Edited by: Renae L. Smith-Ray, Walgreens, USA
Reviewed by: Jo Ann Shoup, Kaiser Permanente, USA
Specialty section: This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Each year, approximately 30% of adults aged 65 years and older fall (
However, integrated community-clinical efforts integral to fall risk management are relatively new endeavors for State Departments of Health (DOH) (
This Commentary builds upon previous work from the State Falls Prevention Project (SFPP), a project funded by the CDC, in which DOH in New York, Colorado, and Oregon were charged with implementing clinical and community fall-prevention programs in specific geographic areas (
During the course of the SFPP, it became apparent the most effective implementation role for the DOH was to identify and connect health-care systems, community providers, and older adults to needed resources. Each DOH facilitated the implementation of three evidence-based fall-prevention programs, which were selected because of their ability to minimize risk of falling by improving balance, increasing strength, and providing education: (1) Tai Chi: moving for better balance; (2) stepping on; and (3) the Otago Exercise Program. Each state also developed strategies to increase clinical engagement in fall risk management through use of the CDC STEADI (STopping Elderly Accidents Deaths and Injuries) tool kit. Through this process, each DOH faced similar implementation challenges, which generated better appreciation of lessons learned from this experience and effective solutions.
During the first pilot year, the DOHs deployed the strategy of: (1) engaging with health-care providers through a traditional academic detailing model (i.e., provide lunch and a brief training session) to facilitate adoption of evidence-based fall risk management practices ( Changing physician practice is a monumental task requiring the development of meaningful value propositions for each practice and ongoing relationship building, which could not be accomplished with a brief “lunch and learn” session. Health-care organizations and providers (e.g., physicians, nurses, and physical therapists) typically have limited knowledge about value and availability of evidence-based fall-prevention programs available in the community. There are many competing health-care and clinic efficiency initiatives that make it difficult for any new project to be viewed as a priority. Each health-care system is unique. What motivates one system to embed fall risk management practices [i.e., modify Electronic Medical Records (EHR), adopt STEADI] will not necessarily be valued or motivating to other health-care systems in the same region. There is widespread dissemination of evidence-based programs; however, a lack of program availability exists in many communities; few communities have a central source to provide a comprehensive, up-to-date list of available programs; this makes it challenging to schedule a patient in a timely manner. Referral systems are fractured. No internal systems exist within a health-care system to refer a patient to a community-based program. The converse was true – no systems existed to connect an older adult identified as a fall risk by a community provider to a health-care provider. There is a supply–demand dilemma – it is a challenge to build referrals from clinics to community programs (demand) while at the same time insuring you have enough programs in the community (supply). It is important to identify potential partners interested in decreasing health-care costs and achieving better outcomes. However, not all partners will be ready to implement evidence-based programs as a cost-reducing measure. Once a clinical-community linkage is created, long term sustainability of the linkage may be challenging due to personnel changes, program availability, and competing demands.
Reflecting on these challenges, the SFPP FETA Team, in collaboration with funders and grantees, gained perspectives about effective solutions. The role of the DOH as a “connector and convener” seemed the most effective model. As connector, the DOH educated and engaged stakeholders from health care and community settings about respective roles in fall-prevention efforts. As convener, the DOH brought stakeholders together to identify problems, discuss feasible strategies and solutions, and create state-specific systems to advance fall prevention. This strategy ultimately created stakeholder buy-in and ownership while developing potentially sustainable solutions to these challenges (
| Learned lesson | Description | Example |
|---|---|---|
| Dedicated staff time from DOH is required for relationship building | Substantial time is required to nurture and redefine (in some instances) pre-existing partnerships to the point where they are vested in implementing and sustaining change | Each DOH had established relationships with health-care systems through advisory boards and planning groups. Additional time required before partners valued and were ready to engage in practice change After committing to change, additional time was required to support/assist partners to complete implementation responsibilities. |
| Potential stakeholders have different goals and initiatives | Understanding market drivers for each stakeholder is an effective adoption and implementation strategy | All three states Provided tailored technical assistance to each partner Specifically addressed program alignment with business goals |
| Roles and responsibilities must be clearly defined | Effective fall risk management requires communication and collaboration between multiple partners Partners do not understand the parameters of their role. Gaps may exist in their management program |
A large academic medical center adopted STEADI Planned to refer to evidence-based programs in the community Did not realize they needed to create a system to make those referrals happen |
| The DOH plays a role as a connector | The DOH can connect established and engaged partners with new partners by showcasing efforts of each | OR convened a “Health Systems Partner” meeting attended by five health-care systems, State Unit on Aging, AAA, DOH, and DHS Champions presented their STEADI model Key stakeholders presented their role in primary care fall risk management Many stakeholders had never met Many did not value partnering to manage fall risk Most health-care partners were unaware of DHS resources available to their patients A stronger connection and greater motivation to improve referrals among all players |
| Begin with early adopters or those in a high state of readiness | Highly motivated stakeholders due to market drivers or incentives or penalties are more willing to invest time and resources into effective partnerships | OR and CO Level -1 Trauma Centers are mandated to provide community injury prevention education Stepping on is one of the few evidence-based injury prevention programs target older adults The Level 1 Trauma Centers motivated to adopt and implement Stepping on In CO, the AAA were motivated to partner with the trauma centers for client referrals |
| OR The health system was motivated to implement fall risk management solutions The DOH was able to connect the system with resources for health-care providers and community programs The system offers STEADI, the Otago Exercise Program, and refers to Tai Chi They were willing to take on STEADI dissemination It aligned with research priorities OHSU Internal Medicine needed to meet CPCi quality standards OHSU was an early adopter of STEADI They had developed a fall risk management program It was not evidence-based |
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| Any new processes needs to fit within the clinical culture | Evidence-based practices to improve fall risk management will only be successful if the implementation process is simple fully integrated into the culture |
NY developed a clinically-specific referral process Physicians were given a referral sheet with program contact information The referral sheet was provided to the patient It is common for patients to receive referrals to a specialist Physicians and health-care organizations have specialty referral systems in place The EBHP Salem Primary Care Clinic implemented a system which directly refers patients to physical therapists to implement the Otago Exercise Program |
| Celebrate successes, regardless of the size | Promote and publicize the accomplishments achieved by partners | NY made a video disseminated nationally about the success of STEADI implementation in one practice ( |
| CO presented Level 1 Trauma Centers with a “Program of Excellence” award to publicly acknowledge accomplishments and reward efforts | ||
| Provide meaningful data to partners | Identify important drivers that influence your partners likelihood to change (i.e., cost, patient satisfaction) | CO Infographic of stepping on outcomes data More trauma centers have adopted the program |
| Make sure data collected and analyzed is in alignment with drivers | NY Systematic evaluation of program processes and outcomes from physician practices implementing STEADI Clinic and provider-level STEADI reports to OHSU demonstrate improvements in claims billing and provider uptake |
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| Identify innovative funding sources | Seeking out new and alternative partners can provide new referral and funding sources | OR – Tai Chi as a Medicare Part C Silver and Fit and Silver Sneakers FLEX now cover Tai Chi programs at the YMCA Similar options are being expanded in Silver Sneakers programs nationwide. |
| Plan for program sustainability from the beginning | Often grant-funded projects focus on number of programs started. This project focused maintaining and growing programs after funding | NY and OR Partners required to create sustainability plans Embed the EBHP into systems Promote systems change Focused on partners embedding the programs within stakeholder organizations Established a policy they would not provide subsidies for agencies or organizations to implement programs Offered mini-grants to cover start-up costs and facilitated instructor training The two major hospital systems hold the Stepping On licenses, cover all the costs of program implementation, and independently run the programs in their facilities |
| Leverage the infrastructure and lessons learned to pursue new fall-prevention funding opportunities | Build upon the strong foundation to continue to expand program reach | CO was awarded a grant by the Administration for Community Living to expand its falls prevention programing statewide |
| NY was awarded a grant by ACL to develop new partnerships with Level 1 Trauma Centers to deliver EBHP across the state | ||
| NY received additional state funds to implement fall risk management | ||
| OHSU was awarded a grant to develop the STEADI toolkit for EHR dissemination with a national EHR company | ||
The challenges and solutions inherent in implementation of fall-prevention initiatives served to define effective roles for DOH in these three states. Each DOH developed its own unique role in fall prevention; however, all the successful initiatives relied on DOH helping organizations identify the problem of falls and guiding them toward evidence-based solutions.
As federal and state agencies continue to fund delivery infrastructures to bring programs “to scale,” more effort should be given to defining the roles of each partner/stakeholder and connecting individual agencies to create/support a continuum of fall-prevention services.
All the authors were involved as evaluators of this 5-year initiative. All the authors wrote the manuscript and critically reviewed the manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The authors would like to thank the leadership and guidance of CDC personnel throughout this SFPP project. More specifically, the authors acknowledge Margaret Kaniewski, Judy Stevens, Erin Parker, and Robin Lee. The authors also acknowledge the hard work and ongoing dedication of the Colorado, New York, and Oregon State Departments of Health. Under the leadership of Sallie Thoreson, Michael Bauer, Lisa Shields, and David Dowler, respectively, these public health teams were able to confront and overcome challenges to realize amazing successes related to fall prevention in their states.
This research was supported under the Health Promotion and Disease Prevention Research Centers Program, funded by the Centers for Disease Control and Prevention, under Cooperative Agreement 1U48-DP005017 at the University of North Carolina at Chapel Hill Center for Health Promotion and Disease Prevention and Cooperative Agreement 1U48 DP001924 at the Texas A&M Health Science Center School of Public Health Center for Community Health Development.