Undergraduate thesis in Public Health, May 2022
Falls are extremely dangerous, especially for the elderly, disabled, and otherwise vulnerable. People who are elderly or disabled are more likely to have conditions that cause them to fall more often while doing everyday tasks, and also more likely to have conditions such as osteoporosis that make it more likely that they will be injured, sometimes severely, when they do fall (CDC 2021). Twenty percent of falls in elderly adults cause a serious injury, like a traumatic brain injury or a broken bone (CDC, 2020). The bones broken during falls are commonly large bones such as hips, which require treatment and affect mobility. These serious falls can also cause death, either directly during the fall or by precipitating a downward trend in general health status after injuries; six months after a hip fracture, one fourth of patients will have died (Fuller, 2000).
Injuries can affect lifespan due to pain, inability to exercise while recovering, medication side effects, and other factors; falls are the most frequent cause of accidental injury (Robinovitz, 2013). Hospitalizations related to these injuries can also be dangerous, as they sometimes lead to hospital- related infections, death during surgery, and other issues. If a patient is bedbound or has limited mobility after a fall, they may acquire pressure sores, which are difficult to heal and may become infected (Budri 2020). Pain can raise blood pressure, and heart rate as well as have other negative physiological effects, while pain medications may have unpleasant side effects like constipation that can be worsened in dementia patients who may struggle to stay hydrated.
Brain injuries can cause death and other physical issues such as stroke, nerve damage, seizures, and infection. Additionally, they can affect cognition and emotional processing as well as cause sensory issues such as vision loss and behavioral problems (NINDS, 2020). All of these can be difficult to treat and worsen quality of life for elderly patients.
11.2% of Alaska’s population are above the age of 65 (Census, 2019); people over the age of 65 are more likely to be disabled and/or need more intensive medical care, due to the physical burden of aging. Alaska is a highly rural state with comparatively few hospitals for its landmass (only 10, spread around the state, with a total capacity of 1,374 beds) (AHD, n.d.), making it more difficult for people to access medical care, especially if they live in one of the many small villages in the state. Since road access is limited, they may require costly, time-consuming airlifts to hospitals. For these reasons, people may not be able to access the emergency care required in time to urgently treat severe injuries.
Additionally, the population of the US is aging (CDC, 2020), including in Alaska (Census, 2019). This means that in the future, a higher proportion of the population will be at risk for falls. Currently, 88 people die from falls per day; this figure is likely to increase as the population ages (CDC 2020). The CDC estimates that by 2030 there will be 52 million falls per year, with 12,000,000 of them ending in injury (CDC, 2020). This problem will worsen unless there is a concentrated effort to improve safety for the nation’s senior population.
Falls cause about 800,000 patients a year in the US to be hospitalized, a significant injury burden (CDC, 2021); this burden will only grow as the population ages because seniors are at higher risk for falls and injuries. Many falling-related hospitalizations are due to brain injuries and broken hips. Additionally, hospitalization itself can raise the risk of falls, with longer hospitalizations increasing the risk (Njafpour, 2019).
In 2015, falls and related injuries cost the US $50 billion in treatment expenditures (CDC, 2021). The average cost for a hip fracture is $26,000 dollars for the initial hospital stay, not counting any nursing home stays afterward, rehabilitation equipment, or other costs. Preventing falls is an important cost-saving measure for governments and health care systems.
Falls can be prevented, but how?
Elected leaders can choose to fund educational programs aimed at outreach and sponsor group classes with occupational and physical therapists at senior centers. Preventing falls not directly related to medical conditions can be accomplished with broader education efforts that can be delivered to wider audiences. This is primary prevention, meaning it is related to reducing the likelihood that someone will be injured before they develop disease or injury. This also reduces the likelihood that people will not receive services due to embarrassment - advertisements and group situations do not rely on people bringing the subject up with their doctors independently and can be more cost-effective as they can reach more people. The CDC provides resources to communities seeking to build their own fall- prevention programs, including resources for doctors like the STEADI program.
The CDC’s STEADI program, or Stopping Elderly Accidents, Deaths, and Injuries, is a program aimed at increasing awareness of falls in elderly people and educating them and their caregivers. They provide pamphlets, educational materials, and other materials for patients, caregivers, and doctors who work with elderly patients. Support for this program, including printing and distributing the educational materials, could be very beneficial in preventing falls among the seniorpopulation. Doctors who serve patients whose insurance comes from Medicaid or Medicare (patients with these insurance policies are likely to be older adults and/or disabled), could be required to take the free STEADI provider training yearly or every two years to maintain state licensure.
This low cost, primary prevention-focused intervention involves minimal costs for the state of Alaska, providers, and patients. The STEADI training is free, and so are their educational materials. The only cost is printing, as well as a time investment.
Like all interventions, the efficacy of this strategy could be partially measured by monitoring the Alaska database of injuries and accidents at the Department of Health and Human Safety and the Alaska Trauma Registry. This database specifically notes when the accident was a fall. Of course, this only shows the falls that result in significant injury or death -- many smaller falls will not be reported. Still, if the number of severe falls decreases after implementing this strategy, this will indicate its efficacy. Additionally, doctors who are a part of this program, and their patients above age 65, can be surveyed to see whether doctors begin seeing fewer falls and injuries and whether or not patients feel safer and have fewer near-falls. It may take some years for this strategy to have any effect, so the surveys should be repeated regularly.
Insurance coverage for fall-related appointments, such as diagnosis of fall-related medical conditions, physical and occupational therapy, and medicine adjustments, is also an issue for many people. Insurance coverage for occupational and physical therapies can be limited; there may be a gap between what the doctor prescribes and what the insurance company considers “medically necessary”; and/or individual insurance policies may include a relatively low cap on costs for occupational, speech, and physical therapy combined, which means people with multiple disabilities or complex cases may not have access to all the therapy they need. Additionally, some insurances, such as Medicaid, consider outpatient therapy an “optional benefit” (Carvalho, 2018).
Also, many Elders in Alaska live in villages and other remote places where they may not have access to occupational and physical therapists. Flying into a hub city may be impractical and it is often useful for occupational therapists to see homes so that they can make specific suggestions. Flying occupational therapists out to villages is difficult, especially since it limits the number of patients a therapist can see in a day. Additionally, Alaska Native and American Indian Elders are most at risk for falls (CDC 2020). For these patients, telehealth may be the best option, so that they can receive evaluation and treatment when at home.
Individual states are able to regulate what must be covered by insurance from carriers based in that state, especially programs like Medicaid. Falls themselves can be incredibly costly, and even if only a proportion of falls were prevented, reducing falls would still save money overall. Laws mandating insurance coverage of fall-specific preventative care could be hugely beneficial to many people with limited insurance coverage, especially as this population, older adults above 65, is mostly composed of people who no longer work and do not get insurance coverage from jobs. Insurance related to employment should also be legally obligated to provide preventative care for falls: mandating insurance coverage for preventative care for falls, such as primary care visits, occupational and physical therapy visits, and medication consultations is an important step for the Alaska legislature to take to reduce fall risk in the state’s older population.
Many of the most vulnerable older adults have insurance through Medicare, a federally funded program. This means that individual states have much less control over what is and is not covered (Medicare.gov, n.d.). However, state legislatures are still able to affect some aspects of how Medicare functions in their state. For example, there is a cap on the total cost of an individual’s treatment plan when they are covered under Medicare Part B, which deals with outpatient care, but cost can be inconsistent from session to session or from therapist to therapist (Carvalho, 2017). Laws requiring transparency in health care costs for occupational and physical therapists allow patients, their doctors, and their insurance providers to make better choices about which occupational and physical therapists to send an individual to. The legislature would need to determine which providers would be affected by the law -- occupational therapists and physical therapists only, or would other providers like primary care physicians be affected? Additionally, they would need to be sure that laws mandating consistency between sessions would not interfere with programs such as need-based sliding fee scales. They could therefore place a consistent upper limit on the cost of appointments, whether self-pay, private insurance, or Medicare and Medicaid. This would give a minimum number of appointments that would be covered by Medicare Part B.
Mandating increased coverage for preventative occupational and physical therapy will cost more upfront than other options, especially to insurance providers, including Medicaid. However, if successful, it will reduce medical costs overall by reducing the number of costly hospitalizations, surgeries, rehab stays, and extended physical therapy that fall-related injuries can require. This strategy would likely work best in tandem with the previous strategy; if patients are not being identified as in need of services, and then being sent to those services, they will not receive preventative care.
Much like the previous solution, the Alaska Trauma Registry could be a valuable source of information on the efficacy of this plan, as could polling doctors and their patients. Additionally, insurance companies themselves -- who will likely care about cost efficiency -- may be able to give information on whether or not costs decrease over a period of years. Looking at the state budget for DenaliCare, and where the costs cluster, will also show whether or not dangerous falls have decreased.
Requiring coverage for preventative care is not the only way regulation can help with fall-related insurance issues. State legislatures can pass laws preventing physical and occupational therapists from charging “excess charges,” or subtracting what Medicare pays from the amount they usually gain from patients with private insurance and charging the remainder to the patient themself. Many elderly people who have no income are hit hard by charges like this. Even older adults who have not yet retired may be on Medicare and struggle with these charges. Some states have banned these extra charges; Alaska doing this would benefit a wide variety of people and could help more older adults access preventative care.
This solution will likely act in similar ways to the previous one, although the cost will fall primarily on occupational and physical therapy clinics, who will lose additional income from taking Medicaid and Medicare patients. It can also be used in conjunction with the previous solutions.
Much like the previous solution, efficacy can be judged by the Alaska Trauma Registry as well as insurance company -- in this case Medicaid and Medicare -- data on what services are being paid for. Increased numbers of preventative occupational and physical therapy are ideal, with decreased broken hip and other post-fall hospital stays and other treatments.
Falls and fall-related injuries are a significant risk for elderly patients. They are expensive and dangerous. They are also quite common and, as the population ages, will only become more of a public health issue. However, many falls can be prevented. Providing information and support to senior patients and their caregivers about the best ways to organize their home environment to reduce falls, providing insurance coverage to treat any medical conditions that might increase fall risk, and paying attention to side effects of medications can all reduce fall risks. The STEADI program from the CDC is an excellent resource. Additionally, many elderly people could benefit from physical and occupational therapy to learn skills and build strength. Many people will only be able to access these services through insurance providers that either do not cover preventative care well or significantly limit the number of appointments. Unfortunately, many people in Alaska do not have easy access to these therapies due to living in small, isolated rural villages with no road access. Expanding telehealth support, both in increasing the technology available for telehealth and requiring insurance companies to cover telehealth visits, could be very helpful for these patients.
Policy changes to prevent falls, including educating patients and providers, promoting the CDC’s STEADI program, and guaranteeing access to needed physical and occupational therapy by increasing access to telehealth, mandating insurance coverage, and limiting excess costs, is an urgent public health matter for Alaska. Taking action to prevent falls will reduce unnecessary injury and death, potentially saving billions of dollars each year in treatment expenditures.
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