Capstone EBP fall prevention programming

Fall Prevention > Fall Treatment
An Evidence Based Proposal to support fall prevention assessments and programming to reduce falls in
community ambulating adults 65+
Grand Canyon University HCA 699
Amanda S Diveley, MHA, PTA
May 9, 2018

• Over 80,000 elderly patients a year are hospitalized due to community falls
• In 2015 over 31 billion dollars was spent by Medicare regarding falls related injuries
• The average cost of fall related injury in the hospital is $30,000 (CDC, 2016).

THIS CAN AND SHOULD BE
PREVENTED

More needs to be
done to decrease
falls, decrease
costs, improve
quality of life and
improve function
of 65+
community
ambulating
dwelling adults

BABY BOOMER GENERATION
• By the year 2030, 79 million persons from the baby boomer
generation will have reached 65 years of age.
• This generation is predicted to have longer life spans than
previous generations.
• These groups are also less of a focus for community based
prevention and wellness initiatives (Altarum Institute, 2012).

BABY BOOMER GENERATION
• Increased generation = increased number of falls in 65+ aged
population
• Increased falls = increased costs (Altarum Institute, 2012)

Falls are a major
public
health care concern
due to:
• Treatment costs
• Impact of quality of
life
• Health outcomes
• Prevalence of
occurrences

Fall Prevention Programming Can Benefit:
• The Patient: Less Falls, Improved quality of life, Improved function

• Health Care Organization: Reduced costs related to falls and increased
revenue generated to outpatient PT centers

• Health Care Organization: Reduced costs related to falls and increased
revenue generated to outpatient PT centers
• Community: Progressions toward programming would extend outward into
surrounding communities.

PROBLEM QUESTION:
Will a fall risk prevention program
decrease fall’s in the community
dwelling adults, and is it worthwhile
to implement this program into the
hospital system?

PICOT FRAMEWORK
• Develop a program for fall prevention in
community dwelling adults 65+
Patient Population

PICOT FRAMEWORK
• Performed in PCP office by a Physical Therapist
Intervention

PICOT FRAMEWORK
• If meets criteria would be referred to outpatient PT in the network
Intervention

PICOT FRAMEWORK
• Patient would complete a fall prevention program designated by EVP
Intervention

PICOT FRAMEWORK
• Patient would complete a fall prevention program designated by EVP
• Regular follow-ups and screens with data collection
Intervention

PICOT FRAMEWORK
Comparison Intervention:
Compare data with fall related injuries requiring
hospitalizations from prior years, compare
improvements in fall assessment data over time

PICOT FRAMEWORK
Outcome of Interest:
The assumption would be the persons participating in the
program would have improved function, balance and
stability with less likelihood of falls, and injuries related to falls

PICOT FRAMEWORK
Time of Intervention to Achieve the Outcome
• The overall data and program would be piloted and
collected for one year
• Participants would be in the program anticipated: 12
weeks
• Initial assessment, follow up every 6 weeks and final
session, 6 and 12 month re-assessment post-
programming

Literature support
• The CDC estimates
one in every three
adults aged 65
years and older fall
each year and less
than half of these
adults talk to their
health care provider
concerning it.
(DPHP, 2014)

Literature support
• Most falls happen
at home and falls
are the leading
cause of injury and
death in this
population (DPHP,
2014)

Literature support
• Post fall, more than
80% cannot return
to functional
independence and
cannot return home
independently
(DPHP, 2014).

Healthy People 2020 is an agenda established by the Federal
Government to build a healthier nation.

The main objectives are to improve the quality of life of
people in the society and ability to live long, healthy lives
(CDC 2014).

Goals for Healthy People 2020:
• Decrease preventable diseases
• Decrease disability
• Decrease premature death
• Decrease injury

Goals for Healthy People 2020
• Eliminate disparities
• Achieve health equity,
• Create social and physical surroundings that encourage
good health, support quality of life, and encourage
healthy development and behaviors across all stages of
life (DPHP, 2017).

Community Falls is discussed in this
initiative and FAILING to meet objectives
• 2020 TARGET: 47
deaths
• Per 2015 data: 60.5
falls/year (DPHP, 2017)

Fall Prevention Research
• Study in Sweden to determine the relationship
between physical function and increased chance
of falling in adults 60+
• Comparison of functional outcome measures
against balance tests revealed that persons with
lower functional capacity scores, tested higher for
falls and placing them at a higher risk (Halaweh
et al, 2016).

Utilized functional and fall assessment tests:
• Timed Up and Go (TUG)
• Short Physical Performance Battery (SPPB)
• Falls Efficacy Scale- International (FES-I)
• Hand grip strength
• History of Falling Checklist (HoFC).

Utilized functional and fall assessment tests:
• Persons with lower functional capacity scores,
tested higher for falls and placing them at a
higher risk.
• This study discusses that risk factors and
prevention needs to be addressed (Halaweh et al,
2016)

Nurse/Nurse Practioner Education:
• 8 weeks of education provided by
interdisciplinary teams
• Based upon Fall Prevention Education
• Little change of fear of falling scores/fall risk
scores from education alone (Harrison, 2017)

Fall Prevention Programming Research
Oregon Fall Prevention Programs
Testing Utilized:
• Timed Up and Go (TUG)
• Functional Reach
• Sit to Stand (STS)
• 50 foot speed walk

• The Tai Ji Quan: Moving for Better Balance program
was utilized in a single group design.
• 36 senior centers in 4 counties 2012-2016
• Frequency: 48 weeks (2x/week)
• 1 hour classes

Results:
• Reduction in the number of falls in the second 6 months
compared to the first 6 months of the intervention
• Improved TUG, 50ft walk, functional reach and chair
stands over the 48-week period

Results Bottom Line:
• Increase in functional performance and decrease in fall
risk severity and the overall benefits of adopting an
evidence based fall prevention intervention, can have on
improving functional performance (Furzhog et al,
2016)and fall risk potential

Validity of TUG for Fall Screening
• A Brazilian study confirmed improved accuracy with
utilizing the TUG was an effective measuring tool for
screening the risk of falls among elderly individuals

• Random by lots without reposition sample, in relation to
gender and included 63 community dwelling older adults
• Those with higher level medical issues, functional
deficits or had a recent fall in 6 months were excused
from being a subject

TUG compared against:
• Performance of activities of daily living
• Instrumental activities of daily living a
• Questionnaire

• Subjects followed for 1 year
• Blinded evaluators and a fall log at the end of each
contact
• Receiver Operating Characteristic Curves were used to
evaluate the sensitivity and specificity of the TUG.

RESULTS:
• The best predictor for persons at a higher fall
risk was 12.47 seconds
• TUG is an accurate measure for screening for
fall risk in community dwelling older adult’s vs
those with acute hospitalized issues (Tiago,
2012).

Solution Description
• Physical Therapist housed within physicians offices

• PT’s perform fall risk screens and refer those that meet
criteria as a fall risk to outpatient clinics in the network

• PT’s perform fall risk screens and refer those that meet
criteria as a fall risk to outpatient clinics in the network
• Patient would participate in the fall prevention program
under the watchful eye of a skilled clinician

• Evidence based fall prevention program would aim to
improve strengthening, balance, endurance and gait

• Utilizing one method throughout the course of treatment
would allow care and data to be standardized

• Utilizing one method throughout the course of treatment
would allow care and data to be standardized
• Results and follow-ups would continually be tracked and
recorded

• PT’s are currently being placed in ER’s throughout the
country
• PT’s in the ER provide interventions for vertigo,
musculoskeletal/orthopedic evaluations and early PT
intervention (Plummer 2015)

• PT’s have been found to be cost effective and beneficial
in the ER setting (Plummer 2015)
• This can easily translate with benefits of PT’s in the PCP
office setting.

• Study of nurses performing random fall screens on
patients in the ER aged 65+
• This study showed a large number of community
ambulating adults that were considered fall risks
• Also showed fall risk screens as an excellent
preventative tool (Huded 2015)

• Shifting Physical Therapists to the forefront of
prevention
• Physicians and PT’s working beside each other as team
• Growing the program out into the community
Organization Culture

• Participants would improve function, balance and
stability with less likelihood of falls, and injuries related
to falls, and compare with fall related injuries requiring
hospitalizations from prior years.
Expected Outcomes

• PT screens at yearly checks, or when physician feels it is
medically necessary
• PT is able to perform selected screens and bill CPT
97750 for 15 min for Physical Performance Test or
Measurement with appropriate documentation
• The National Average reimbursement for this code is
$32.34 (Noridian, 2017)
Methods to Achieve Outcomes

• Fall Risk Management Collaboration team created
• Team would research largest clinics with 65+ patients to
house PT’s at
• Deciding upon evidence based screening tools,
questionnaires and programming to use

• Teams would also work on specific criteria for at risk
patients
• Determining training and staff placement needs
• Data collection methods and timelines

• Improvement of patient quality of care and quality of life
• PT’s in office would be 1st step in fall risk assessment
and assist physician in musculoskeletal assessments, aid
in proper placement for injuries (ie, specialist referral vs
physical therapy clinic referral vs home)
Outcome Impact

• PT’s in office would also decrease the need for increased
unnecessary testing and costs (MRI’s, CT scans)
• This would also enhance the process of care, by cutting
out unnecessary steps for most patients
• Improving access from within the network and allowing
patients quicker treatments for pain vs pain medication
alone.
Outcome Impact

• The Iowa Model of Evidence Based Practice would
guide this project
• This design was chosen due to its layout of ideas and
appropriateness for implementing a new program with
the development of a team for collaboration, in order to
implement this change (Doody, 2011).
Change Model

FORM A TEAM:
• Collaboration team created to create policy, procedures
that are directed toward the program and evidence based
• Team comprised of PT/PTA’s, physician (s), nursing and
front office coordinators
• Coordinated effort would direct and manage the flow
from all departments, as well as improve coordination as
an effort to streamline process’ across the network
(Doody, 2011).
Iowa Change Model

EVIDENCE RETRIEVAL:
• Upon the first team meeting, brainstorming would be
necessary in order to identify key terms to direct the
search for evidence regarding assessments, and specific
programming models to fit the clinics (Doody, 2011).
Iowa Change Model

GRADING THE EVIDENCE:
• The group will evaluate the evidence presented and its
strengths and weakness’
• Evidence collected and discussed would be able to
identify areas of effectiveness, feasibility and
appropriateness.
• Grading sheets would be created, agreed on and
distributed in order for the team to individually grade the
evidence presented (Doody, 2011).
Iowa Change Model

DEVELOPING AN EVP STANDARD:
• Guidelines, assessments, actions, treatment and
reassessment would be discussed among the
collaboration team and decided upon due to the evidence
collected and strength of studies presented.
• This would include but not limited to pre and post
questionnaire, screening assessment tools, method of
hand off and follow-up to PT clinics in the network,
specific programming utilized, training and resources for
staff, re-assessment timelines during and post treatment
and data collection efficiency and metrics (Doody, 2011).
Iowa Change Model

IMPLEMENTING THE EVP:
• The guidelines, policies and procedures would be
documented in writing and direct interaction between
clinical staff would be required
• Face to face meetings would be directed to direct care
providers, office coordinators for both physicians’
offices and therapy facilities, billing and leadership
• Emphasis would be placed on the strengths and benefits
directed toward improved, personalized patient care and
quality of life.
Iowa Change Model

IMPLEMENTING THE EVP:
• Wording would need to be decided upon and different
for each discipline and handled directly by the team
representative in that role. e.
• Support and value would need to be placed on the
importance of implementing this program into practice,
and the application of the research data collected during
this piloted program time period (Doody, 2011).
Iowa Change Model

EVALUATION:
• Audit, metrics and feedback timelines and criteria
determined by the collaboration team
• Re-assesment time periods determined by the
collaboration team
• Barriers addressed by the collaboration team
Iowa Change Model

BARRIERS TO ADDRESS:
• Patient hand off and compliancy with scheduling, and
completing patient care plan
• Lack of follow-up regarding re-assessments to track over
the year from initial screening, in order to track
improvements of decreased percentage of fall risk.
• Physicians not on board with fall programming or having
complete knowledge of why the program is beneficial
and when to utilize the PT
Iowa Change Model

3 Phases to Cover:
• Phase 1: Education and Training
• Phase 2: Implementation
• Phase 3: Data Collection
IMPLEMENTATION PLAN

• Tools and screening training for clinicians (PT’s/PTA’s)
• Fall prevention programming training for clinicians
(PT’s/PTA’s and tech’s)
• Front office staff/referral coordinators: trained on hand-
off procedures between physician’s office and PT
outpatient facility
Phase 1: Education and Training

• Training course fee: $200/clinician participant
• Clinicians would have 5 weeks to complete training
• Time will be offered on and off clock, to complete
training modules to become certified.
Phase 1: Education and Training

• Stay Active and Independent for Life (SAIL) would be
the chosen evidence based fall programming to initially
utilize
• Re-assessments made: every 6 weeks while participating
in the program, last day of completion, 6 and 12 month
mark
• Re-assessments can take place in PT clinic or with PT in
physicians office
Phase 2: Implementation

Stay Active and Independent for Life (SAIL)
• Evidence based program recognized by the
Administration on Aging, and studies performed to show
decreased fall risk factors in participants (York 2010).
• places an emphasis on 65+ older adults that target
strength, balance and fitness and included
accommodation to scaling exercise as needed to level of
fitness (SAIL, n.d.).

• Aims to improve strength, flexibility and balance (SAIL,
n.d.).
• Will be utilized 2-3x/week expected to run an average of
12 weeks, until goals achieved

• Piloted for one year to follow and track results and
assess patient performance
• Staff utilized for this program would be the physicians in
the office, PT placed in the office, front office staff of
physician’s office and PT clinic, PT’s/PTA’s and tech’s in
the outpatient facility.

• Anticipated timeline of program from initiation to Go
Live would be 75 days.
• This would include team formation, hiring, training and
marketing prep
• Collaboration team would continue to meet to move
toward objectives and measure performance after Go
Live
Timeline

The tests chosen which are including
questionnaires, balance, gait and strength
assessments are selected due for their reliability
to consistently and discriminately analyze fall
risk in this age group of community ambulating
adults, from many angles that include gait,
balance, strength and cognitive standpoints.
Phase 3: Data Collection

Questionnaires
• The chosen questionnaires will assess the level of
concern of falls, quality of life and general health
• Falls Efficacy Questionnaire
• World Health Organization Quality of Life Assessment

Screen Assessment
• The chosen assessments would assess static balance,
proactive balance, and strength and power (Gschwind,
2013).
• Time Up and Go (TUG), hand grip strength
measurement, biceps curl, Rhomberg Test, Chair Stand
Test, Functional Reach test and weight measurement.

Timeline of Assessment/Re-Assessment
• Patient complete all written and physical assessments at
each marker
• Timeline would consist of baseline, every 6 weeks when
involved in active programming, at final session, and at
the 6 and 12 month mark
• Any falls during this time period would be recorded

• Re-assessments can take place with PT in the clinic
during active programming
• Post assessments can take place with PT in the clinic or
in the physicians office.
• All data to be sent to PT in the physicians office
following all testing

• All data will be reviewed in person with patient,
comparing baseline measures and explaining results
• Collaborative leadership will be sent weekly metrics by
the physician office PT who will house all data
• Collaborative team will meet 1x/month to review
progress made and make any adjustments to the program
if needed.

• Staffing would be increased as there would be a PT
hired for placement into the specified number of
physicians offices
• This PT would be paid competitive market rate for an
outpatient PT within the network
• Training for staff would be $200/certification as well as
money disbursed for extra training hours
Budget Concerns

• Initial staffing would not need to be added into the clinics as
current clinicians would absorb the patient load, if census
increases past manageable load considerations would be
made for increased staffing
• Clinics that are staffed with a PTA would be recommended to
have the PTA perform most fall prevention treatment sessions
• PTA’s are a cost-effective measure to manage patient flow,
and open up PT schedules to accept more evaluations
Budget Concerns

Expense Category Budget
Advertising/Marketing Operating $2,500.00
Supplies Operating $2,500.00
Training Operating $2,400.00
Staffing Personal $255,000.00
Other Personal
Total Expenses $260,900.00 $-
Anticipated Budget Required for the
Program

• Success in implementing the fall prevention program
would be based upon results from questionnaire and
objective functional measurement data and fall related
yearly data
• If outcomes do not produce positive date correlations,
consistently over the year of the pilot, other fall
prevention programs would be considered to replace
SAIL.
Evaluation of Process

Evaluation of Process
Metrics should be created on:
• Keeping track of hand off from physicians office to
clinic are essential to track in order to avoid any fall out
and skew results
• Patients compliancy toward plan of care as this also will
be a factor in more reliable results
• Increased revenue created from the program

Implications of Success
• Demonstrate a positive shift toward prevention measures
• Expansion of access of the program, will allow
assessments to reach further into the community and
refer more patients into the outpatient clinics, generating
more revenue for the PT side and improving the quality
of life with those community ambulating adults, within
our communities.
• Improving the public health in the community by
decreasing falls and improving quality of life

Prevention>Treatment
Prevention is key here, and results have shown that costs
are decreased by prevention of falls, versus fixing the
injuries related to the falls. It’s time to change healthcare
and move the needle toward prevention vs treatment.

References
Altarum Institute. Sept 2012. Recommendations to Promote Health and Well-Being Among
Aging Populations: Prepared for Trust for America’s Health. Altatum Institute: Systems Research for Better Health.
Centers for Disease Control and Prevention. August 29, 2016. Costs of Falls Among Older
Adults. Retrieved from https://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html
Centers for Disease Control and Prevention. March 2014. Healthy People 2020. Retrieved from
https://www.cdc.gov/dhdsp/hp2020.htm
Centers for Disease Control and Prevention. 2017. 30- second chair stand. Retrieved from:
https://www.cdc.gov/steadi/pdf/STEADI-Assessment-30Sec-508.pdf
Halaweh, H., Willen, C., Syantesson, U. & Grimby-Ekman, A. (2016). Physical functioning and
fall-related efficacy among community-dwelling elderly people. European Journal of Physiotherapy, 18(1), 11-17.
Huded, J.M., Dreseden, S.M., Gravenor, S.J., Rowe, T., & Lindquist, L.A. (2015). Screening for
Fall Risks in the Emergency Department: A Novel Nursing-Driven Program. Western Journal of Emergency Medicine:
Integrating Emergency Care with Population Health, 16(7), 1043-1046.

References
National Council on Aging. (2017). Fall Prevention. Retrieved from:
https://www.ncoa.org/healthy-aging/falls-prevention/
Noridian Healthcare Solutions. Jan 2017. Medicare Coverage Articles: Therapy Evaluation and
Assessment Services. Retrieved from: https://med.noridianmedicare.com/web/jea/policies/coverage-articles/therapy-evaluations-
and-assessment-services
Office of Disease Prevention and Health Promotion. 2014. HealthyPeople. Gov: Injury and
Violence Prevention. Retrieved from: https://www.healthypeople.gov/2020/topics-objectives/topic/injury-and-violence-
prevention/objectives
Office of Disease Prevention and Health Promotion. 2017. Healthy People.Gov: Injury and
Violence Prevention Deaths from unintentional falls data search. Retrieved from: https://www.healthypeople.gov/2020/data-
search/Search-the-Data#objid=4753;
Plummer, L., Sridhar, S., Beninato, M., & Parlman, K. (2015). Physical Therapist Practice in
Emergency Observation Unit: Descriptive Study. Physical Therapy, 95(2), 249-256.
Stay Active and Independent for Life (SAIL). N.d. Wellness Place in Collaboration with
Washington State Department of Health. Retrieved from: http://www.wellnessplacewenatchee.org/sail-home
Tiago, S., A., Debora M., Natalia C., R., & Simone K., M (2012) Accuracy of Timed Up and Go
Test for screening falls among community-dwelling elderly. Brazilian Journal of Physical Therapy, (5), 381.

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