Reports From the Field

Improving Primary Care Fall Risk Management: Adoption of Practice Changes After a Geriatric Mini-Fellowship

Journal of Clinical Outcomes Management. 2020 November;27(6):270-280 | 10.12788/jcom.0026

Author(s):

Colleen M. Casey, PhD, ANP-BC

Jamie M. Caulley, DPT

Angela F. Fox, BA

Marian O. Hodges, MD, MPH

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References

1. US Department of Health and Human Services. 2018 Profile of Older Americans. Administration on Aging. April 2018.

2. Roberts AW, Ogunwole SU, Blakeslee L, Rabe MA. The population 65 years and older in the United States: 2016. Washington, DC: US Census Bureau; 2018.

3. American Board of Medicine Specialties. 2017-2018 ABMS Board Certification Report. https://www.abms.org/board-certification/abms-board-certification-report/. Accessed November 3, 2020.

4. US Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. National and regional projections of supply and demand for geriatricians: 2013-2025. Rockville, MD: US Department of Health and Human Services; 2007.

5. American Association of Nurse Practitioners, NP Facts: The Voice of the Nurse Practitioner. 2020. https://storage.aanp.org/www/documents/NPFacts__080420.pdf.

6. Tinetti ME, Naik AD, Dodson JA, Moving from disease-centered to patient goals-directed care for patients with multiple chronic conditions: patient value-based care. JAMA Cardiol. 2016;1:9-10.

7. Fried LP, Hall WJ. Editorial: leading on behalf of an aging society. J Am Geriatr Soc. 2008;56:1791-1795.

8. Tinetti M. Mainstream or extinction: can defining who we are save geriatrics? J Am Geriatr Soc. 2016;64:1400-1404.

9. Jafari P, Kostas T, Levine S, et al. ECHO-Chicago Geriatrics: using telementoring to “geriatricize” the primary care workforce. Gerontol Geriatr Educ. 2020;41:333-341.

10. Fulmer T, Mate KS, Berman A. The Age-Friendly Health System imperative. J Am Geriatr Soc. 2018;66:22-24.

11. Mate KS, Berman A, Laderman M, et al. Creating Age-Friendly Health Systems - A vision for better care of older adults. Healthc (Amst). 2018;6:4-6.

12. Tinetti ME, et al. Patient priority-directed decision making and care for older adults with multiple chronic conditions. Clin Geriatr Med. 2016;32:261-275.

13. Stevens JA, Phelan EA. Development of STEADI: a fall prevention resource for health care providers. Health Promot Pract. 2013;14:706-714.

14. Rubenstein LZ, et al. Validating an evidence-based, self-rated fall risk questionnaire (FRQ) for older adults. J Safety Res. 2011;42:493-499.

15. Grossman DC, et al. Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319: 1696-1704.

16. Tricco AC, Thomas SM, Veroniki AA, et al. Comparisons of interventions for preventing falls in older adults: a systematic review and meta-analysis. JAMA. 2017;318:1687-1699.

17. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012(9):CD007146.

18. Bergen G, Stevens MR, Burns ER. Falls and fall injuries among adults aged ≥65 years - United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65:993-998.

19. Burns E, Kakara R. Deaths from falls among persons aged >=65 Years - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2018;67:509-514.

20. Shankar KN, Liu SW, Ganz DA. Trends and characteristics of emergency department visits for fall-related injuries in older adults, 2003-2010. West J Emerg Med. 2017;18:785-793.

21. Hoffman GJ, et al. Posthospital fall injuries and 30-day readmissions in adults 65 years and older. JAMA Netw Open. 2019;2:e194276.

22. Eckstrom E, Parker EM, Shakya I, Lee R. Coordinated care plan to prevent older adult falls. 2018. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2018.

23. Eckstrom E, Parker EM, Lambert GH, et al. Implementing STEADI in academic primary care to address older adult fall risk. Innov Aging. 2017;1:igx028.

24. Johnston YA, Bergen G, Bauer M, et al. Implementation of the stopping elderly accidents, deaths, and injuries initiative in primary care: an outcome evaluation. Gerontologist. 2019;59:1182-1191.

25. Phelan EA, Mahoney JE, Voit JC, Stevens JA. Assessment and management of fall risk in primary care settings. Med Clin North Am. 2015;99:281-293.

26. Gell NM, Mroz TM, Patel KV. Rehabilitation services use and patient-reported outcomes among older adults in the United States. Arch Phys Med Rehabil. 2017;98:2221-2227.e3.

27. Phelan EA, Aerts S, Dowler D, et al. Adoption of evidence-based fall prevention practices in primary care for older adults with a history of falls. Front Public Health. 2016;4:190.

28. Solberg LB, Carter CS, Solberg LM. Geriatric care boot camp series: interprofessional education for a new training paradigm. Geriatr Nurs. 2019;40:579-583.

29. Solberg LB, Solberg LM, Carter CS. Geriatric care boot cAMP: an interprofessional education program for healthcare professionals. J Am Geriatr Soc. 2015;63:997-1001.

30. Coogle CL, Hackett L, Owens MG, et al. Perceived self-efficacy gains following an interprofessional faculty development programme in geriatrics education. J Interprof Care. 2016;30:483-492.

31. Lam R, Lee L, Tazkarji B, et al. Five-weekend care of the elderly certificate course: continuing professional development activity for family physicians. Can Fam Physician. 2015;61:e135-141.

32. Warshaw GA, Modawal A, Kues J, et al. Community physician education in geriatrics: applying the assessing care of vulnerable elders model with a multisite primary care group. J Am Geriatr Soc. 2010;58:1780-1785.

33. Solai LK, Kumar K, Mulvaney E, et al. Geriatric mental healthcare training: a mini-fellowship approach to interprofessional assessment and management of geriatric mental health issues. Am J Geriatr Psychiatry. 2019;27:706-711.

34. Christmas C, Park E, Schmaltz H, et al. A model intensive course in geriatric teaching for non-geriatrician educators. J Gen Intern Med. 2008;23:1048-1052.

35. Heflin MT, Bragg EJ, Fernandez H, et al. The Donald W. Reynolds Consortium for Faculty Development to Advance Geriatrics Education (FD~AGE): a model for dissemination of subspecialty educational expertise. Acad Med. 2012;87:618-626.

From the Senior Health Program, Providence Health & Services, Oregon, Portland, OR.

Abstract

Background: Approximately 51 million adults in the United States are 65 years of age or older, yet few geriatric-trained primary care providers (PCP) serve this population. The Age-Friendly Health System framework, consisting of evidence-based 4M care (Mobility, Medication, Mentation, and what Matters), encourages all PCPs to assess mobility in older adults.

Objective: To improve PCP knowledge, confidence, and clinical practice in assessing and managing fall risk.

Methods: A 1-week educational session focusing on mobility (part of a 4-week Geriatric Mini-Fellowship) for 6 selected PCPs from a large health care system was conducted to increase knowledge and ability to address fall risk in older adults. The week included learning and practicing a Fall Risk Management Plan (FRMP) algorithm, including planning for their own practice changes. Pre- and post-test surveys assessed changes in knowledge and confidence. Patient data were compared 12 months before and after training to evaluate PCP adoption of FRMP components.

Results: The training increased provider knowledge and confidence. The trained PCPs were 1.7 times more likely to screen for fall risk; 3.6 times more likely to discuss fall risk; and 5.8 times more likely to assess orthostatic blood pressure in their 65+ patients after the mini-fellowship. In high-risk patients, they were 4.1 times more likely to discuss fall risk and 6.3 times more likely to assess orthostatic blood pressure than their nontrained peers. Changes in physical therapy referral rates were not observed.

Conclusions: In-depth, skills-based geriatric educational sessions improved PCPs’ knowledge and confidence and also improved their fall risk management practices for their older patients.

Keywords: geriatrics; guidelines; Age-Friendly Health System; 4M; workforce training; practice change; fellowship.

The US population is aging rapidly. People aged 85 years and older are the largest-growing segment of the US population, and this segment is expected to increase by 123% by 2040.¹ Caregiving needs increase with age as older adults develop more chronic conditions, such as hypertension, heart disease, arthritis, and dementia. However, even with increasing morbidity and dependence, a majority of older adults still live in the community rather than in institutional settings.² These older adults seek medical care more frequently than younger people, with about 22% of patients 75 years and older having 10 or more health care visits in the previous 12 months. By 2040, nearly a quarter of the US population is expected to be 65 or older, with many of these older adults seeking regular primary care from providers who do not have formal training in the care of a population with multiple complex, chronic health conditions and increased caregiving needs.¹

Despite this growing demand for health care professionals trained in the care of older adults, access to these types of clinicians is limited. In 2018, there were roughly 7000 certified geriatricians, with only 3600 of them practicing full-time.^3,4 Similarly, of 290,000 certified nurse practitioners (NPs), about 9% of them have geriatric certification.⁵ Geriatricians, medical doctors trained in the care of older adults, and geriatric-trained NPs are part of a cadre of a geriatric-trained workforce that provides unique expertise in caring for older adults with chronic and advanced illness. They know how to manage multiple, complex geriatric syndromes like falls, dementia, and polypharmacy; understand and maximize team-based care; and focus on caring for an older person with a goal-centered versus a disease-centered approach.⁶

Broadly, geriatric care includes a spectrum of adults, from those who are aging healthfully to those who are the frailest. Research has suggested that approximately 30% of older adults need care by a geriatric-trained clinician, with the oldest and frailest patients needing more clinician time for assessment and treatment, care coordination, and coaching of caregivers.⁷ With this assumption in mind, it is projected that by 2025, there will be a national shortage of 26,980 geriatricians, with the western United States disproportionately affected by this shortage.⁴Rather than lamenting this shortage, Tinetti recommends a new path forward: “Our mission should not be to train enough geriatricians to provide direct care, but rather to ensure that every clinician caring for older adults is competent in geriatric principles and practices.”⁸Sometimes called ”geriatricizing,” the idea is to use existing geriatric providers as a small elite training force to infuse geriatric principles and skills across their colleagues in primary care and other disciplines.^8,9 Efforts of the American Geriatrics Society (AGS), with support from the John A. Hartford Foundation (JAHF), have been successful in developing geriatric training across multiple specialties, including surgery, orthopedics, and emergency medicine (www.americangeriatrics.org/programs/geriatrics-specialists-initiative).