January/February 2015

Healthy Steps for Older Adults: A Statewide Approach to Preventing Falls
By Steven M. Albert, PhD, and Lois Shelton, RN, MSN
Today's Geriatric Medicine
Vol. 8 No. 1 P. 24

The evidence-based, low-cost, community-based fall risk screening and education class for adults aged 60 and older has been offered through the Pennsylvania Area Agencies on Aging network of senior centers.

Falls among older adults present an increasingly serious health care and long term care problem. As the National Council on Aging notes, "falls are the leading cause of injury-related deaths of older adults, the primary reason for older adult injury emergency department visits, and the most common cause of hospital admissions for trauma."1

The Centers for Disease Control and Prevention (CDC) tracks nonfatal falls requiring hospital or emergency department (ED) treatment as well as fatal falls. Figures 1a and b are drawn from the CDC's Web-Based Injury Statistics Query and Reporting System and indicate falls' close association with age.2

Between the ages of 50 and 85 or older, nonfatal falls increase from about 2,000 to 14,000 per 100,000 people. Likewise, the risk of fatal falls increases from about 25 to 250 per 100,000 over the same age range. This level of need for medical care and risk of death dwarfs every other kind of injury, including motor vehicle crashes. Indeed, falls are the primary reason for ED treatment. But even noninjurious falls create concern; they can be disabling in that they are associated with activity restriction, isolation, deconditioning, and depression. A significant challenge for public health is to reduce fall risk in older adults without encouraging reduced physical activity, which in itself carries health risks.

CDC injury surveillance also shows that men and women differ in fall risk (Figures 1a and b). Women are at greater risk of nonfatal falls, while men's risk of fatal falls is greater. Men and women may differ in the activities that lead to falls, the types of falls they experience, or underlying medical conditions associated with falls.

Importantly, CDC data also show that the number of fall injuries is increasing. Figure 2 plots the incidence of nonfatal falls by age between 2004 and 2008 and again from 2009 to 2013. The number of fatal falls is increasing as well. Reasons for this increase are unclear but may point to a paradox in public health. That is, as medical and public health advances keep older adults healthier at later ages, they are likely to be more active and risk new kinds of injuries, such as injuries from bicycling or home repair, even at very old ages.

One injury-related fall can result in Medicare costs of $13,797 to $20,450 (in 2012 dollars)3, not to mention the disability, lack of independence, depression, and caregiver burden incurred following a fall. While many falls go unrecorded, the CDC identified 2.4 million older adults treated in EDs for fall-related injuries in 2012, of whom 722,000 needed to be hospitalized.3

Primary Prevention Needed
Given the prevalence and morbidity associated with falls, reducing falls has become a public health imperative. A solid body of research has identified risk factors for falling, including polypharmacy, sedative use, cognitive impairment, lower extremity weakness, poor reflexes, abnormalities of balance and gait, foot problems, alcohol use, and environmental hazards.4,5 Ideally, individuals who fall should receive comprehensive assessments and a multifactorial intervention, a personalized fall prevention "cocktail" to address a particular profile of risk factors.

However, this approach suffers from the horse-out-of-the-barn syndrome. These elders have already fallen. It would be more beneficial if we could identify those at high risk of falling and offer effective fall prevention strategies before a fall lands them in the ED. The challenge is to adapt clinical interventions that address fall risk factors for community-level efforts. These interventions generally involve a combination of communitywide education, reduction in environmental hazards, and training of health care personnel and have successfully reduced fall-related fractures and hospitalizations by between 6% and 33%.6,7 The CDC has compiled a compendium of successful interventions for public health practitioners and community-based organizations.8,9

An alternative approach is primary or universal prevention, in which all older adults are screened and educated regarding fall risk. Those identified as being at high risk are then referred to primary care providers and home safety resources using current aging services' infrastructure. The strategy for this study demonstrates a smaller reduction in fall risk for any individual but distribution over large numbers of people may, in fact, move the needle for a public health challenge more effectively than more intensive interventions targeted to high-risk individuals.10 Pennsylvania's Healthy Steps for Older Adults is such an intervention.

Healthy Steps for Older Adults
Healthy Steps for Older Adults is a community-based fall risk screening and education class for adults aged 50 and older. While the program has been offered through the Pennsylvania Area Agencies on Aging network of senior centers, the program is expanding to include more sites where older adults congregate, such as fire companies, libraries, fitness clubs, and high-rise senior apartments.

Healthy Steps is a two-part program, starting with a fall-risk physical assessment using the timed up and go, one-leg stand, and chair-stand tests.11 Performance is referenced to age- and gender-based norms. An individual who scores below such norms on one or more of the assessments is advised of his or her fall risk. Next, the older adult is counseled on lifestyle factors that can increase fall risk, such as the use of four or more medications, poor eyesight, obesity, or misuse of an assistive device.

Participants attend a two-hour workshop addressing proper footwear, safety at home, good nutrition for bone health, and the importance of exercise to prevent falls. Counseling also includes information on local fitness programs designed to reduce the risk of falling. With permission from the participant, a referral form is faxed or mailed to his or her physician, indicating the fall risk status and the recommended exercise programs to reduce fall risk.

The second part of the Healthy Steps program, Healthy Steps in Motion, focuses on exercise. Adults aged 60 and older at any fitness level can begin Healthy Steps in Motion, even if they use a wheelchair or walker. Over time, participants can advance to Levels II and III, which involve weights and resistance bands. Success stories from both parts of the Healthy Steps program are numerous. Older adults report eating more healthful meals, making repairs and improvements aimed at reducing in-home falls, being able to carry their own groceries, or no longer using a walker after program attendance.

Evidence Base for Healthy Steps for Older Adults
To assess the effectiveness of the Healthy Steps screening-education-referral paradigm, 1,833 older adults were recruited from senior centers across 20 Pennsylvania counties from October 2010 to December 2011 for a fall prevention trial.12,13 Participants completed monthly telephone follow-up calls to track and log falls over a 12-month period. Recruited just before or after the program, 814 participants completed Healthy Steps. Another 1,019 seniors who did not complete the program were recruited from the same senior center sites. Participation was high, with 90% of participants providing contact information and signed consent, and 83% who provided consent completed the baseline assessment. Follow-up response was also excellent, with 97% completing one or more months of follow-up and 84% completing all monthly follow-up assessments in the study period.
The walk-in nature of the program and the short time interval between program announcement and enrollment did not allow for random assignment of participants to the two study arms. However, Healthy Steps participants and the comparison group were similar on most sociodemographic indicators and did not differ in measures of fall risk at baseline.

The proportion reporting a fall over follow-up was similar in the groups (Healthy Steps: 31.2%; comparator: 32.1%), but participants in Healthy Steps were less likely to have multiple months with falls, 9.3% vs 12.9%, an important difference. Overall, elders in the Healthy Steps program had an 18% lower fall risk over follow-up. The difference became clearest in comparing fall incidence in the two groups among participants reporting fair or poor balance at baseline. Among those reporting fair or poor balance, Healthy Steps participants reported 14 months with a fall per 100 months of follow-up compared with 18 months in the comparison group.

What aspects of Healthy Steps may be responsible for this benefit? Healthy Steps offered benefit despite some gaps in delivery. As reported by participants, 84.1% of them were told by staff the results of their mobility and balance screening. Among participants who were told by staff that they were at high risk of falls (21.3%), 21.5% reported that they saw a physician to discuss their Healthy Steps assessment.

Virtually all Healthy Steps participants (92.1%) reported that they were given a home safety checklist, and 78.6% reported use of the checklist to conduct a home safety assessment. And 32% reported a change in the home environment as a result of this effort.

The education component of Healthy Steps may also be important in fall risk reduction. Participants reported increased confidence in their ability to prevent falls as a result of the program (88.3%). When asked about changes in physical activity as a result of the program, 25.5% reported an increase and only 2% reported a reduction; the remainder reported no change.

Evaluation of the companion program, Healthy Steps in Motion, is under way. We saw great interest in the program in a trial effort in a mostly frail population residing in 12 senior housing sites. While the program did not reduce falls in this sample, we did note that older adults sought out exercise even when not assigned to this study condition and that older adults unable to continue the program were at the highest risk of falls. A challenge for fall reduction in this population is frequent hospitalization over the course of follow-up.

Prospects for Widespread Use
Aging services providers have a clear incentive to adopt programs that have a strong evidence base. As of 2012, congressional appropriations to states require that funds used for "Disease Prevention and Health Promotion Services" from Title IIID of the Older Americans Act be reserved for programs that meet criteria for effectiveness. Essentially, local Area Agencies on Aging cannot expect to be reimbursed if they offer health promotion programs that have not undergone evaluation and lack an evidence base. Ideally, candidate health promotion programs would meet stringent evaluation criteria, such as assessment using an experimental or quasi-experimental design; implementation and translation in a variety of community sites; and mature dissemination products available to the public.

Healthy Steps meets these criteria. As described earlier, it was assessed in a large statewide quasi-experiment with a comparator group, used standardized pre- and posttests, and implemented a long-term follow-up. Participation was high, as was study retention over 12 months. The benefit of the program was clear in reduced fall incidence across the board but especially in people with fair or poor balance at baseline. Results from the evaluation have been published in a variety of competitive peer-reviewed journals. Thus, Healthy Steps is an effective evidence-based program and accordingly eligible for reimbursement for state units on aging who wish to adopt it.

Healthy Steps is also primed for widespread use because of its low cost. In 2010-2011, the Pennsylvania department reimbursed sites $70 per person for delivering the program and allocated $1.2 million to the program as a whole to reach about 4,500 older adults. With such a relatively small investment, Healthy Steps is a scalable, effective platform for mass screening, referral, and education of older adults for fall risk. It relies on existing aging services infrastructure and simple clinical assessments to identify older adults at high risk of falls and refer them to personal physicians for falls assessment and local resources for home safety. The program provides a booklet with exercises and demonstration of balance and strength exercises for falls prevention but does not involve exercise classes, though the add-on Healthy Steps in Motion develops this component of the program further.

The strong evidence base, low cost to implement, and public health priority of falls prevention make Healthy Steps ripe for export and adoption. One potential obstacle is the cost of training other state units to use the program. Another is reliance on a well-developed aging services infrastructure for rolling out the program. States or counties lacking such an infrastructure will not be able to benefit from economies of scale in training or data management. Pennsylvania has also invested in a cadre of health promotion personnel (PrimeTime Health) to work with local Area on Aging sites for training and to ensure fidelity to the program. States or counties lacking these resources may need to invest in such infrastructure to implement the program in ways likely to yield similar success.

Other evidence-based programs for fall prevention are available, such as A Matter of Balance, EnhanceFitness, and Active Choices, and many programs, such as the Chronic Disease Self-Management Program, include falls prevention components. However, Healthy Steps may be a good alternative (or supplement) because of its low cost and comprehensive format.

Physician Use of Healthy Steps Evaluation in Fall Reduction
According to the American Geriatrics Society, physicians and other health care professionals should, at a minimum, document their patients' fall risk score; educate patients or recommend a program such as Healthy Steps to educate them on methods to reduce their risk of falling; prescribe an appropriate exercise program for strength and balance; review nutritional needs and determine whether vitamin D and calcium levels are adequate to keep bones strong and reduce pathologic fractures; and lastly, prescribe a home safety assessment ideally conducted by an occupational therapist.

This fall risk assessment should be easier given changes in health care reimbursement with the 2012 Affordable Care Act. Health care providers can now be reimbursed through Medicare Part B for an initial preventive physical exam (IPPE) and annual wellness visits (AWV). The IPPE and AWV are for preventive care planning only; no EKGs or lab work should be ordered. The IPPE is performed in the first 12 months upon Medicare enrollment. The AWV can be billed once per year after the physician or health care professional reviews the current preventive plan of care and provides the patient with a revised plan for the coming year.

More specifically, it may be best to bring physicians, pharmacists, and other health care professionals into the Healthy Steps model. Older adults in Healthy Steps whose screening indicates fall risk currently receive a relatively passive referral, which is limited to their primary care physician only. The program has begun to close the loop in this area by sending the results of screening directly to physicians. At this point, it remains unclear how physicians use such information or whether older adults benefit from the more direct referral. Similar kinds of referral would likely be useful for pharmacists and allied health professionals. This is an active area for extensions of Healthy Steps.

Final Thoughts
Healthy Steps is an important illustration of the potential for the aging services network to address a public health challenge. The program shows that primary prevention of falls using existing aging services infrastructure is feasible and is associated with significant reductions in the rate of falls, especially among older adults who report fair or poor balance. This is a significant achievement and likely to be an important model for other kinds of health promotion efforts among older adults.

— Steven M. Albert, PhD, is a professor and chair of the department of behavioral and community health sciences in the Graduate School of Public Health at the University of Pittsburgh. He led the evaluation of Healthy Steps, which was funded by the Centers for Disease Control and Prevention (CDC). The findings and conclusions herein are those of the author and do not necessarily represent the official position of the CDC.

— Lois Shelton, RN, MSN, is the statewide coordinator for all health and wellness programs for older adults operating under the direction of the Pennsylvania Department of Aging's Education & Outreach Office.

References
1. Standing Together to Prevent Falls. National Council on Aging website. http://www.ncoa.org/calendar-of-events/webinars/standing-together-to-prevent.html?print=t. Updated August 28, 2012.

2. Injury prevention and control: data and statistics (WISQARS). The Centers for Disease Control and Prevention website. http://www.cdc.gov/injury/wisqars/index.html. Updated July 7, 2014. Accessed November 8, 2014.

3. Cost of falls among older adults. The Centers for Disease Control and Prevention website. http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html. Updated September 22, 2014.

4. Tinetti ME, Williams CS. The effect of falls and fall injuries on functioning in community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 1998;53(2):M112-M119.

5. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331(13):821-827.

6. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9:CD007146. doi: 10.1002/14651858.CD007146.pub3.

7. Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ. 2008;336(7636):130-133.

8. Stevens JA, Sogolo ED. Preventing Falls: What Works. A CDC Compendium of Effective Community-Based Interventions from Around the World. 2nd ed. Atlanta, GA: National Center for Injury Prevention and Control; 2010.

9. National Center for Injury Prevention and Control. Preventing Falls: How to Develop Community-Based Fall Prevention Programs for Older Adults. Atlanta, GA: Centers for Disease Control and Prevention; 2008.

10. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14(1):32-38.

11. STEADI (Stopping Elderly Accidents, Deaths and Injuries) tool kit for health care providers. The Centers for Disease Control and Prevention website. http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html. Updated February 19, 2014.

12. Albert SM, King J, Boudreau R, Prasad T, Lin CJ, Newman AB. Primary prevention of falls: effectiveness of a statewide program. Am J Public Health. 2014;104(5):e77-84.

13. Albert SM, Edelstein O, King J, et al. Assessing the quality of a non-randomized pragmatic trial for primary prevention of falls among older adults. Prev Sci. 2014;Epub ahead of print. doi:10.1007/s1121-014-0466-2.