Posted By Alex Stackpole,
Thursday, September 4, 2014
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with Dorothy Baker, Ph.D., RN, Research Scientist
Director, CT Collaboration for Fall Prevention, Yale University School of Medicine
A common term in today’s healthcare landscape is population health, or "the health outcomes of a group of individuals, including the distribution of such outcomes within the group".[1] In other words, population health aims to improve the health of entire communities.
Helping older adults prevent debilitating and costly falls is one example of how broad-based health strategies can benefit entire communities. Because most falls happen when older adults are doing things they’ve done many times before, home health care providers are the first observers and responders to fall prevention. As healthcare at home expands its services from single-patient care to a population focus, falls prevention and education play strongly into the mix.
In a series of Connecticut-based studies that began in 1990, researchers at Yale were among the first to show that fall prevention efforts decrease the number of older adults who are admitted (or re-admitted) to hospitals as a result of falling, thereby reducing health care costs.
In 1996, the State of Connecticut Injury Data report revealed that Connecticut's most common and costly unintentional injuries were fall related. In response, the Connecticut Hospital Association, the Connecticut Association for Home Care, Inc. (now the Connecticut Association for Healthcare at Home), Gaylord Hospital, Qualidigm, Yale School of Medicine; and University of Connecticut School of Medicine proposed an interdisciplinary fall prevention effort to translate original work at Yale University into protocols that could be used in clinical and community settings. The Connecticut Collaboration for Fall Prevention (CCFP) was born.
Today, the Connecticut Collaboration for Fall Prevention reaches clinicians and the older adults they serve statewide. Working in hospitals, home care agencies, emergency medical service organizations, and health departments, they’re helping health care professionals identify characteristics that increase the chance of falling and how those risks can be reduced. Over the past seven years, the Collaboration has embedded fall prevention into the state’s health care system as well as into the daily practices of thousands of older Connecticut residents.
We chatted recently with Dorothy Baker, the Collaboration’s director, about why falls prevention is so important, and how home health organizations are working at the front lines of this effort.
Q: How does the Collaboration’s falls prevention program demonstrate the concept and goals of population health management?
A: We’re addressing a problem that’s huge for older people, their families and all who are paying taxes into our healthcare system, because the cost of falls is expensive for society.
Because most falls happen to people in their own homes, the home health care community has been extremely receptive to our program. And in any town, home care agencies are in the best position to identify the people who are most vulnerable for falls.
While falls happen most in the elderly, Yale researchers demonstrated that each individual’s health and lifestyle over their lifetime create conditions that increase (or prevent) the risk of falls when they get older. The incidence of falls is high for Medicare patients, but the factors that will contribute to falls can be high even when you are young.
So we work with physical and occupational therapists, home health nurses and home care aides to identify problems before falls happen with people of all ages.
Q: What are the conditions that increase the risk of falls, and how do you help your home health care partners address these?
A: You are never too young or too old to reduce your chance of falls. We have collaborated with home health care providers to convert our research tools into clinical tools that can cue the clinician to intervene, reduce risks and hence reduce the chance of the first or repeated falls.
A typical scenario in this country is being overweight. Risks for having difficulty in old age begin to accumulate early if one is too heavy and out of shape. This can lead to orthopedic and other health issues that commonly lead to using multiple medications. A sedentary lifestyle, dehydration, overuse of prescription drugs, hearing, vision or other sensory problems. These are all examples of risks that accumulate over a lifetime and are then compounded when one experiences the normal changes that come with age. Some problems could be prevented with intervention early in life. For example, think about the number of young people currently using electronic devices to project music directly at the eardrum at high decibel levels, or babies in their car seats subjected to music at excessive volume.
Q: Tell us about some of the home health care organizations you’ve worked with over the past seven years. How are they implementing falls prevention programs in their communities?
A: The Collaborative has trained over 1500 home care, hospital and outpatient clinicians including nurses, rehabilitation therapists, doctors, pharmacists, and home health aides.
We began by working with 27 home care agencies in Greater Hartford region that helped us develop our protocols for fall prevention in home care. We also engaged them in providing in-service training, and speaker scripts that they could use to discuss falls prevention strategies with community groups. We helped develop local coalitions of people who understood the specific health challenges in their communities.
VNA Community Healthcare was one of the first home health care agencies to implement our program. We worked with them to do multi-factorial falls risk assessments in the 34 towns they serve from their Guilford and Hamden offices. After working for two years with residents who volunteered to participate in falls reduction assessments, the agency found that 92 percent of those participants experienced no falls upon follow up. Building on this success, VNA Community Healthcare continues to educate health professionals and family caregivers in the regions they serve.
VNA East (now part of VNA Healthcare) approached falls risk prevention from a medication perspective. They developed a relationship with the University of Connecticut School of Pharmacy. Pharmacy students were given the opportunity to home visit with the VNA staff, and thereafter worked with UConn faculty to review patients’ medication lists to identify ways to reduce polypharmacy and therby reduce the risk of falling. VNA East nurses combined the pharmacy analysis with observations of their home care patients’ behaviors and risk factors; using this information to advocate adjustments in medications with the patients’ physicians.
The physical therapy manager at Visiting Nurse and Health Services of Connecticut in Vernon worked with us to help her agency implement our program in 2009 and continues to be a falls prevention advocate in that region. Currently VNA Northwest in Bantam/Litchfield offers various opportunities for screenings and education about reducing the risks for falls across they many communities they serve.
At Visiting Nurse and Hospice of Fairfield County, occupational therapists lead Tai Chi Moving for Better Balance classes and also integrate these movements into her therapy for homebound patients, helping them improve their balance, coordination and reduce their fall risk. Students and faculty in the Physical Therapy department at Quinnipiac University are also engaged in working with older adults and researching the effects of this specific form of Tai Chi.
Our home health care partners across the state are committed to implementing fall risk reduction programs. They gather evidence (baseline data) on the factors that contribute to falls from patients and other volunteer participants. And they measure their progress in terms of falls reduction over time. Given that falls are a leading reason for older adults to be readmitted to the hospital, these efforts are very timely and are gradually receiving more (well deserved and long overdue) recognition within the other segments of the health care system.
Q: What should people think about that can help them reduce their risk of falling?
A: We encourage people to do everything possible to gain or retain strong muscles and bones – that speaks to diet, exercise and lifestyle. When a problem develops, don’t immediately look for medications. Rather, ask yourself or your primary care provider about how your lifestyle choices may be the root cause. We need water. We need to go to the bathroom every 2-3 hours. We need exercise, healthy food and clean air. We need rest. We need to resist the advertising that encourages excesses of more sugar, salt, calories, fat, alcohol, or “junk food” and even more “stuff”, as a cluttered home increases the risk of falls.
We can also think about fall prevention seasonally. In the winter, with ice and snow, we think about concentrating to ensure we walk safely and balanced. In the summer, we emphasize hydration so the blood pressure doesn’t drop too low, but also planning regular, timed trips to the bathroom to avoid rushing—a common cause of falls. Patients who take diuretics can become dehydrated, which puts them at risk of fainting and falling, especially when it is hot. Air conditioning is dehydrating.
We always ask people: “If you fell tonight, would you know how to get up? And if you can’t get up, do you have a plan in place to get help?” We ask people, ‘What resources do you have to call others in a fall emergency?’
For us, the “low hanging fruit” is just helping older people stop and think about their fall risk (and what a fall injury could mean for their long-term health), and then actively engage with their primary care provider to explore preventive measures they can take.
1. Kindig D, Stoddart G. What is population health? American Journal of Public Health 2003 Mar;93(3):380–3. Retrieved 2008-10-12.
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