Thinking strategically about falls prevention - Business Strategies

Nursing Homes, Feb, 2003 by Laura Hyatt

Effective strategies involve "doing the right thing," while simultaneously raising revenues, decreasing costs, improving operations, and service delivery. Post-acute, long-term, and residential-care facilities have an opportunity to accomplish all of this by evaluating and implementing strategies that prevent and/or reduce fall-related injuries.

Fall-related injury is one of the most serious public-health problems confronting the elderly. The Centers for Disease Control and Prevention reports that one in three people age 65 years and older falls each year. As many as 30% of those who fall suffer injuries severe enough to reduce mobility and increase the risk of premature death. What is even more disturbing is that two-thirds of those who fall will do so again within six months.

Falls are costly. Direct costs account for such expenses as hospital and nursing home care, physician and other professional services, rehabilitation, medical equipment, and prescriptions. Direct costs, however, do not account for longterm results, such as chronic disability or diminished quality-of-life issues. The federal government reports that in 1994, direct costs of fall injuries for people 65 years or older were $20.2 billion. By 2020, these same costs are expected to increase by more than 150% to nearly $33 billion.

These costs extend beyond the patient/resident and the payer. Fall-related injuries are also increasing costs for long-term care facilities in the form of increased liability. Liability premiums for facilities have, on average, increased 200 to 600%. In some states, such as Florida, premiums have increased as much as 1,000% with deductibles as high as $100,000 per incident.

Frequently serving as an advisor to risk-management organizations, insurers, and pharmaceutical companies, I ma always surprised to hear that many long-term care facilities don't address this problem as part of their ongoing strategic planning. Most continue to deal with falls based on a plan that was developed years ago and has long been antiquated. Information, education, and new technologies exist today that could reduce fall-related injuries and consequently decrease financial costs to the facility, as well as the physical and emotional costs to residents and their families.

I asked an expert to take a fresh look at an old problem. Steven C. Castle, MD, professor of medicine, UCLA and clinical director of geriatrics, Veterans Administration (VA) Greater Los Angeles Healthcare System, offered his assistance. Internationally recognized for his expertise in geriatric care, program development, healthcare professional training, and research in managing the complexities of aging, Dr. Castle is the recipient of two National Institute on Aging grants studying the effects of disease and chronic illness on immunity. Dr. Castle, based on six years of implementing a falls-prevention clinic, has served as a consultant on a VA-funded clinical initiative to develop and implement comprehensive falls-prevention programs throughout hospitals and long-term care in the VA System in Southern California, Nevada, and Florida. He also has participation a treatment advisory group that addressed falls-prevention standards for the VA National Patient Safety Center in Tampa, Florida.

Hyatt: There is a shortage of geriatric clinicians in the U.S. How did you become interested in the field?

Castle: I became interested in geriatrics when I was an intern. I was put on a committee to look at needs of elders in my hospital and was struck by the huge opportunities that opened for me. I later became fascinated with the challenge of diagnosis and management in complex medical situations and the unique aspects of aging. I am attracted to elders who are aging well, much like the unbridled potential of a baby. Both are rare and valuable.

Hyatt: Could you discuss your recent falls-prevention project?

Castle: I was never satisfied with my approach to diagnosing the causes of falls. I decided to immerse myself in the issue by a very thorough review of the literature, with a focus on medications, and by working with a physiatrist, Dorene Opava-Rutter, MD, to broaden my skills. Based on some preliminary models for a fails-prevention clinic we piloted at the VA Greater Los Angeles, we received VA funding for a clinical initiative to expand and evaluate our assessment-and-intervention model throughout Southern California, Nevada, Florida, and Puerto Rico. While we did not do a randomized trial, we did demonstrate a reduction in falls, especially in those who fell frequently. We feel confident in identifying the causes of falls 90% of the time.

Hyatt: Current research tells us that falls among the elderly are a serious problem at home and in hospital-based facilities, free-standing nursing homes, and assisted living centers. What factors increase the risk of falls among older patients/residents?

Castle: There are several obvious risk factors for falls including age, history of previous falls, weakness of legs, and poor balance. It is important to recognize readily preventable causes of falls, especially a change in condition, such as from infections or worsening of underlying disease. Anyone with agitation or delirium is 20 times more likely to fall than someone who is calm and alert. Medications are important to consider, especially the use of sedatives or sleepers, or overuse of antihypertensives and some medications that are strongly anticholinergic, such as some cold medications, bladder relaxants, and psychotropics.