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2	MN Chapter, APTA Cheryl Anderson, PT, PhD, GCS cheryldl@rea-alp.com 320-762-5066 Laura Gilchrist, PT, PhD lsgilchrist@stkate.edu 651-690-7738 Kris Gjerde, PT kgjerde@gmail.com 651-334-5622
3	Project Description Kris Gjerde, PT Project Manager
4	State of Minnesota Falls Prevention Initiative The Vision Older Minnesotans will have fewer falls and fall-related injuries, maximizing their independence and quality of life.
5	Minnesota Falls Prevention Initiative MN Board on Aging, MN Dept. Human Services CSSD grants to decrease LTC costs MN Department of Health Tier 1 Planning team: broad range of public/private partners (including MN Chapter) State, regional and local levels Implementation of coordinated evidence-based falls prevention strategies
6	Falls – The Evidence One third of adults 65 and older fall each year Falls are the leading cause of injury death among older adults 95% of hip fractures are caused by falls People 75 and older who fall are 4-5 times more likely to be admitted to LTC for one year or longer CDC (2007) Retrieved Jan. 1, 2008 from http://www.cdc.gov/ncipc/factsheets/adultfalls.htm
7	Falls in Minnesota Leading cause of hospitalized injury Leading cause of ER-treated injury Fourth highest unintentional fall death rate in the country (all ages) Fifth highest death rate from falls, age 65 & older Rate of falls is increasing at a faster rate than the rest of the country Falls in the elderly are driving rates MN Dept. of Human Services, (2006)
8	Unintentional Fall Death Rates, United States and Minnesota, 1999-2003
9	MN State Falls Prevention Initiative Objectives Increase awareness of prevalence and risk factors Increase assessment of fall risk Increase availability of evidence-based interventions Increase access to these interventions Enhance quality assurance efforts related to falls prevention Create a replicable model for falls prevention MN Dept of Human services, 2007
10	MN State Falls Prevention Initiative Key Elements Education of public & providers Exercise to increase lower-body strength and balance Conduct home assessments and modification Review medication use and modification Support self-management of risk factors and fear
11	Why MN Chapter? Membership expertise & creativity Membership provided program dissemination vehicle Funding opportunity through grant PTs with Community Partners provide positive community action team The workgroup had a good idea & plan
12	MN Chapter Acknowledges Cheryl Anderson, PT, PhD. GCS Corinne Ellingham, PT, MS Laura Gilchrist, PT, PhD Kris Gjerde, PT Judy Hawley, PT, MAPL Kiri Ness, PT, PhD, GCS Marilyn Woods, PT Sarah Noonan, PT Consultant: Blake T. Andersen, PhD HealthSciences Institute, www.healthsciences.org/
13	MN Chapter Workgroup Reviewed the falls prevention evidence Reviewed Fall Risk Factors Decreased strength and balance Medication use Vision impairment Unsafe home environment Unsafe outside environment Having fallen in past year Fear of falling
14	Guiding Evidence Falls Prevention Interventions in the Medicare Population, Rand (2003) Multifactor approaches are most effective Two most effective interventions are: lower body strengthening and medication review Strengthening was recommended or provided but was not sustainable in the nine programs reviewed Rand. Falls prevention interventions in the medicare population(2003) Retrieved Jan. 1, 2008 from http://www.rand.org/pubs/reprints/RP1230/
15	MN APTA Project Goals: Create a community-based system of fall risk assessment & prevention that is readily available Enable individuals to self assess lower body strength & fall risk Enable individuals to take action to decrease risk or maintain low risk
16	MN APTA Stand Up & Be Strong! System Change proposal submitted to MN DHS to create falls prevention community based model Funded by MN DHS CSSD grant to encourage decreased LTC usage Demonstration project created to prevent falls in older adults
17	Stand Up & Be Strong! What is it? Community Based Falls Prevention program Screening tool of lower body strength Simple promotion of physical activity Easily replicated public application Public relations/marketing tool: encourages interaction between colleagues, public, and students
18	Development Assumptions: Physical therapists will serve as trainers & consultants Focus: community dwelling older adults Adults currently perform single repetition of sit to stand Requirements of screening tool: Enables self assessment Applicable to groups or individuals Community based, not medical intervention Includes action steps that allow technique variation Simplicity
19	Initial Phase Brochure development Oct. 2005: MN APTA invited members in 10 pilot counties to participate Apr 2006: MN APTA trained 30 PTs May-Dec. 2006 PTs trained 587 community partners Jun. 2006: Community partners started screening participants
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21	Primary Fall Risk Screen Have you fallen in the past year? Are you afraid that you might fall? Do you frequently need to use your arms to rise from chairs? “YES” indicates that you may be at risk
22	Physical Prescreen Cross your arms Rise to standing Successful rise: continue with timed sit to stand Unable: Proceed to high risk category
23	Timed Sit to Stand
24	Risk Assessment
25	Action Steps High Risk: Consult your doctor or Physical Therapist for advice & instruction to improve your strength. Do the exercises only if you feel safe doing them on your own. Moderate Risk: Do the exercises. Seek assistance if you do not feel safe Low Risk: Continue your active lifestyle, add the exercises to your program Groups: Add the exercises to your program Reassess every 3 months
26	Exercises Sit to Stand Side Hip Raise
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31	Home Care Application Screening / Assessment tool PT referral indicator In-home strengthening program that does not require skilled care Enables measurement of progress
32	Benefits to Minnesota Support the health of Minnesota residents Providing common protocol and material Sharing the protocol with our communities Health Promotion for Community Partners Leverage lessons learned Provide assistance & Limited technical support to PTs and Community Partners Encourage physical therapist connections Other health professionals Community partners Payers Consumers
33	Benefits to MN Chapter Membership Support, protocol, and materials available to members Method to foster connections between physical therapists and their community Establish physical therapists as a key community resource for falls prevention Effective community marketing tool for PT practice Service to Members / increased engagement Health Plan relationships
34	Initial Postcard Response Total age 60 and older = 2710 Score Percent High 929 34% Moderate 776 29% Low 673 25% Unknown 332 12%
35	Postcard Demographics
36	Postcard Data Who performed the screen? 1534 Health care worker 608 Other 430 Family member 238 Tested self 250 Not indicated
37	Stand-Up and Be Strong: Initial Outcomes Laura Gilchrist PT, PhD College of St. Catherine DPT Program
38	Data Collection Follow up calls at 3, 6, 12 months Revised to 1, 3, 6 months July 2007 Retention of information Action taken after screening MD, PT visit Performed exercises Falls since screen Overall functional mobility 4 mobility questions
39	Initial Data Collection 3 month follow-up phone calls, made between November 2006 and Feb 2007 In that time: 418 participants eligible for follow-up 70 Follow-up interviews completed by student researchers Program Evaluation was approved by the IRB of the College of St. Catherine
40	Results - Demographics 418 total subjects returned postcards Age 79.27 ± 9.21 82 men (19.6%) 326 women (78.0%) 8 not indicated 96.1% rural 3.9% urban 70 subjects, follow-up phone calls at 3 mo Age 79.06 ± 11.28 17 men (24.3%) 52 women (74.3%) 1 not indicated 92.86% rural 7.14% urban
41	Fall Risk Comparison
42	Percent of Participants Reporting a Fall in last year 31.8% (133/418) Total Participants 21.4% (12/56) Interviewed
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45	Following Recommendations 41.1% Reported completing exercises within the last week Avg 2.6 ± 2.3 times per week No significant correlation between exercise adherence and fall risk category (p=0.31) Exercise encouragement was not shown to be statistically significant in regard to exercise adherence (p=0.77) 25% (8/32) individuals at High-Risk reported following up with MD or PT 5 MD à 1 referred to PT 3 PT
46	Adverse Events 1 Fall reported due to Exercises No injury needing attention from health care provider No significant change in self-reported fear from initial screening to follow-up (p=0.08)
47	Preliminary Data Suggest that screening into the moderate or high risk category increases future risk of falls Screening prompted action (exercise or referral) across risk categories No major safety concerns Data collection continued by research firm, will start analysis of large dataset soon
48	Acknowledgements: Doctor of Physical Therapy Program College of Saint Catherine Dr. John Schmitt PT, PhD Elizabeth Barrie, SPT Erin Egan, SPT Melissa Goerlitz, SPT Jennifer Mellem, SPT
49	Health Plan Connections
50	Health Plan/ Payer Interest Medicare plans and Part D sponsors have specific quality initiatives to meet every year Dually-eligible plans (Medicare and Medicaid) must provide health promotion programs that are age appropriate Private insurers are interested in member benefits and health promotion Private insurers follow Medicare’s lead Falls are receiving national interest from all levels of government, with many current initiatives
51	Health Effectiveness Data Information Set (HEDIS) HEDIS health plan measurement of provider compliance with evidence-based medicine 90% of health plans participate in HEDIS including most state Medicaid plans Setting the Quality initiatives for EBM by health plans and the providers that participate with those health plans HEDIS 2008 has 71 specific measures; 4 relate to falls in the older adult
52	HEDIS continued HEDIS 2008 measures recognize the issues of falls in older adults These measures are considered “actionable” Health plans are looking for partners to provide the action Physician practice settings will need assistance to improve HEDIS scores
53	HEDIS continued Four measures specifically address falls and falls outcomes, including: Falls Risk Management Osteoporosis Testing in Older Women Osteoporosis Management in Women who had a fracture Physical Activity in Older Adults
54	Health Plan Interest – Quality Initiatives Focus studies – minimum requirements Performance Improvement Projects (PIPs) Mandated research studies of at least 3 years New projects begin yearly for every health plan Certain projects must address older adults specifically Directed at high cost or high risk diagnoses Often based on HEDIS measure outcomes and trends
55	Health Plan Interest – Quality Initiatives Rationale for support – health plans need application of knowledge Paradigm change – health plans are charged with creating EBM change Falls prevention activities offer inexpensive health promotion Measurement: Change in E 880 codes, ED visits, V15.88 codes
56	Health Plans = Unique Opportunity for PTs Health plans present unique opportunities for PTs Consulting Population-based health promotion EBM promotion Provide potential practice venue outside of 1/1 patient care Consider the health plan needs: Employer-based/private – HEDIS is crucial; health promotion is a growing piece to push responsibility of health to the employee All Medicare/Part D plans – focus studies and PIPs; HEDIS Medicaid – HEDIS; focus studies; health promotion PPOs/HMOs – will follow Medicare’s lead
57	What’s Next? Train your community partners County Pubic Health Departments Assisted Living Facilities Home Health Agencies Senior Centers Area Agency on Aging Senior Dining / Meals On Wheels Parish Nursing Elder Networks Provide ongoing support to partners Get involved with health plans and large employer groups
58	"Questions" Questions?
59	Stand Up & Be Strong! Cheryl Anderson, PT, PhD, GCS Laura Gilchrist, PT, PhD Kris Gjerde, PT Minnesota Chapter American Physical Therapy Association www.mnapta.org 651-635-0902