A Focus on Falls: Anatomy of a Hospital Push to Improve Population Health | Healthcare of Tomorrow

Fred Neebe of Vestal, New York, recalls going to his doctor in 2012 for a checkup and getting an unusual order. “It was a prescription to take a Tai Chi class,” says the 87-year-old retired electrical engineer. The free, 12-week class offered by a local YMCA “still sticks with me,” says Neebe, adding that “Tai Chi made me a lot more aware of my walking characteristics.”

His doctor knew Neebe, an avid skier and hiker, previously fell and fractured his ankle. That put him at risk for another fall. That fall “was frustrating and slowed me down,” Neebe says. But he was lucky, confined to a boot for a few weeks. “It could have been a lot worse,” he admits.

Falling is a huge problem for adults 65 and older: “Every 13 seconds, an older adult is treated in an emergency department for a fall,” says Dr. Debra Houry, director of the Center for Disease Control and Prevention’s National Center for Injury Prevention and Control. “Every 20 minutes an older adult dies from a fall.”

Neebe’s internist, Frank Floyd, M.D., medical director at United Health Services’ Endwell primary care clinic, knows all too well the bad outcomes for patients. Years ago, Floyd’s grandmother fractured her hip, and “she never recovered from her injury from that fall,” he says. Today, Floyd is vigilant in screening his older patients for falls risk.

Floyd’s employer, the Binghamton, New York-based, 916-bed hospital and health care system UHS, is tackling an issue that has been akin to a hidden epidemic and one rarely touched by hospitals or health systems. Each year, one third of seniors fall, and falls are the leading cause of unintentional injury deaths among older adults.

And in Broome County, where Binghamton is located, the prevalence of falls was off the charts – about the highest in the state – before the nonprofit UHS put in place an evidence-based strategy in 2012 to address them. “Falls was top of the list” of problems in the county, notes Claudia Edwards, director of the Broome County Health Department.

Working with the local health department and others in the community, UHS has played a key role in significantly reducing the falls rate in Broome County by 25 percent between 2010 and 2013. Since September 2012, UHS has screened nearly 17,500 older patients for falls, along with educating and referring or providing interventions to reduce patients’ risk of falling. UHS saw hospitalizations and ER visits for fall-related fractures decline 12 percent across Broome County in 18 months following implementation. As a result of UHS’ success, the CDC is expanding the program nationwide.

“Screening for the risk of the problem is such a crucial aspect of the whole process,” notes Edwards, adding that “it’s not an easy process to pull this off.”

But UHS has been able to pull it off. Falls are not an issue many hospitals and health care systems address. It’s challenging, and under the traditional payment system there was no incentive to focus on fall prevention. Fixing people who had fallen is lucrative under fee-for-service medicine.

“The U.S. spends $34 billion a year on direct medical costs alone,” Houry notes. “Falls also result in significant medical costs and are among the 20 most costly medical conditions.” Consider that in 2012, the average cost for a hospitalization for a fall in Broome County ran $23,136; the typical ED visit for a fall cost nearly $3,000.

With the advent of Obamacare, the calculus on medical care has changed. The Affordable Care Act put a premium on prevention and lit a match to the traditional fee-for-service system. Instead, health insurers, including Medicare and Medicaid, increasingly are putting hospitals at financial risk or creating incentives for institutions to keep people out of the hospital and avoid readmission. For example, Excellus BlueCross BlueShield has introduced a pay-for-performance incentive if 75 percent or more of UHS patients who need screening get it.

Instructor Gail Goldberg and class participants
practice Tai Chi for Older Adults to help prevent falls.
Mary McFadden/Broome County Health Department

The result: lots of health care delivery innovation is occurring. One hallmark: health systems and public health departments increasingly are partnering. That’s on display in Broome County. “All health care providers realize we’re very costly and our efficacy is mediocre at best,” Edwards notes. “We have to step back. We’ve learned enough about prevention.”

“In many instances health departments and medical providers are in different orbits,” Floyd says. “The Affordable Care Act has increased UHS’ awareness of the need for population health and for increasing staffing and infrastructure to better care for patients with chronic illnesses and that are at risk.”

Seeing that the falls rate was extremely high in Broome County – resulting in about a 25 percent higher death rate than the New York State average, for example – the CDC in 2010 approached Edwards about implementing proven community-based programs, like Tai Chi classes and Stepping On, an exercise and falls-education program designed for older adults. Classes were introduced in the county but Edwards knew that to make a dent, the area’s largest health system needed to be on board.

In 2012, CDC looked to Broome County to help pilot a promising intervention, called STEADI, or Stopping Elderly Accidents, Deaths and Injuries. STEADI uses scientifically tested clinical interventions to help health care providers address their patients’ fall risk, identify modifiable risk factors and provide effective interventions.

Edwards approached UHS’ Chief Medical Officer Rajesh Davé to get UHS to implement the provider-focused, evidence-based program to prevent falls. “I told him, ‘We need a champion,'” Edwards recalls. “He gave us Dr. Floyd.”

Floyd knew UHS needed to be active on falls prevention. “The fastest-growing portion of the county’s population is 85 and older,” he notes. But looking at the intervention, he determined, “This is not going to work in the real world.” The biggest hurdle: adding yet another screening to a large list of screenings – alongside pain, tobacco and alcohol use, depression and others – that primary care doctors already were shoehorning into the office visit.

He met with nursing administration and the information technology department and pulled out the essence of the algorithm, and the team fit it into clinicians’ workflow. UHS had fully implemented an electronic health record system, and the most five important questions in the algorithm were teased out and put into the EHR as prompts for clinicians. If a patient responded “yes” to any questions, a trigger would pop up.

“The CDC provided us with the material and allowed us to build a system that would work,” says Floyd, who tested the falls risk assessment in the Endwell clinic. The team’s work enabled clinicians to incorporate the falls initiative into their work and provide patients flagged or a risk for falling with an array of interventions. This includes referring patients to evidence-based community programs like Tai Chi, prescribing Vitamin D or a cane or other walking device, reviewing medications for falls risk or providing referrals to physical therapy or to UHS’ own balance program, which sends clinicians to patients’ homes to help them with balance and conducting in-home assessments to reduce the risk of falls at home.

The program has been rolled out to 18 UHS sites, and through mid-September, 41,300 screenings have been conducted on 17,459 Broome County patients. The system also achieved the pay-for-performance mark set by Excellus of 75 percent of patients in need of screening received a falls assessment in the year that ended July 1, says Floyd says.

Moreover, UHS piloted STEADI for CDC, and prompted the government agency to make changes that made the fall prevention effort more sustainable at UHS.

“An important change CDC made was to develop more focused asks of providers,” Houry notes. “Since providers only have a limited amount of time with each patient, we created STEADI Step One. STEADI Step One focuses on primary care physicians and asks them to conduct three screening questions and two clinical interventions for their patients 65 and older.”

The tool not only provides a realistic tool for busy providers but “also ensures two evidence-based clinical interventions – medication review and Vitamin D supplementation – are a default in patient care,” says Houry, adding “the pilot also showed us the importance of combining STEADI with the provider’s electronic health record system.”

“There is an administrative burden for UHS to do this,” Edwards notes. In addition to modifying its IT system and redoing patient flow, UHS trained hundreds of providers. But in the changing economics of hospital care, investing in prevention and health can be the route to delivering a positive bottom line.

Thanks to the local health department’s efforts to establish proven community-based programs and UHS’ efforts for home-based fall prevention programs, most providers in Broome County have even more interventions for older residents at risk of falling.

“The health department set up excellent programs,” Floyd says. “This is what set us apart.” Since taking the Tai Chi class, Neebe has not had another fall, and he remains active.

“The Affordable Care Act was the big stick that said to hospital people and public health people: ‘You need to get together to see what can be done outside the hospital to improve health,'” Edwards says. “We need each other. Together, this is prevention and they realize there are savings in that.”