The Union County Health Department (UCHD) is a government agency that serves approximately 56,700 county residents through its four divisions: Health Promotion & Planning, Environmental Health, Nursing, and Administration (includes Vital Statistics). Union County is a primarily rural area northwest of Columbus, Ohio. The county population is predominantly white (92%) and the median age is 38.2 years. Ninety-two percent of the population received their high school diploma or further education, and the median household income is $71,282.
Unintentional falls among older adults are a leading cause of fatal and nonfatal injury in Ohio and in Union County. According to the Centers for Disease Control and Prevention, one out of every four older Americans will fall each year. This startling statistic has been confirmed by local survey and hospital data.
In response to this, UCHD pursued and received funding in 2014 to form a local coalition and build a comprehensive falls prevention program for Union County older adults. This project includes multiple evidence-based strategies, including a home assessment and modification program. In 2017, UCHD started expanding falls prevention programming to surrounding counties, beginning with Hardin County. Hardin County is a rural county located northwest of Union County in an area that is designated as a medically underserved geography and primary medical care and health professional shortage area. Twenty-one percent of Hardin County's population is 60 years of age or older and 16% of the population lives below poverty level. Similarly to Union County, Hardin County's older adult population and rates of falls among older adults are rising.
In 2017, UCHD sought to collaborate with an organization located in Hardin County to develop falls prevention programming with a focus on home safety. UCHD engaged with faculty from Ohio Northern University's Raabe College of Pharmacy who were fellow members on the Ohio Older Adult Falls Prevention Coalition. With temporary funding from the state coalition, ONU had already began engaging students in learning about older adult falls prevention and conducting events at local senior living communities. UCHD developed a partnership with ONU to build a sustainable falls prevention program serving Hardin County residents. The original scope of the project was expanded to not only include home safety intervention, but also clinical intervention through medication management.
The goals of the project are to: 1. Prevent falls among older adults in Hardin County through the provision of targeted medication reviews, home safety education, and home safety items; 2. Expose pharmacy students to the importance of falls prevention while contributing to their professional development. The program operates via a partnership with Vancrest of Ada, a skilled nursing facility located in Hardin County. A faculty member from ONU works with the Director of Therapy at Vancrest to identify patients who are preparing to be discharged home and are deemed to be at a high risk for a fall. The faculty member has an affiliate agreement with the skilled nursing facility which provides her with full access to the patient's medication list and provider relationships. A visit is scheduled with the identified patients while they are still at the facility. Prior to the visit, trained pharmacy students work with the faculty member to review the patient's medication list and identify any medication issues in relation to falls risk. During the patient visit, an upperclassman student discusses the resident's specific medications that may increase the likelihood of falls and non-medication strategies to reduce falls. A lowerclassman student provides home safety education to the patient and explains home safety items that are given to the patient for use at home. Home safety items include sensor nightlights, nonslip shower mat, nonskid material, grabber, adjustable shower head, and pill boxes. Prior to participating in the program, students engage in a two-hour training that includes mock patient encounters.
Since its launch in fall of 2017, the program has provided training and professional development to 60 pharmacy students, provided 61 older adults with medication reviews and home safety education/items, and modified 20 older adults' medication regimens.
The unique partnership between the health department, ONU, and the skilled nursing facility has allowed for the sustainability and success of this program. The program has had a significant impact in providing much needed education and modifications to older adults and in preparing future pharmacists to fulfill their important role in preventing falls. The program also has the potential for a significant long-term impact on the state of Ohio as student participants go on to apply their education and experience throughout their careers.
The UCHD website can be found at: www.uchd.net.
Every year one fourth of US older adults suffers a fall. In Ohio, this equates to a fall occurring every two minutes. Hundreds of thousands of these falls result in injuries severe enough to require emergency department treatment, hospitalization, and rehabilitative care. Thousands of these falls are so devastating that they are fatal. The annual economic costs associated with these injuries and deaths in Ohio total $4.2 billion. These staggering statistics are compounded by the fact that the older adult population is projected to significantly increase over the next thirty years.
This national and state injury epidemic for the aging population is also very present in Hardin County. In 2014, Hardin County had a fall-related Emergency Department visit rate of 76 per 1,000 adults over age 65. Nearly 6,700 adults over the age of 60 reside in Hardin County, making up 21% of the total population. Despite the growing older adult population and the growing falls epidemic, no regular older adult falls prevention programming was implemented in Hardin County prior to 2017. In 2017, UCHD utilized grant funding received from the Ohio Department of Health to expand falls prevention efforts into Hardin County. UCHD partnered with Ohio Northern University Raabe College of Pharmacy to develop a program that provides targeted medication reviews and home safety education and modifications to older adults with the purpose of lowering their risk of falling. The program is administered by trained pharmacy students and has the additional benefit of educating future pharmacists about the importance of falls prevention and providing them with direct experience working with older adults.
Each of the program components was developed from evidence-based strategies identified in the CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults” (https://www.cdc.gov/homeandrecreationalsafety/pdf/falls/cdc_falls_compendium-2015-a.pdf). The medication review is the clinical component of the intervention in which trained pharmacy students conduct a medication review with the purpose of identifying any medications that may increase the risk of falls and provide education to the patient. The pharmacy students utilize the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults” when conducting the medication review (https://www.sigot.org/allegato_docs/1057_Beers-Criteria.pdf). The program also includes a home safety component in which trained students review the CDC Home Safety Checklist” (https://www.cdc.gov/steadi/pdf/check_for_safety_brochure-a.pdf) with the patient and provide home safety items including, motion sensor night lights, a grabber, a nonslip bathroom mat, a roll of nonslip material, adjustable shower head, and pill boxes. Home assessments and modifications are an evidence-based strategy and identified by the Centers for Disease Control and Prevention as a building block to a successful community-based fall prevention program.
While the collaborative program with ONU is evidence-based and is modeled from strategies identified in the CDC's guide listed above, it is very innovative in its design and approach. While most medication review interventions are conducted in a pharmacy clinic or provider office setting, this program engages pharmacy students in providing medication reviews in partnership with a rehabilitation program at a skilled nursing facility. The partnership with the skilled nursing facility allows for the program to provide additional support to patients who are at high risk of falling at a critical time, before they are returning home following rehabilitation from an injury.
The involvement of the students in program implementation is innovative and has a number of advantages. The students provide benefit to the rehabilitation program and its patients by offering falls prevention assessment and education before patients return to the home environment. It also provides great benefit to the students and the future of the pharmacy workforce by giving students the opportunity to learn about their crucial role in preventing falls among older adults, to participate in professional development activities, and to experience interdisciplinary collaboration in working with the therapy team. Additionally, participation in the program helps students to meet service learning requirements. Students at the ONU Raabe College of Pharmacy are required to do 20 hours of general service learning during their first two years and 40 hours of direct patient community outreach by the end of their fifth year of study.
The program is also innovative in its multifaceted approach to falls prevention. Though the program is implemented by pharmacy students, it also incorporates non-clinical approaches to falls prevention. The majority of falls occur in the home and many falls risks in the home can be easily mitigated to reduce the likelihood of a fall. This program engages the pharmacy students in reviewing the CDC Home Safety Checklist and providing home safety education to patients during the visit. The patients are also provided with some of the most common home safety items that they can utilize upon returning home. The inclusion of home safety in the program also provides the participating students with a more well-rounded understanding of falls prevention methods.
UCHD recruited ONU's Raabe College of Pharmacy and a program plan was developed that includes both home safety intervention and clinical intervention through the use of targeted medication reviews and home safety education and items. It was determined that the program would be administered through a partnership between ONU and Vancrest of Ada that would allow trained students to conduct visits with patients preparing to be discharged home following rehabilitation. This partnership was facilitated by a faculty member within the College of Pharmacy who had an established affiliate agreement with Vancrest. During the first half of 2017, ONU and UCHD collaborated to develop the program description, procedures, detailed timeline, budget, objectives, and materials for student training. A contract was also developed for UCHD to provide funding to ONU for purchasing home safety materials that are distributed to older adults through the program. A reporting process was created for UCHD to monitor program progress and provide technical assistance as needed. UCHD maintains regular contact through phone calls, emails, and visits with program partners.
The goals outlined in the program description are: 1. Prevent falls among older adults in Hardin County through the provision of targeted medication reviews, home safety education, and home safety items; 2. Expose pharmacy students to the importance of falls prevention while contributing to their professional development.
The program was launched in the fall of 2017 with the beginning of the school year. Students participating in the program completed a two-hour training that included education on falls prevention methods, interactive case discussions, and mock patient visits. A falls prevention resource folder was created and provided to students administering the program that included the CDC Home Safety Checklist”, the American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults”, and an action plan form to be completed during patient visits.
The faculty advisor to the program collaborates with the Director of Therapy at Vancrest to identify patients for participation in the visits with the target of scheduling 3-5 patient visits per month. Initially, the program was designed with the intention of conducting the visits in the patient's home so that the home assessment could be conducted by the student during the visit. However, coordination between therapy and student availability was found to be extremely challenging and prohibitive to scheduling the targeted 3-5 visits per month laid out in the program plan. All program partners agreed to address this barrier by shifting away from home visits to conducting the visits at the facility. In place of the home safety assessment, the students provide home safety education during the visit at the facility with the older adult and their spouse (if present) in conjunction with the therapy team. The therapy team often reports what modifications in the home might be needed, and provides their input on concerns that they have regarding home safety for a particular patient. Participating patients are provided with the CDC Home Safety Checklist and a basket of some of the most common safety modifications to utilize upon returning to his/her home.
During the visit, a targeted medication review is also conducted and the student provides education to the patient on falls risks associated with his/her prescription and non-prescription medications. Upon the patient's consent to participate in the program, his/her medication list is made available to the students prior to the home-based falls prevention visit. An action plan is completed to list the recommendations that were provided by the two students during the patient visit and any further steps that need to be taken in the future. The action plan is reviewed and signed by the faculty advisor before being copied and provided to both the patient and the Director of Therapy.
In addition to the regular programming, students at ONU have developed and coordinated falls prevention events with the facility activities director at Vancrest in order to increase awareness of the falls prevention programming and to increase collaboration between partners. These events have included a falls prevention bingo game day and a falls event that coincided with the facility Christmas party for residents within the rehabilitation unit and assisted living residents within the same facility. The bingo game provided home safety education and medication counseling and home safety baskets were distributed to the winners. At the Christmas party, 28 residents received a medication review, a review of the CDC Home Safety Checklist”, and a falls prevention basket with home safety items. These events will be incorporated regularly into programming to enhance the relationship between ONU and Vancrest.
Three thousand dollars was provided by UCHD to fund the cost of home safety items to be distributed by the program. The main cost for program development and implementation is staff time, however, this is considered as in-kind support from all the participating partner organizations. Program folders were also supplied as in-kind support by ONU. Home safety items were purchased throughout the year as needed. An estimated breakdown of material costs for one year of the program is provided below:
Student program folders/materials (estimate of in-kind) - $72.00 – 60 folders/materials at $1.20 each
Anti-slip bath mats - $481.60 – 70 mats at $6.88 each
Motion sensor nightlights - $557.90 – 70 at $7.97 each
Non-slip material backing- $331.80-70 at $4.74 each
Adjustable handheld shower head-$649.60-70 at $9.28 each
Grabbers-$691.60-70 at $9.88 each
Pill boxes-$232.40-70 at $3.32 each
As described in previous sections, the goals of the program are to prevent falls among older adults in Hardin County through the provision of targeted medication reviews, home safety education/items, and to expose pharmacy students to the importance of falls prevention while contributing to their professional development. Evaluation measures were identified during the creation of UCHD's 2017 falls prevention work plan to monitor the implementation progress. Additional measures were developed upon identifying the project partners and developing the detailed program plan and reporting mechanism.
Process outcomes measures included:
Identification and recruitment of Hardin County partner organization.
Completion of program description and implementation plan.
Completion of training materials and program materials.
Completion of contract to provide funds for modifications.
Completion of quarterly and yearly reporting.
The above measures allowed UCHD and program partners to monitor the implementation progress and determine if process objectives and projected timelines were being met. The process outcomes were monitored regularly by the UCHD injury prevention coordinator and all process objectives were achieved.
Outcome evaluation measures included:
Number of pharmacy students who received training.
Number of pharmacy students who participated in medication reviews/home safety education.
Number of older adults who received medication review.
Number of older adults who had changes made to their medication regimens.
Number of older adults who received home safety education.
Number of older adults who received home safety materials.
Number of older adults who received an in-home safety assessment.
The outcome evaluation measures above were chosen to help evaluate whether the program is achieving the intended outcomes and to assess the impact of the program on pharmacy students, older adults, and key project partners. In addition to the outcomes listed above, the program is also measuring short-term outcomes via an anonymous survey given to older adult participants following their visit from the pharmacy students. The survey measures their satisfaction with the visit, their self-efficacy to make changes to their home, their perceived knowledge of falls prevention measures, and the likelihood that they will follow up with their physician. Faculty leaders of the program track the outcomes listed above and complete a quarterly report that is shared with UCHD. The faculty leaders also provide a written report every 6 months that details program progress, challenges, and successes.
Some adjustments were made to the program based on the information collected through regular monitoring. When the program launched in fall 2017, numbers indicated that the patient visits were not being scheduled at the expected frequency (3-5 visits per month). Upon further discussion with program partners, scheduling the patient visits to occur in the patient's home was a significant barrier that was not anticipated during planning. The program plan was then adjusted to have all activities scheduled and occurring onsite at Vancrest of Ada before the patient is discharged. Following the adjustment, scheduling and communication improved and visits were able to be scheduled regularly as intended. Due to the location shift, the home assessment portion of the visit was adjusted to include a review of the CDC Home Safety Checklist” with patient and spouse (if in attendance) and education about safety improvements that could be made to the home to reduce the risk of falls. The patients were also given a basket containing the most common home safety items instead of being provided with individualized modification items based on the assessment of the home. An in-home assessment was then offered directly to the patient following their onsite visit. Results indicate that very few older adults opt to participate in the in-home assessment.
During the first school year of the program (September 2018-May 2018), 50 pharmacy students participated in the falls prevention training, 27 older adults received a targeted medication review and home safety education (1 of them being an in-home assessment), 33 older adults were impacted by home modification items (includes participants and spouses), and 28 students participated in offering medication reviews/home safety education. The program was slow to start due to the initial scheduling challenges detailed above, but with adjustments to the implementation, the program averaged the targeted 3-5 visits per month during its first year.
With many of the initial challenges and barriers addressed during the first year, the program has been steadily performing patient visits during the first half of its second year. From September 2018 to December 2018, 34 individual patient visits were conducted (an average of 7 visits per month).
One hundred percent of older adults who participated in the program indicated via survey that they felt more capable of making changes to their home. The survey also showed that 90% of participants perceived that their knowledge had increased in relation to what increases their risk for falls and 90% indicated that they found the experience useful to very useful. Seventy percent indicated that they planned to follow up with their doctor after the visit.
When setting out to expand falls prevention programming into Hardin County, UCHD intentionally sought out a Hardin County organization with the will and ability to house and sustain such a program long term. Throughout the development of the home safety assessment and modification program in Union county, our staff have learned that it is much more effective and sustainable to embed programming into organizations and systems already operating in the target community. Having ONU as a committed partner ensures a consistent availability of students to provide the programming. Building their services into the discharge process at Vancrest allows the program to systematically identify and reach older adults at high risk for a fall.
ONU has demonstrated a strong commitment to falls prevention and continues to offer and even expand their programming. The ONU American Society of Consultant Pharmacists (ASCP) student chapter adopted the falls prevention project as their outreach program and is committed to continuing the program in the community for years to come. Every year the ASCP chapter plans to train its' current and new members on how to implement this program in partnership with Vancrest of Ada. If current funding for home safety items becomes unavailable, the faculty leaders will continue to seek other funding opportunities. However, the rest of the program does not require funding and the students will still be able to conduct the home safety education and medication review session without items to distribute.
Due to the success of the program thus far, ONU has begun to expand their programming and will continue to do so in 2019 to offer additional professional development opportunities for their students in the area of falls prevention. ONU has begun utilizing a mobile clinic bus owned by the college to offer medication reviews and home safety education, particularly in low income areas of Hardin county. Additionally, ONU plans to build the falls prevention activities into a class in 2019 that will conduct medication review/home safety education visits at various low-income senior housing locations throughout Hardin and Allen counties.
An additional aim of this project has been to promote falls prevention programming to other pharmacy schools in the state of Ohio. ONU has worked to promote their work to the other 6 colleges of pharmacy in Ohio through sharing their falls prevention bingo and medication safety sheets and presenting on their program. Plans are underway for University of Cincinnati to develop their own falls prevention program in 2019 with technical assistance and funding support from ONU and UCHD.
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