Preventing Falls With Evidence-Based Initiatives
Initiatives designed to prevent falls employ a variety of different strategies. Some, such as falls risk assessment and medication management, occur in clinical settings with the help of health care providers.
Others, such as exercise and mitigation of fall hazards in the home, occur in nonclinical settings and may involve nontraditional providers such as community health workers. Combined, these efforts can help provide a comprehensive approach to address the risk and impact of falls in older adults.
The opioid epidemic has drawn considerable interest in the development of new prescription guidelines, practices, and restrictions to ensure the appropriate use of opioid painkillers. Meanwhile, less attention has been paid to another public health challenge with a link to prescription medications: falls among older adults. While improved management of pharmaceuticals can reduce the risk of falls for older adults, neither this approach nor other evidence-based policies and practices are being fully implemented.
Each year, an estimated 29 million adults ages 65 and older fall—meaning an older adult falls every second of every day. The result, as a new study by researchers from the Centers for Disease Control and Prevention (CDC) recently published in the Journal of the American Geriatrics Society reports, is costly. Using a methodology that can be updated annually to track expenditures over time, the authors found that in 2015, the estimated medical costs attributable to older adult falls was approximately $50 billion. For nonfatal falls, Medicare paid approximately $28.9 billion, Medicaid $8.7 billion, and private and other payers another $12 billion. Overall medical spending for fatal falls was estimated to be $754 million in 2015.
Future costs associated with falls are likely to increase substantially. Part of the challenge may be a perception among policy makers and health care providers that falls are an inevitable part of aging. In fact, a number of interventions can be used to identify older adults at risk of falls, assess individual risk factors, and intervene to reduce risk. We highlight several here and then note the policy levers that can be engaged to improve uptake.
Falls Risk Assessment
There is considerable room for improvement in the current state of falls risk assessment utilization. A survey of providers found that a majority did not assess falls risk in their older patients nor did they consider falls a high priority when compared to other chronic conditions such as diabetes and cardiovascular disease. To facilitate provider understanding and prioritization of falls prevention, the CDC’s Injury Center developed the STEADI (Stop Elderly Accidents, Deaths, and Injuries) initiative.
STEADI’s tools and resources include a streamlined algorithm that helps health care providers incorporate fall risk assessment, treatment, and referral into clinical practice and facilitates patient referrals to evidence-based prevention programs (such as exercise programs, discussed below) or other medical providers as needed. Similar approaches that focused on the management of multiple risk factors have been shown to reduce the rate of falls by up to 24 percent.
Medication Management Strategies
Older patients are regularly prescribed medicines that could increase their risk of falling. Research suggests medications such as opioids and narcotics used for pain, sedatives and sleeping pills, antidepressants, anti-anxiety pills, anti-epileptic pills, anti-hypertension pills, and medicines for psychiatric illnesses are associated with an increased risk of falls and fractures. Medication review by appropriate providers should be regularly conducted to minimize the risk of falls among older adults brought about by side effects of medication.
For example, one home health agency successfully employed medication management strategies with the help of pharmacists to better manage risk of falls among its patients. Similar strategies can be employed by a range of health care providers and programs. The CDC and the American Pharmacists Association have developed a training on “The Pharmacist’s Role in Older Adult Falls Prevention.”
The United States Preventive Services Task Force is in the process of updating its recommendation in support of exercise to prevent falls in community-dwelling adults ages 65 and older who are at increased risk of falls (the update was undertaken to add additional falls-related outcomes to the analysis and to modify, and ultimately rescind, an earlier recommendation in favor of vitamin D supplementation for falls prevention).
Exercise programs designed to prevent falls by increasing strength and balance include SilverSneakers, the Otago Exercise Program, Tai Chi for Arthritis, Stepping On, and Stay Active and Independent for Life. Evidence suggests that these programs can be very successful when done in accordance with program requirements. For instance, the Otago Exercise Program has managed to reduce the rate of falls among participants by 35–40 percent. When delivered in community settings, the CDC found Otago, Stepping on, and Tai Chi to be cost-effective at reducing falls.
Mitigating Risks In Home And Other Environments
Hazards in the home and other environments in which older adults spend their time can increase the risk of falls. Identifying and addressing (literal) stumbling blocks such as uneven or slippery walking surfaces, clutter, dysfunctional interior design, and dimly lit areas is essential to ensuring a living environment that is safe and meets the specific needs of the individual.
Systematic reviews of environmental interventions to identify and modify fall hazards found environmental assessment and modification reduced both the number of older adults who fall and the total number of falls. This was particularly true of high-risk older adults—that is, older adults who had fallen in the past year, had a recent hospital admission, a chronic condition, or visual impairment—and in high-intensity interventions—that is, delivered by occupational therapists with functional assessment in the home environment.
Policies To Address Falls
Medicaid and Medicare represent the second- and third-largest providers of health insurance in the United States, surpassed only by employer-sponsored health insurance. Those older than the age of 65 rely even more heavily on public health insurance coverage, particularly Medicare; 93.6 percent of older adults have some form of government-sponsored health insurance. There are a number of existing policy levers within the Medicare and Medicaid programs that can be used to address falls prevention, but they have not all been leveraged to their full potential.
As the insurer of more than 48 million Americans ages 65 and older, the Medicare program can require, permit, and incentivize provider actions related to falls prevention. There are several existing Medicare policies that support falls prevention.
When people first become eligible for Medicare, they are entitled to a “Welcome to Medicare Preventive Visit” (or Initial Prevention Physical Exam) that must include screening for both fall risk and home safety. Subsequently, all Medicare enrollees are entitled to an “Annual Wellness Visit” that includes falls and safety screenings. Use of annual wellness visits has increased since the passage of the Affordable Care Act (ACA) but remains low. More than half of practices did not provide a single annual wellness visit in 2015, and less than a quarter provided annual wellness visits to at least a quarter of eligible beneficiaries during the same year.
Three quality measures that providers can choose in Medicare’s Merit-based Incentive Payment System (MIPS) are related to falls prevention: percentage of patients ages 65 and older with a history of falls who had a risk assessment for falls completed within 12 months, percentage of patients ages 65 and older who had a plan of care for falls documented within the past 12 months, and percentage of patients ages 65 and older who were screened for future fall risk during the measurement period. The impact of these measures in MIPS remains to be seen, but the measures’ inclusion could encourage some providers to undertake reporting and, ideally, improvement on falls prevention activities.
Provisions in the ACA, including those creating the Center for Medicare and Medicaid Innovation, provide Medicare with the flexibility to deliver servicesthat are not reimbursable under Medicare fee-for-service; these could include reimbursement for falls prevention strategies recommended by STEADI or environmental assessments and modifications to reduce fall hazards.
In addition, several Medicare Advantage (MA) plans have contracted with community-based organizations to provide falls prevention services. MA plans are private insurance companies that provide Part A and Part B services to Medicare beneficiaries at reduced cost (on average 6 percent less than services contracted directly by the federal government) and use these savings to provide supplemental benefits to attract potential beneficiaries. Many MA plans offer free fitness programs for eligible members. While supplemental benefits offered vary between MA plans, older adults who have access to programs such as SilverSneakers report better emotional and physical health and less impairment in activities of daily living than their counterparts without access to fitness programs.
Dually eligible older adults (that is, beneficiaries eligible for both Medicare and Medicaid) may also receive falls prevention services through Medicaid.
Many states have pursued Medicaid waivers that would allow Medicaid to reimburse for falls prevention services. For example, Maine’s Elderly and Adults with Disabilities Medicaid waiver allows Medicaid reimbursement for home modification and exercise programs such as Matter of Balance, a program designed to reduce the fear of falling and increase activity levels among older adults. Area Agencies on Aging, established by the Older Americans Act in 1973 to support and provide services to older adults so that they may continue to live in their homes and communities, have been able to offer more evidence-based falls prevention programs in Maine than the national average thanks, in part, to funding from Medicaid waivers.
Forty-three states and the District of Columbia have used Medicaid’s Money Follows the Person (MFP) grants to allow older adults to continue living in their homes and communities instead of nursing homes by providing reimbursement for a number of services typically reserved for long-term care facilities, including home modifications for falls prevention. For instance, Maryland’s MFP Bridge Subsidy Program provides funding for rental subsidies for individuals moving out of long-term care facilities back into their communities and includes reimbursement for accessibility modifications and assistive technology that can prevent falls. As of December 2016, MFP programs have enabled more than 75,000 people with chronic conditions and disabilities to transition from long-term care facilities back into their homes and communities.
While the policies outlined above set important groundwork, there is much that can be done to scale up falls risk assessment and prevention, and to further develop an evidence base in this area.
Fund Falls Prevention At The CDC
Policy makers should continue to give the CDC adequate resources to continue advancing effective strategies for falls prevention. Within the Center for Injury Prevention, the CDC engages in a range of surveillance, research, and implementation activities to reduce older adult falls. In addition to developing and refining STEADI resources, the CDC reviews data to identify and disseminate effective falls prevention programs, develops education resources for providers and pharmacists, develops clinical decision support tools to integrate STEADI into electronic health records systems, and supports state efforts to reduce adult falls through Core State Violence and Injury Prevention Program grants. The administration’s FY2018 budget request proposed to eliminate funding for falls prevention activities at the CDC, but in the Omnibus agreement released on March 21, Congress proposed instead to continue funding the CDC’s efforts at approximately $2 million—an important continuing investment, but one that should be increased in future years, in light of the $50 billion in annual medical costs to treat falls.
Prevention And Public Health Fund
Congress should preserve and enhance the Prevention and Public Health Fund (PPHF), which sets aside a specific amount of funding for Congress to allocate to a variety of public health and prevention initiatives in communities; in the past, falls prevention grants have been funded under the PPHF.
Continue To Develop And Articulate A Strong Evidence Base
There is a need to demonstrate to payers and other stakeholders and decision makers the value of falls risk screening and assessment and the return on investment (ROI) for screening initiatives. The CDC’s latest research is an important step; additional research should be done to better document the value and ROI associated with falls prevention, particularly with regard to non-medical costs. Johns Hopkins University is currently recruiting participants to test the effect of LIVE-LiFE, a 12-week, home-based falls prevention program with components including home assessment, environmental modification, and medication review.
Facilitate Provider Reimbursement For Falls Prevention Activities
Reimbursement for falls prevention assessment and counseling is an important component of engaging providers. The American College of Preventive Medicine and the National Council on Aging have developed a resource outlining how providers can use existing Evaluation and Management Current Procedural Terminology codes for counseling on falls risk.
As baby boomers continue to age, the costs associated with falls, both fatal and non-fatal, will likely grow, along with the corresponding mortality and loss of quality of life. Policy makers and other stakeholders should respond to this projected trend as the public health challenge it is and use policies and practices to encourage the use of interventions to improve falls prevention.
The authors were subcontractors on a falls prevention policy research project for the CDC Injury Prevention Center from July 2015 to September 2016.