T. Franklin Williams

Falls in Older Adults: Implementing Research in Practice University of Leuven February, 2012 Mary Tinetti MD T. Franklin Williams Symposium: Valpreventie bij ouderen 1

Phases in the research First phase: Acquire the evidence Establish falling as a health condition warranting attention Determine whether and how falls can be prevented Second phase: Implement the evidence Disseminate the evidence Incorporate the evidence into practice Falls in the community: Frequency and Morbidity 30% of adults 70+ fall each year with age (50% by 80+) 10% of falls serious injury (fracture, TBI, soft tissue ) 8% persons 70+ ED after fall; ½ were admitted to hospital Symposium: Valpreventie bij ouderen 2

Morbidity and consequences Independent of demographic, medical, cognitive, and psychosocial factors, Non-injurious and injurious falls lead to: daily living, social and physical activities Risk long term NH 5 fold $24000 extra health costs Determine whether and how falls can be prevented Can persons at risk be identified (who)? Can factors leading to falls be identified (why)? Can falls be prevented (based on who and why)? Symposium: Valpreventie bij ouderen 3

Predict who falls and why: Geriatric syndrome model Falls occur when older adult with: accumulated effect of multiple impairments / conditions that compromise stability or risk of injury (Predisposing factors) exposed to precipitating factor(s) environmental or intrinsic Predisposing factors: Falls, injuries* Strength Impaired balance, gait Vision impairment Psychoactive meds * risk 2-fold Postural BP Cognitive impairment Foot problems Depression 4+ medications Symposium: Valpreventie bij ouderen 4

Risk of falls by number of predisposing risk factors 100 Percent Falling 80 60 40 20 8% 19% 32% 60% 78% 0 0 1 2 3 4+ Number of Risk Factors Yale FICSIT Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) Symposium: Valpreventie bij ouderen 5

Yale FICSIT Aim: Compare effectiveness of targeted multifactorial intervention (TI) and usual care + social visits (SV) at falls Hypothesis: Risk of falling with # risk factors risk of falling by reducing risk factors Yale FICSIT Design: cluster RCT Population: 301 community living persons 70+ with 1 fall risk factor Intervention: Standardly-tailored multifactorial, multidisciplinary intervention targeted at 6 modifiable risk factors Symposium: Valpreventie bij ouderen 6

Yale FICSIT: Targeted risk factors TI (153) SV (148) Postural hypotension 46% 39% Sedative use 19% 18% 4+ Prescriptions 42% 49% Leg strength 37% 49% Arm strength 22% 24% Balance/gait impair 62% 69% Multifactorial, targeted intervention Feasible - 85% enrolled; 80% adhered Safe - No injuries during 20,000 unsupervised exercise sessions Effective % who fell by 25% rate of falling by 31% Cost-effective 2 yr. health costs $2000 less in TI vs. SV Symposium: Valpreventie bij ouderen 7

First phase: Acquiring the evidence Falling established as a health condition warranting attention Risk of falls predictable and falls preventable In retrospect, THE EASY PART! Disconnect between evidence (>60 RCTS) and practice (ignored) Second Phase: Implementing the evidence in practice Disseminate the evidence Incorporate the evidence into practice Symposium: Valpreventie bij ouderen 8

Implement evidence in practice Scale up; diffusion, spread, translating, dissemination Emerging field of implementation science; practice change Used to be a backwater activity Recent increased credibility Connecticut Collaboration for Fall Prevention (CCFP) Funded by the Donaghue Foundation and the National Institute on Aging 18 Symposium: Valpreventie bij ouderen 9

CCFP: Aims Aim 1: To disseminate effective fall prevention practices and encourage clinicians to adopt them Aim 2: To determine effect on serious fall injury and fall-related health utilization Aim 3: To identify barriers and facilitators to adopting fall-related practices Symposium: Valpreventie bij ouderen 10

CCFP Methods: Initial tasks Increase awareness of importance of fall prevention Determine core intervention to disseminate Develop practice materials (checklists; manuals; passbooks, website) Establish referral patterns among ED, PT, homecare, 1 care Address payment for clinical services Increase clinicians and public s awareness of falling as a preventable cause of morbidity: website, bus ads, posters, brochures, media Symposium: Valpreventie bij ouderen 11

Provider/ Facility EDs Acute hospitals Recommended Practices Assess/ Refer X Gait Bal. Risk Factor Management Muscle streng Post. BP X X X Vision Med. adjust Rehab X X X X X Env Home care 1º MDs X X X X X X X X X X X X CCFP Methods to increase fallrelated practices Followed Implementation Science methods Composite of professional change strategies enhance knowledge, skills, behavior No one strategy ideal or effective multiple strategies most effective Symposium: Valpreventie bij ouderen 12

Methods to increase fall-related practices Buy in from leaders; champions; early adopters; train the trainers Working groups; local participation in planning and implementation Patient-mediated (patients request fall management) Methods to increase fall- related practices Outreach visits (academic detailing) Time consuming but necessary Symposium: Valpreventie bij ouderen 13

Health providers targeted E.D.s and hospitals: 7 Home care: 27 agencies (>200 staff) Rehab. facilities:130 offices (>300 PTs / OTs) 1 care: 212 offices (>500 doctors and nurses) Encounters with Clinicians / Facilities Clinicians/facilities Outreach visits Primary doctors 175 -- Older adults MDs - not 1º Care 26 -- Home care 116 -- Rehab (PT/OT) 194 -- Hospital discharge coordinators Emergency department 101 -- 15 -- Symposium: Valpreventie bij ouderen 14

Other Clinicians / Facilities Clinicians/facilities Pharmacists Emergency medical responders Outreach visits 102 Older adults Assisted living 136 1180 Subacute facilities 185 ~3000 Senior centers 99 4608 100 90 80 70 % offices with 1 outreach visit P e r c e n ta g e 60 50 40 30 20 Home Care Agencies (n=26) Outpatient Rehabilitation Offices Primary Care Offices (n=212) (n=133) 10 Senior Centers (n=41) 0 10/2001 10/2002 10/2003 10/2004 10/2005 10/2006 Year Symposium: Valpreventie bij ouderen 15

Aim 2 To compare serious fall injury and fallrelated utilization rates in a region in Connecticut exposed to CCFP interventions relative to a usual care region. Aim 2 Methods Design: Non randomized Sampling units local post office areas Primary outcome: ED or hospital for serious fall injury (hip fracture, other fracture, serious head injury, joint dislocation) Secondary outcome: ED or hospital for fall-related event Symposium: Valpreventie bij ouderen 16

Characteristics of regions (%) Intervention 95,433 persons 70+ Usual care 109,413 persons 70+ Female 61.3 61.4 White 91.8 92.3 Education high school 66.9 63.8 <$15,0 000 income 23.3 22.9 >$75,000 income 14.3 18.2 Persons 65+poverty status 7.6 7.2 Persons 65+ in institution 7.4 5.3 Noninstit. 65+ w. disability 24.0 24.0 Serious fall injury / fall-related utilization rates in intervention vs. usual care regions R a t e p e r 1 0 0 0 P e r s o n s 7 0 Y e a r s a n d O l d e r 36 34 32 30 28 26 Usual Care Intervention Pre-Intervention Intervention Evaluation 10/1999-9/2001 10/2001-9/2004 10/2004-9/2006 R a t e p e r 1 0 0 0 P e r s o n s 7 0 Y e a r s a n d O l d e r 90 85 80 75 70 65 60 Usual Care Intervention Pre-Intervention Intervention Evaluation 10/1999-9/2001 10/2001-9/2004 10/2004-9/2006 Symposium: Valpreventie bij ouderen 17

CCFP: What we found There were fewer srious fall injuries in intervention than control area, but Many barriers and challenges to implementing fall-related practices despite compelling evidence for clinicians for payers ( Medicare-CMS) Aim 3 To identify barriers to implementing fallrelated practices Symposium: Valpreventie bij ouderen 18

Challenges for clinicians: Knowledge Clinicians and older adults unaware of falling and fall prevention Patients aren t asking for it Clinicians do not understand other s roles and skills (e.g. MD, home care nurse, PT) Fragmentation of health care- who does what, where? Challenges for clinicians: Skills Perceived lack of expertise Multi-factorial nature of fall evaluation and management Initiating behavioral interventions Working with multiple disciplines Competing demands from coexisting conditions: how to balance/ Symposium: Valpreventie bij ouderen 19

Health care system challenges Fragmentation among multiple clinicians in multiple settings Need to coordinate and refer across settings and provider groups No coordination between health care and community facilities Disconnect between who provides the prevention services and who saves Challenges for health care payers High potential cost of services Multiple components -? sinlge vs. multiple payment to whom? Don t know what the service is; is it evidence-based?; too variable Too easy to manipulate (fraud) Symposium: Valpreventie bij ouderen 20

More successful implementation Physical therapy progressive balance) New source of clients and services Home care Assess fall risk, postural blood pressure role of medications, environmental Less successful implemntation Physicians Fall risk Pstural blood pressure Medications Emergency and hospitals Fall risk Referral for fall prevention Symposium: Valpreventie bij ouderen 21

Collaborators D. Baker M. Gottschalk M. King D. Acampora J. Agostini H. Allore L. Bianco C. Brown P. Charpentier W. Chou L. Graff G. Hawthorne-Jones R. Fortinsky L. Leo-Summers T. Murphy J. O Leary J. Preston Cheney and Co. Katzman 3000+ clinicians, providers, administrators Symposium: Valpreventie bij ouderen 22