practitioners to implement a falls-reduction care plan with follow-up monitoring.

Independence Blue Cross has formed a partnership with its local A rea Agency on Aging to conduct

home safety evaluations for M edicare members. For members who need home adaptation, it works

with a local agency, Children of Aging Parents. Senior Buena Care, a PACE (Program of A ll- Inclusive

Care to the Elderly) in East Los Angeles teaches members how to get up after a fall . Kaiser Permanente,

Colorado Region, has developed a falls prevention video entitled, No M ore Falls, which is available

in the public domain.

Implementation BarriersM any practitioners are not fully aware of the signif icant threat falls pose to older members or are

unfamiliar with effective interventions. Typically, the focus of the evaluation is on the effect of the fall

rather than the underlying cause. The first step to implement an effective falls intervention program is

to increase awareness for the hazards of falls amongst the wide range of practitioners that come into


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18 Section 3 Falls

contact with older members (e.g., PCPs, ambulatory care nurses, emergency physicians and nurses,

orthopedic surgeons, physiatrists, physical therapists, home care nurses, and case managers). The second

step is to encourage them to be proactive. M COs can play an important role in providing education

and simple evaluation tools (e.g., pocket cards with algorithm for diagnosis and treatment of falls).

Another barrier to implementing intervention programs for falls is that this condition currently is not

readily assessed from diagnoses that are coded in administrative data. Often it is only the manifestation

of the fall (e.g., contusion, dizziness, syncope, laceration, etc.) that is coded. The Lahey Clinic found

that the underlying fall was coded in only 47 percent of cases.

Finally, older members may be reluctant to participate in a falls intervention program. They may minimize

their problem out of fear that admitting the problem could result in loss of independence. Some older

persons also refuse a home safety evaluation for this same reason. Oxford H ealth Plan refers to i ts falls-

reduction program as an Activity and Safety Program to enhance acceptance. Further, some of the

interventions described in the previous section involve out of pocket costs (e.g., installation of grab bars

in the toilet or a home alert lifeline necklace). Transportation to physical therapy appointments or

exercise programs can represent a significant barrier to adherence and subsequent improvement. M COs

can work with members to raise awareness for the fact that falls are often preventable and that, by

seeking help, these older members stand to gain rather than lose their independence.

Economic Impact

An estimated eight percent of people over the age of 70 visit an emergency room each year as a

result of a fall, about one-third of whom will be hospitalized (4). Further studies have confirmed that,

compared with non-fallers, recurrent fallers have significantly higher rates of hospital, emergency

department, home health, and skilled nursing facility use (10;14).

The economic impact of multiple-r isk factor reduction programs has been rigorously evaluated in two

randomized trials. Rizzo and colleagues conducted a cost-effectiveness analysis of a multi-factorial

risk reduction program (14). Over the subsequent 12 months, health care costs were reduced by an

average of $2,000 per subject compared to a program cost of $925. Savings were primarily attributed to

a reduction in hospitalization. The program was found to be even more cost-effective when targeted at

older adults with at least four risk factors.12 Moreover, these savings were realized wi thin the year of

program implementation.

Salkeld and colleagues conducted a randomized trial to evaluate the effectiveness of home modif ication

for preventing falls in a population of older adults (31). The main intervention involved an in-home

assessment of potential environmental hazards followed by home modification. The authors examined

changes in resource use within and between the hospital, home, and community sectors. For subjectswho had fallen in the year prior to randomization (i.e., the high-risk group), the authors were able to

demonstrate cost savings over the subsequent 12 months of follow-up. This study strongly suggests

that in order to be cost-effective, interventions must target those older members at greatest risk.

12 Risk factors included sedative use, use of at least four prescription medications, postural hypotension, unsafe tub or toilet transfers, the presence of

environmental fall hazards, and impaired strength, balance, or gait.


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These analyses demonstrate three important lessons. First, both of these studies point to the potential

of community partnerships for delivering high quality cost-effective care, such as with senior centers,

meals on wheels, Visiting Nurses Association, physical activity programs and local Area Agencies on

Aging (32). Second, both studies demonstrated the importance of targeting resources to members with

the highest risk for adverse events. Finally, falls prevention programs can lead to favorable economic

outcomes, with gains realized within a year.

Reference List

(1) Tinetti M E, Speechley M , G inter SF. Risk factorsfor fallsamong elderly personsliving in the community. New England Journal of M edicine

1988; 319(26):1701-1707.

(2) Sattin R. Fallsamong older persons: a public health perspective. A nnual Review of Public Health 1992; 13:489-508.

(3) Rubenstein LZ, Robbin AS, Schulman BL, et al. Fallsand instability in the elderly. Journal of the American G eriatricsSociety 1988; 36(266):278.

(4) Rubenstein LZ. A pproaching fallsi n older persons. A nnalsof Long-Term Care 2000; 8(8):61-64.

(5) K ing M , T inetti M . Fallsin community-dwelling older persons. Journal of the American GeriatricsSociety 1995; 43(10):1146-1154.

(6) Nevitt M C, CummingsSR, Ki dd S, Black D . Risk factorsfor recurrent non-syncopal falls. JA M A 1989; 261:2663-2668.

(7) G risso JA , Schwartz DF, Wolfson V, et al. The impact of f alls in an inner-city elderly A frican-American population. Journal of the American

G eriatricsSociety 1992; 40:673-678.

(8) Sjogren H, Bornstig U . Injuriesamong the elderly in the home environment. Journal of Aging Health 1991; 3(107):125.

(9) A lexander BH, Rivara FP, W olf M E. The cost and frequency of hospitalization for fall-related injuriesin older adults. A merican Journal of

Public Health 1992; 82(1020):1023.

(10) K iel D, O Sullivan P, Teno J, M or V. H ealth care utilization and functional status in the aged, following a fall. M edical Care 1991;

29(3):221-228.

(11) Wolinsky FD, Johnson RJ, Fitzgerald JF. Falling, health status, and the use of health servicesby older adults: a prospective study. M edical Care

1992; 30(7):587-597.

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trial. A nnalsof Internal M edicine 1990; 113(4):308-316.

(14) Rizzo J, Baker D, M cAvay G , T inetti M . The cost-effectivenessof a multifactorial targeted prevention program for fallsamong community

elderly persons. M edical Care 1996; 34(9):954-969.

(15) Cutson T.M . Fallsin the elderly. A merican Family Physician 1994; 49(149):156.

(16) Sattin RW, Rodriguez JG , DeVito C A , W ingo PA , and the Study to Assess FallsAmong the Elderly (SAFE) Group. Home environmental

hazards and the risk of fall injury events among community-dwelling older persons. Journal of the A merican Geriatrics Society 1998;

46:669-676.

(17) Leipzig RM , C ummings RG , T inetti M E. Drugs and falls in older people: a systematic review and meta-analysis: II. cardiac and analgesic

drugs. Journal of the Am erican GeriatricsSociety 1999; 47(1) :40-50.

(18) Rizzo JA , Baker D I, M cA vay G , T inetti M E. The cost-effectivenessof a multifactorial targeted prevention program for fallsamong community

elderly persons. M edical Care 1996; 34(9):954-969.(19) G illespie LD, G illespie WJ, C umming R, Lamb SE, Rowe BH. Interventionsfor preventing fallsi n the elderly. The Cochrane Database of

Systematic Reviews 2000; 3:1-51.

(20) Baraff L, Della P, SandersW. Practice guideline for the ED management of fallsin community-dwelling elderly persons. A nnalsof Emergency

M edicine 1997; 30(4):480-492.

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older adults. Journal of the American GeriatricsSociety 1993; 41(3) :321-325.


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(22) Ti netti M E. Performance-oriented assessment of mobili ty problems in elderly patients. Journal of the American GeriatricsSociety 1986;

34(2):119-126.

(23) Podsiadlo D, Richardson S. The timed Up & G o : A test of basic functional mobility for frail elderly persons. Journal of the American

G eriatricsSociety 1991; 39:142-148.

(24) Duncan PW, Weiner DK , C handler J, Studenski S. Functional reach: a new clinical measure of balance. Journal of Gerontology 1990;

45(6):M 192-M 197.

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Williamsand Wilkins.

(28) G regg EW, Pereira M A , C aspersen CJ. Physical activity, falls, and fracturesamong older adults: a review of the epidemiologic evidence.

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Section 4

Medication-Related Complications

Clinical Vignette

Mrs. J .K. is a 70-year-old female new Lahey Clinic patient who reported a sensation of dizziness

and a history of repeated falls. She had recently fallen and had suffered a compound fracture of

her humerus. At the time of her first appointment, she was taking 14 different prescribed

medications for her multiple chronic illnesses, which included coronary artery disease, diabetes,

asthma, depression, anxiety, and a recent stroke. She was living in an assisted living environment

and used a wheeled walker due to gait instability.

Her primary care physician suspected that part of Mrs. J .K.s instability might be attributable to

adverse effects of her medications. Together they reviewed all of her medications and found that

an error had been made in the dosage of her antidepressant, resulting in her receiving several

times the recommended dose.

Mrs. J .K. improved significantly after her primary care physician adjusted her antidepressant and

reduced her total number of prescribed medications to nine. She enrolled in a physical activity

program and regained her strength. She also participated in community activities that she had

previously given up and was able to return to independent living.


M COs should:

Implement programs targeting medication-related complications for older members irrespective of

whether they offer a pharmacy benefit. Such programs should target overuse, under-use, and misuse

of medications.

Improve compatibil ity of internal and external data systems to maximize the potential use of

administrative data (diagnosis, pharmacy, and utili zation) for targeted interventions.

Employ pharmacists in a liaison role between pharmacy benefit managers, practitioners, and members.

Provide educational materials and tools to practi tioners and members designed to reduce medication-

related complications.


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22 Section 4 M edication-Related Complications


The likelihood of medication-related complication increases with the number of medications con-

sumed, both prescribed and over-the-counter. Older patients received a disproportionate number of

prescribed medications and therefore represent a part icularly high-risk group (1-3). Approximately 14

to 24 percent of community-dwelling older adults take medications believed to be inappropriate (1-5).

M edication-related complications contribute to common geriatric condit ions such as falls, depression,

cognitive impairment, and undernutri tion (1;6-8).

M edication-related complications are an important factor in hospitalization of older adults. D ifferent

studies have reported rates that range from 10 to 31 percent of all hospitalizations and up to 45 percent

of all hospital re-admissions (1;9-12). Patients who suffer adverse drug reactions in the hospital have

longer lengths of stay, with an associated additional cost of $3,224 per episode (13). Medication-

related complications are also a contributing factor in the 32,000 hip fractures reported each year (1).

Medication-related complications also contribute to higher util ization in settings other than the hospital.

In one study, 63 percent of older adults experiencing a medication-related complication resulted in a

visit to their physicians office and 10 percent resulted in a visit to the emergency department (14).Although not all of these encounters were avoidable, the fact that medication-related complications

increase utili zation is well established.

The term medication-related complications is used in this report because it incorporates the range of

potential problems older members experience, including underuse, overuse, and misuse. Specific examples

include polypharmacy; the use of high-risk medications; suboptimal dosing; or underuse of medications

for conditions such as congestive heart failure, depression, and chronic pain. The recommendations

included in this report are consistent with national efforts to reduce medication errors and improve

patient safety (15).


The risk of medication-related complications not only increases with the number of prescribed

medications, it also increases with age as a result of reduced physiologic reserve. Aging is associated

with a decline in the ability of the liver and kidneys to metabolize medications and eliminate them

from the body. In addition, age-related changes in the distribution of fat and muscle throughout the

body also contr ibute to older adults sensitivity to adverse effects of certain medications. This sensitivit y

is heightened with concurrent use of alcohol. Because of these age-related changes in physiologic

reserve and fat distribution, older adults often have a narrow therapeutic window between benefit and

harm. Virtually any medication can lead to an adverse event.

M edication-related complications increase with the number of medications taken (including bothprescribed and over-the-counter) due to problems of confusion over the regimen, non-adherence, and

harmful drug-to-drug interaction (1). I n addit ion, improper consumption of a single medication can

pose a risk (e.g., long-acting benzodiazepines) (5;16;17). In some cases, the potential risks of the

medication outweigh the potential benefits.


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Older members making transitions between sites of care (e.g., those who receive short-term care in

skilled nursing facilities after being hospitalized) are an often overlooked population at risk for

medication-related complications. Their medication regimens require close coordination between

prescribers in the hospital, skilled nursing facility, and outpatient settings to avoid inadvertent

discontinuation and duplication. Furthermore, the hospital, skilled nursing facility, and community

pharmacies may all have different formularies. These different formularies can confound attemptsmade by the older patient or the PCP to fully comprehend the regimen following discharge.

Because practitioners are prescribing medication regimens that are increasingly complex, older adults

with low literacy skills or cognitive impairment are particularly at risk for complications. Similarly,

older patients who cannot afford to purchase their medications are also at risk for medication-related

complications, particularly due to non-adherence.


The multiple approaches for characterizing high-risk older members have implications for screening

and assessment strategies. The ini tial step, choosing the target population, is determined by the focusof the program, available resources, and the nature of the subsequent intervention. Strategies can target

a wide range of potential medication-related complications or focus on those that are associated with

certain adverse events, such as falls or confusion. Alternatively, a MCO can identify a cluster of

practitioners who care for a substantial proportion of older members and screen older members within

just those practices.

Analysis of pharmacy records, part icularly claims fi les or other administrative data can serve to identify

high-risk patients. Access to such data facilitates the periodic screening of the entire population of

older members. Most MCOs have arrangements that allow access to claims files for their Pharmacy

Improving the Care of Older Adults Full Report

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