by Dr. Babak M. Nayeri
Falls and consequent injuries are major public health problems that often require medical attention. The duration of hospital stay due to falls varies; however it is much longer than other injuries. In addition, falls may also result in a post-fall syndrome that includes dependence, loss of autonomy, confusion, immobilization and depression, which will lead to a further restriction in daily activities.
The health challenges of older adults with multiple chronic conditions are substantial human and financial burdens. The multifactorial nature of fall(s) risk among older adults occur as a result of a complex interaction of factors. The main risk factors reflect the multitude of health determinants that directly or indirectly affect well-being. Those are categorized into four dimensions: biological (e.g., age, gender, chronic illness, decline in physical, cognitive and affective capacities), behavioral (e.g., multiple medication use, excess alcohol consumption, lack of exercise, inappropriate footwear), environmental (e.g., poor building/sidewalk design, slippery floors, insufficient lighting) and socioeconomic factors (e.g., low income, education levels, inadequate housing, lack of social interaction, limited access to health and social services, lack of community resources).
According the latest facts published by the Arizona Department of Health Services, falls accounted for over forty thousand emergency department visits, and nearly thirteen thousand hospitalizations. Moreover, as the leading cause of injury-related mortality among our fellow citizens 65 years and older, the Arizona six-year trend indicates a mortality rate 7% higher than the national incidents. Falls exponentially increase with age-related biological change, therefore a definite number of persons 80+ years will trigger substantial increase incidence of fractures, spinal cord and head injury.
The good news: Falls are not an inevitable consequence of aging; there are proven, effective strategies for preventing falls.
The Arizona Falls Prevention Coalition (AFPC) is a collective representation of public and private organizations and regional chapters working collaboratively to reduce the growing number of falls and fall-related injuries among older adults. Our statewide coalition actively involves partners representing older adults, policy-makers, educators, researchers, first responders, health and social service providers.
As we coalesce and rally around this important public health initiative, we must ask ourselves:
The framework suggested by the AFPC includes five focus areas for public and private health systems strategies: policy, systems change, environment, strategic promotions and communications (including media), and program and service delivery.
AFPC is grounded in key strategies and action plans for fall prevention to address the following five priority areas: • physical mobility; • medications management; • home safety; • environmental safety in the community; and • cross-cutting issues, such as advocacy, policy, links to health care systems and integration of interdisciplinary activities – – it truly takes the whole village to make a difference.
We call to deliberate actions to build local collaborative capacity for evidence-based falls prevention and reduction. This includes collaboration among all private and public partners to prioritize policy and systems change that produce the largest returns on investment, especially given the recent as well as forecast context of evolving healthcare, which include collaborative community-based initiatives, Medicare innovation and investment in prevention including hospital readmissions.
The rate of decline can effectively be influenced at any age through empowerment of individuals and initiatives through: A) Systems change, B) Policies, and C) Environment change. Public policy measures, such as promoting an age-friendly living environment. An important context of falls and impact on the gravity of physical wellbeing, relates to bone mass. Access to proper nutrition and optimum levels of physical activity throughout earlier age are critical for the development of healthy bones. It is a scientific fact that as individuals age they are most likely to experience a gradual decline in bone mass, hence the push for healthy life styles to slow down the process.
While we recognize the difficult and potential constraints under which member-partners are operating, public and private agencies responsible for health and social services for older persons are well placed to provide leadership by establishing a policy-making infrastructure, collaborating to set priorities and targets, and overseeing and supporting national and regional efforts to reduce falls and related injuries. In addition, promoting the need for integrated policy options and falls prevention strategies, including standard practice guidelines, for men and women based on gender differences in locations, circumstances and events preceding falls and fall-related injuries are needed.
It behooves us to support scalable, sustainable and immediate strategic action; vital to course correcting the rising trajectory. Otherwise, the number of injuries caused by falls is projected to be significantly higher as the population in Arizona advances in age.
The Coalition is in position to advocate for standard practice guidelines such as annual falls risk assessments for all persons 65 and older (with or without history of falls). Furthermore, cost reimbursement incentives can be explored and the circle of influence may be at the forefront of payor system policy modification. Falls are coded as E880-E888 in International Classification of Disease-9 (ICD-9), and as W00-W19 in ICD-10, which include a wide range of falls including those on the same level, upper level, and other unspecified falls.
According to the study published by the American Occupational Therapy Association (2010), “Falls prevention is not a singular service, so is not as easily defined as a vaccine or a screening procedure.” Subsequently, one of the challenges we will collaboratively overcome is reimbursement incentives for falls risk assessments and evidence-based (EvB) service delivery.
In documenting an individual being at risk for falling and ICD-10-CM clinical management (CM) code of Z91.81 is a billable/specific code that can be used to indicate history of falling and therefore, at risk. This is a diagnosis for reimbursement purposes. The challenge however is:
A number of programs being promoted by the CDC have shown a positive return on investment (ROI) and offer health providers a range of low-cost intervention options that can reduce costs. For example, the older adult tai chi falls prevention program “Moving for Better Balance” has demonstrated that for every $1 invested in the program, there is a $1.60 saved in direct medical costs.
An African proverb often states: “If you want to go quickly, go alone. If you want to go far, go together.” We are so fortunate to have such passionately dedicated partners coalescing around this great cause, and as we break the silos, aiming to reduce the number of falls and related injuries in Arizona. Thank you for joining this fabulous and growing statewide coalition – partnering together, Arizona will soon boast the lowest falls related mortality in the nation.