NATIONAL INITIATIVES FOR

FALLS PREVENTION*

Marcia G. Ory, PhD, MPH Texas A&M Health Science Center

University of Sydney

Faculty of Health Sciences

July 2, 2013 *With Appreciation to Centers for Disease Prevention and Control for Grant Support

Policy and System

Change

Community Programs

Clinical Interactions

MULTI-FACTORIAL APPROACH TO FALLS PREVENTION

Special Initiative Projects (SIP) 1 & 2 Key Research Questions

• Overall Question SIP 1: State Falls Prevention Program

- If we have multi-level programs in place, can we reduce fall related injuries by 10%?

• Overall Question SIP 2: Policies, Programs, and Partnerships for Falls Prevention

- How do we facilitate the adoption of fall prevention programs and

practices by all stakeholders

SIP 1 & 2 Building on Lesson Learned

SIP 1 SIP 2 Focused on program capacity building and outcomes research for the 3 states

Focuses on understanding adoption and implementation issues as the programs and policies are broadly disseminated

Focuses broadly on a wide range of interventions (community, clinical, and policy)

Focuses more in-depth on three interventions, policy, Otago, and Community Health Worker (CHW)

Identified process and outcome measures Will be considered/utilized

Focuses on State Injury Prevention Units Stakeholders are State FP Coalitions and actual deliverers (e.g., PTs and CHWs) as well as program participants

SFPP EVALUATION FRAMEWORK EVIDENCE-BASED PROGRAMS

Stepping On Tai-Chi Otago STEADI

STEPPING ON

• Developed in Australia (Clemson and associates)—Translational dissemination unit at University of Wisconsin

• Shown to reduce falls by 31%. • Offered once a week for seven weeks using adult

education and self efficacy principles by two trained workshop facilitators, one health professional and one peer leader.

• Follow-up calls and booster session • Participants include those who are at risk of falling,

have a fear of falling, or have fallen one or more times.

TAI-CHI MOVING FOR BETTER BALANCE

• A group based exercise program focusing on 24 Tai-Chi forms for weight shifting, postural alignment, and coordinated movements.

• Shown to reduce falls by 55%. • Offered three times a week for an hour a session for

12-24 weeks • Designed and tested by Fuzhong Li • Program adapted and standardized by CDC and now disseminated through YMCAs

OTAGO

• An individually tailored exercise program delivered in the home by a trained nurse or physical therapist.

• Shown to reduce falls by 35%. • Designed by the Falls Prevention Research Group at

the University of Otago Medical School and adapted to American settings

• Consists of a series of leg-strengthening and balance-retraining exercises that become progressively more difficult as the participant gets stronger over 52 weeks.

• Program adapted and standardized by CDC www.med.unc.edu/aging/cgec/.../FINALOEPManual_v16_090911.pdf

STOPPING ELDERLY ACCIDENTS, DEATHS, & INJURIES (STEADI)

Tool kit for assisting health care providers in falls screening and referral

• Patient self assessment for falls • Evaluate gait, lower body strength, and balance • Case studies and conversational starters • Referral forms • Educational handouts for patients

• http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html#practice

Integrating Clinical Care with Community

Programs

Tai Chi Moving for Better Balance

Stepping On Fall Prevention Program

Otago Exercise Program

Changes in Clinical Care

CDC Falls Prevention Initiative Multiple Partners in Action

FETA National Advisory

Group

Program Developers

CDC

State Grantees

HAN

SFPP EVALUATION FRAMEWORK LONG-TERM OUTCOMES

System Changes

Injury Data Cost

SFPP EVALUATION FRAMEWORK INTERMEDIATE OUTCOMES

Reach & Representation

Program infrastructure

Health and health beliefs

Functional status

Long Term Outcomes

1. Does a county-wide, multi-level fall prevention (FP) intervention change county injury rates among older adults? If so, to what extent and for whom?

2. What is the cost of implementing a county-wide, multi-level intervention (STEADI, OTAGO, SO, & TCMBB*)?

3. What organization changes, systems changes, and other practice/policy changes occurred?

4. What FP infrastructure has been established and program implementation/maintenance/dissemination materials/protocols embedded into injury centers and partner organizations for continuation/sustainability of FP beyond the 5-year funding period?

Intermediate Outcomes Does a community-based fall prevention program improve self-efficacy to prevent falls among participants?

Does a community-based fall prevention program improve self-assessed general health status among participants?

Does a community-based fall prevention program decrease difficulties in carrying out activities among participants? Does it decrease the frequency of activity restrictions? If so, to what extent and for whom?

Does a community-based fall prevention program improve functional performance among participants?

Intermediate Outcomes Cont. Does providing primary care providers with a fall risk assessment, treatment and referral intervention program (STEADI) result in increased provider adoption of the intervention?

After initial training, does adoption increase over time?

Does STEADI result in increased provider referrals to community FP programs over the 5-year program?

Increased engagement of policymakers

Increased attention to FP by professional association

State Policy Toolkit for

Advancing Fall Prevention

• Built on Promoting a National Falls Prevention Action Plan: National Action Plan

• Consistent with Falls Free Logic Model

• Gives state and local coalitions strategies, tools and resources for falls prevention

Hawaii

AK

MT

ID

WA

CO

WY

NV

CA

NM AZ

MN

KS

TX

IA

WI

IL

KY

TN

IN OH

MI

AL MS

AR

LA

GA

FL

SC

WV VA

NC

PA

VT

RI

ME

NH OR

SD

ND

MO

OK

NE

NY

CT

MA

NJ

MD DE

Fall Prevention Coalition Map

Color Legend FP Coalition

Inactive FP Coalition No FP Coalition

Policy: Establish and enforce evidence-based laws, regulations and standard institutional practices that promote prevention, create healthy environments and foster healthy behaviors

Systems Change: Establish procedures and protocols within institutions and networks that promote prevention, create healthy environments and foster healthy behaviors

Environment: Create social and physical environments that promote healthy choices

Communication and Media: Raise awareness and strengthen social norms

Program and Service Delivery: Offered in a variety of clinical and community settings

Targets for Effective Change

National Prevention Council 2010

Falls Free Policy Goals Increase awareness of the issue and effective prevention strategies among stakeholder

Increase provider participation in fall prevention practices

Increase funding opportunities and investments for fall prevention

Enhance data surveillance collection, analysis and system linkages

Increase the availability and accessibility of community programs and services

Build and leverage an integrated, sustainable fall prevention network

Improve fall prevention activities in places where older adults reside

Institute ongoing evaluation of state efforts and outcomes

Policy Change to Advance Falls Prevention:

Training, Examples, and Resources

(Bonita) Lynn Beattie, National Council on Aging

Ellen Caylor Schneider, University of North Carolina at Chapel Hill

Webinar*

April 11, 2013

*http://www.ncoa.org/improve-health/center-for-healthy-aging/content-library/implementing-policy-change-to.html

Designed to give state and local coalitions the strategies, tools, and resources to make that happen. Offers a rich compendium of suggested policy changes to advance falls prevention Including opportunities, strategies, and examples of what is possible through education and engagement of key stakeholders.

www.ncoa/org/FallsPolicy

State Policy Toolkit for Advancing Fall Prevention

State Policy Toolkit for Advancing Fall Prevention

• Toolkit

– 8 Overarching Goals, each featuring:

• Policy changes

• Strategies

• Select Examples

• Suggested Indicators

• Select Resources

Goal: Increase awareness of the issue and effective prevention strategies among stakeholders

Policy change: Create a statewide awareness campaign

Strategy: Leverage NCOA Falls Prevention Awareness: Findings and Lessons Learned From State Coalitions on Fall Prevention and other readily available documents

Strategy: Obtain Governor’s and local leader proclamations

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Goal: Increase provider participation in fall prevention practices

Policy change: State and local health departments collaborate with clinical delivery systems to promote FP referrals and services.

Strategy: Older adults who present to the emergency room for fall-related injuries but are not admitted will be scheduled for a home visit

Example: MaineHealth

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Goal: Increase funding opportunities and investments for fall prevention

Policy change: All State Departments’ budget requests for aging services will incorporate FP activities.

Strategy: SUA will require AAA budgets to include FP programs and activities.

Strategy: DPH will require local PH budgets to include FP programs and activities.

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Goal: Enhance data surveillance collection, analysis and system linkages

Policy Change: Create an easy to read, annual falls report for the legislature. Strategy: Assess available data sets and develop a template for an annual report.

Example: Florida Department of Public Health falls data: Florida Injury Facts: Unintentional Falls: Seniors

Goal: Increase the availability and accessibility of community programs and services

Strategy: Recognize the contributions of a healthy life style as promoted through other evidence-based programs and promote fall prevention by offering a menu of programs and services

Goal: Build and leverage an integrated, sustainable fall prevention network

Policy Change: The State Coalition leadership will set a priority to build and sustain a statewide fall prevention network. Strategy: The State Coalition seeks out opportunities to partner with other coalitions and organizations. Strategy: The State Coalition develops a targeted partnership and stakeholder engagement working group. Strategy: The State Coalition encourages the development of local and regional coalitions.

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Goal: Improve fall prevention activities in places where older adults reside

Policy Change: Fall prevention is viewed as a priority across the continuum of care and in all transition activities.

Strategy: Partner with the state affiliate of the National Association of Professional Geriatric Care Managers, the state hospital association, the state nursing home association and other long term care associations

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Goal: Institute ongoing evaluation of state efforts and outcomes

Policy Change: Department of Public Health/Injury Prevention Section develops, implements and monitors an evaluation of the overall efforts as an expanded function of its epidemiological activities.

Strategy: Collaborate with the State Coalition’s Evaluation Initiative to measure impact; look to the Evaluation Guidelines for additional information. www.ncoa.org/fallsevaluation

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Resources—Fact Sheets

• Medicare and Reimbursement for Falls-Related Services

• Community Fall Prevention is a Good Investment

• Inviting Physical Therapists to Join Us in Preventing Older Adult Falls

• Inviting Occupational Therapists to Join Us in Preventing Older Adult Falls

OTAGO EXERCISE PROGRAM SIP 1 UPDATE

TIFFANY SHUBERT

OTAGO TRAINING 2013

• Otago Online Training Course: Launched April 1, 2013

Purpose: Online course designed to train

physical therapists to integrate the Otago Exercise Program as part of their practice

http://www.aheconnect.com/newahec/cdetail.asp?courseid=cgec3

OTAGO ONLINE TRAINING

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NEW DATA INITIATIVES

• Otago Outcomes Database

• Purpose: An online database created to help facilitate

tracking of patients through the Otago Exercise Program

Outcome measures collected will provide information on the implementation process and fall-risk reduction outcomes for the Otago Exercise Program

Outcomes collected meet FETA goals

• https://apps.hpdp.unc.edu/pppfp/

NEW DATA INITIATIVES

• Training Physical Therapists in Evidence-Based Outcome Measures

Archived Implementation Webinar available*

Purpose: Demonstrate how to access and use the Otago Outcomes Database, as well as how to collect and record the necessary outcome measures from Otago Exercise Program patients

• Request information on Implementation Webinar by e-mailing otago@unc.edu

OTAGO PROCESS CHECKLIST FOR PHYSICAL THERAPISTS

Complete Otago Online Training*

View archived Implementation Webinar

Request Otago Outcomes Database Access* • Contact Otago Outcomes Database Team (otago@unc.edu) • Provide Name, E-mail Address, Agency Name and Location

Log-In/Set-Up Otago Outcomes Database Account*

• Username and password provided via e-mail

Enroll Otago Exercise Program patient in database* *indicates required step

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SFPP: Next Steps

• Moving from alpha to full implementation in the three state injury programs

• Lessons learned

– Takes longer to build infrastructure

– Evidence-based programs maintain positive effects

– Mixed feedback on value of data collection efforts

– Streamline data collection expectations for community partners

PPPFP: Next Steps

• Providing continual TA/feedback to state coalitions

– Most state coalitions working on multiple Fall Prevention goals and strategies

• In the field with Otago training and implementation

– Online training very helpful as is online database

– Definition of eligible patients

– Need for stable funding reimbursement stream

• CHW curriculum drafted

– More interest than originally anticipated

Questions

1. Question relating to payment of funding for the programs

Questions

2. Question relating to program providers

Questions

3. Question relating to Use of Technology

Questions

4. Question relating to cognitive impairment and participation in programs

Questions

5. Question relating to skills development for providers to deliver programs