Implementation and Assessment of a Fall Screening Program in Primary Care Practices Suzanne E. Landis, MD, MPH*† and Shelley L. Galvin, MA*
Fall prevention strategies for older adults are underused in primary care. A study was designed to examine the Centers for Medicare and Medicaid Services Physician Quality Reporting System (PQRS) fall measures and to reduce injuries and costs from falls by 10%. This quality improvement project using a pre/post design was implemented in four primary care practices with 2,021 patients aged 65 and older in Asheville, North Carolina. The project used a patient registry, electronic templates, standardized care protocols, a falls clinic to evaluate individuals who reported falling, and patient resource materials. Data were collected from medical records on processes of care, fall-related injuries, and anticipated payments. Individuals billed for at least one outpatient visit from July 2011 through June 2012 (n = 2,021) constituted the cohort for the intervention and for analysis of injuries from falls requiring hospital visits (before the intervention (T1): July 2010 to March 2011; after the intervention (T2): July 2012 to March 2013). Practice sites properly screened 68.8% of older adults for falls, assessed 87% of those who reported falling, and documented the PQRS required plan of care in 23%. Only 20% self-reported falls. Numbers of falls requiring a visit to the hospital were small overall and did not decrease (T1, 2.4%; T2, 2.9%; P = .32); 61% of individuals seen in the hospital for fall-related injuries had not reported previous falls. Incorporating the PQRS fall measures into primary care was challenging, and the program was not robust enough to reduce serious falls and hospital costs. J Am Geriatr Soc 62:2408–2414, 2014.
Key words: fall prevention; older adults; quality improvement; Physician Quality Reporting System
From the *Mountain Area Health Education Center, Asheville; and Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina. †
Address correspondence to Suzanne E. Landis, Mountain Area Health Education Center, 121 Hendersonville Road, Asheville, NC 28803. E-mail: [email protected]
O
ne in three adults aged 65 and older fall annually, and one in three of those who fall sustain a moderate to severe injury.1 Morbidity from falls includes fractures of the hand, arm, leg, hip, pelvis, and spine; traumatic brain injuries; and death. Medical costs for falls in the United States in 2010 exceed $30 billion annually.1,2 For these reasons, our national public health priorities, Healthy People 2020, include fall prevention objectives.3 In addition, the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) has established various indices that physician practices may choose to report by 2015; falls screening is one option.4 Evidence-based strategies to successfully implement the PQRS fall measures have not been published for primary care providers.
BACKGROUND AND KNOWLEDGE Although there are at least 22 effective community-based fall prevention programs, the adoption of provider components in clinical settings has been slow.5–7 Variation in recommendations for providers confound the issue. The American Geriatrics Society recommends that physicians ask patients yearly whether they have had two or more falls, had an acute fall, or have difficulty with walking or balance.8 The Centers for Disease Control and Prevention (CDC), through their Stopping Elderly Accidents, Deaths, and Injuries tool (STEADI), recommends that primary care physicians screen patients annually for falling in the past year, feeling unsteady when standing or walking, worrying about falling, and scoring four or more on the Stay Independent survey.9 The PQRS screening requirement is limited to self-report of falling in the past 12 months as a trigger for the risk assessment and subsequent plan of care as needed.10,11 The PQRS measures require a falls risk assessment (#154) and falls plan of care (#155).10,11 A falls risk assessment requires the reporting of the “percentage of patients aged 65 years and older with a history of falls who had a Risk Assessment for falls completed within 12 months.”10 A falls plan of care requires the reporting
DOI: 10.1111/jgs.13137
JAGS 62:2408–2414, 2014 © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society
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of the “percentage of patients aged 65 years and older with a history of falls who had a Plan of Care for falls documented within 12 months.”11 How physicians incorporate these risk assessments and plans of care into their practices is left up to them. Physicians are also responsible for developing methods of tracking and reporting the percentages of their patients with documented risk assessments and plans of care. In addition to the burden of systems development and implementation, physicians reported that screening for falls increases the difficulty and length of a patient encounter.12 Reports of quality improvement (QI) methods in the physician office setting applied to implementing the PQRS falls measures have not been found. An opportunity was seen to apply QI to develop, implement, and test a falls screening, assessment, and plan of care program in which the items necessary for PQRS would be collected and reported. In addition, the opportunity was seen to incorporate the assessment of the intervention’s outcomes, including whether individuals sustained fewer falls with injuries over time and whether costs related to fall-related injuries decreased. The addition of these two outcomes allows for the integration of PQRS objectives into those of the Institute for Healthcare Improvement’s Triple Aim Initiative: improved patient experience of care, improved health of populations, and reduced per capita costs of health care.13,14
LOCAL PROBLEM According to the North Carolina Falls Prevention Coalition, the leading cause of injury deaths for older adults in 2011 was falls. On an average day in North Carolina, there are 531 visits to emergency departments (EDs), 69 individuals admitted to the hospital, and two fall-related fatalities. North Carolina medical costs associated with falls in 2011 were $806 million.15 In 2012, western North Carolina, the western-most 16 counties, had higher rates of older adults (12.9% vs 19%) and injury-related deaths due to unintentional falls (47% vs 52%) than the rest of North Carolina.15–17 Thus, effective interventions in western North Carolina have the potential to effect substantially the morbidity, mortality, and costs of fall-related health care in older adults.
STUDY QUESTION Could a falls screening, assessment, and plan-of-care intervention in primary care for individuals aged 65 and older, patterned after the PQRS falls measures to achieve Triple Aim objectives, be implemented? Specifically, the objectives were to implement this intervention successfully to reduce injuries from falls by 10% and per capita costs from fall-related injuries by 10%.
METHODS Ethical Concerns The Mission Health institutional review board in Asheville, North Carolina, approved this project.
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Setting Four primary care practice sites operated by the Mountain Area Health Education Center Division of Family Medicine and located in Asheville, North Carolina (population ~70,000), in Buncombe County (population ~240,000)18 encompass two continuous care retirement communities (CCRC) with approximately 800 residents with an average age of 82, a rural site with 4,000 patients of all ages, and an urban family medicine residency with 10,000 patients of all ages; more than 2,000 patients are aged 65 and older. All practices have received the National Committee for Quality Assurance’s Patient Centered Medical Home level three recognition.19 Faculty physicians, family medicine residents, geriatric fellows, and midlevel providers operate in a fee-for-service environment providing more than 35,000 patient visits annually. The Mountain Area Health Education Center payer mix is 32% Medicare, 29% Medicaid, 28% commercial insurance, 9% self-pay, and 2% indigent.
Planning the Intervention A 25-month continuous quality improvement (CQI) process engaged a team including family medicine residents, physicians, nursing staff, and patients beginning in March 2011. Using the Find a process to improve; Organize a team; Clarify current understanding; Understand variation; Select an intervention; Plan-Do-Study-Act (PDSA) process improvement model, the team set about understanding variations in clinical processes across the four practices, selecting interventions, and using rapid-cycle PDSAs to check on small tests of change.20 The CQI team designed the intervention, which included a clinical protocol, a falls evaluation clinic, patient self-management resources, a falls registry, and an electronic health record (EHR) template. The protocol detailed the assessment and development of care plans for individuals who reported falls based on the PQRS falls measures. Assessment (#154): nursing staff asked patients annually during check-in whether they had fallen in the past 12 months. If they had not fallen or had fallen once without sustaining injuries requiring a visit to a physician, no further assessment was required. If they had fallen two or more times or had one fall requiring a visit to a physician, PQRS required a risk assessment and a plan of care. The risk assessment includes a gait and mobility assessment such as the Timed Up and Go (TUG) test21 and one of the following: orthostatic vital signs, vision check, home safety assessment, or documentation of use of high-risk medications.10 The plan of care includes proper use of or referral for an assistive walking device and referral for appropriate exercise program.11 PQRS falls measures do not require documentation or reporting of the specific management of individuals who have fallen except for the above mentioned items, although good medical care requires investigating other contributory factors such as inadequate footwear and cardiac, neurological, and orthopedic problems; if an expanded risk assessment was performed, this information was also recorded in the EHR. Likewise, the PQRS does not require
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documentation and reporting of follow-up, including adherence to a plan of care. A geriatric physicians’ assistant, trained in the clinical protocol by one of the authors (SEL), started falls evaluation clinics at three of the four practices. Self-management resources included lists of local tai chi and other appropriate exercise programs. The CQI team developed a falls registry to monitor the PQRS measures monthly and report to physicians quarterly whether their patients were screened and assessed if self-reporting falls and had a plan of care— referred for evaluation for an assistive device and exercise programs. A nurse proactively managed the registry by calling individuals who had not been screened or who screened positive but had not been assessed to schedule further evaluation. A falls template was designed and inserted into the EHR to capture all of the important clinical and PQRS-required data fields.
Planning the Study of the Intervention While this model of the PQRS falls measures was established through multiple practice-wide trainings, an evaluation plan with process and outcome measures was concurrently implemented. The objectives were to track and describe progress toward successful implementation of the PQRS falls measures and compare rates of actual falls and fall-related hospital expenses in a cohort of individuals before and after implementation of this intervention. The intervention was initiated in July 2011.
Methods of Evaluation A pre/postimplementation study was designed, and a cohort of individuals who had been seen at least once in the practices during the intervention period from July 2011 through June 2012 was selected (n = 2,021). The preintervention period (T1) was July 2010 through March 2011, and the postintervention period (T2) was July 2012 through March 2013.
Measures Process measures that PQRS required were (i) the percentage of individuals aged 65 and older screened for selfreported falls and, if they reported falling (≥2 times or one fall with an injury requiring a visit to a physician), were properly assessed in the primary care practice using the TUG test and one of orthostatic vital signs, vision assessment, home safety check, and use of high-risk medications (PQRS #154) and (ii) the percentage of this cohort who screened positive who had a documented plan of care focused on proper use of, or referral for, an assistive device and referral for proper exercise program (PQRS # 155).10,11 PQRS #154 includes the individuals who were screened and reported that they did not fall and those screened who reported that they had fallen and were properly assessed. PQRS #155 requires both elements of the plan of care to be in place. Individuals with limited mobility or who were bed ridden, immobile, confined to chair, or wheelchair bound were exempt from the risk assessment and documentation
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of a plan of care. All these data for the PQRS measures were collected electronically from the EHR. Process measures were calculated and reported according to month for the entire 25 months of the CQI process. Outcome measures were injuries in the cohort of older adults associated with unintentional falls requiring an ED visit or a hospital admission and anticipated payments for those visits. International Classification of Diseases, Ninth Revision, codes 800 to 848, 850 to 854, and 920 to 924 and E codes 880.0 to 886.9 and 888 for injuries from unintentional falls were used to determine causes of ED visits and hospitalizations.22 Outcome data were extracted electronically from hospital databases for T1 and T2. Follow-up data were extracted from the EHR for individuals whose records contained documentation of PQRS risk assessments to determine what percentage of individuals adhered to their plan of care and whether postintervention hospitalizations were related to exposure or follow-up to the PQRS-based intervention. Follow-up data included completion of referral appointments to physical therapy, physician specialists, and other fall-specific follow-up documented in the EHR.
Analysis Data for the cohort of 2,021 individuals over the 12month intervention period were combined, and annual rates for the PQRS measures were calculated. Inpatient and observation admissions were combined as hospitalizations. Follow-up data were categorized as adherence to the plan of care or none. The incidence of falls treated at the hospital was reported per 1,000 people. The rates of individuals who fell in T1 and T2 were compared using the McNemar test. Changes in types and durations of hospitalizations were examined using Chi-square and Mann-Whitney analyses, respectively. To determine changes in anticipated payments to the hospital, an increase in hospital Medicare costs (S&P Healthcare Economic Hospital Medicare Index) of 1.03% in 2010–11 and 2.61% in 2011–12 was assumed.23,24 Anticipated payments to the hospital were adjusted using costs for 2012 as the base rate: [Costs2010 + (Costs2010 9 1.03%)] +[(Adj Costs2010 for 2011 9 2.61%)] = Adj Costs for 2012.25 Changes in hospital costs for treating falls were examined using Mann–Whitney tests. Percentage of hospitalizations for individuals with full exposure to the intervention and appropriate follow-up (assessment, plan of care and adherence), with exposure without follow-up (assessment and plan of care but no adherence), and with inadequate exposure (not assessed and/or no plan of care) was compared using chi-square analysis. SPSS version 21 (SPSS Inc., Chicago, IL) was used for analysis, with significance at P < .05.
OUTCOMES Process Measures PQRS Measures Assessed Monthly Although steady improvement in the rate of screening and appropriate assessment of individuals seen each month
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was demonstrated, the goal of 80% was not attained, with 76% reached during the final months of the CQI process (Figure 1). The intervention was not successful in ensuring that individuals needing a plan of care (according to PQRS) had one documented; at best, only 29% were reached in any of the months during the CQI process.
PQRS Measures for Intervention Cohort (n = 2,021) The annual rate of screening for the cohort of individuals seen during the intervention year was 68.8% (n = 1,391). This included individuals who were screened and reported that they did not fall (n = 1,135), those screened who reported that they fell and then were properly assessed (n = 204), and those who screened positive but were too immobile to assess (n = 52). Only 31 (13.2%) who should have been assessed were not.
Outcome Measures Falls Requiring Hospital Visits The rate of falls in this cohort increased slightly from 25 (95% confidence interval (CI) = 17.9–31.6) per 1,000 people to 33 (95% CI = 26.3–40) per 1,000 people. The rate of frequent falls (≥2 falls within 9 months) increased from 1 (95% CI = 0.03–5.6) in 1,000 people to 4 (95% CI = 1.1–10.2) in 1,000 people. During T1, 48 (2.4%) individuals experienced 50 falls requiring an ED visit or hospitalization, compared with 60 (3.0%) people with 67 falls during T2 (P = .32); four individuals fell in both time periods. ED visits made up 60.0% (30/50) of the total visits in T1 and 61.2% (41/67) in T2 (P > .99). Median length of stay for hospitalizations was not significantly different over the two time periods (T1 = 3 (interquartile range (IQR) 1–9) vs T2 = 3 (IQR 1–9); P = .66). Of the 60 individuals who fell in T2, 47 (78.3%) had been screened for falls before their hospital visit. Of those who had been screened, 36.2% (17/47) reported one fall with injury or two or more falls within the past year. Of
80
Anticipated Payments The total expected hospital payments for fall-related care increased 8.6%, from $201,330 in T1 (adjusted to 2012 dollars) to $293,063 in T2. The average expected adjusted payment per fall to the hospital was $4,027 5,006) in T1 and $4,374 6,228 in T2 (P = .94; See Figure 2).
Follow-Up to Plan of Care Of the 204 individuals who had risk assessments, 77 had documentation in their charts of all of the PQRS assessments (TUG, orthostatic vital signs, vision, home safety, high-risk medications) and were healthy enough to participate in a plan of care; 40 (51.9%) had been seen in the falls clinic, and 56 (72.7%) had a properly documented plan of care. Of the 56 with a plan of care, 34 (60.7%) had documentation that they had followed through with their plan of care; only one (2.9%) was seen in the hospital for a fall after the intervention. Of the 22 who had no documentation about adherence to the plan of care, three (13.6%) were seen in the hospital for falls (P = .26). Of the 21 with no plan of care documented, three (13.6%) had hospital care for a fall-related event during the postintervention phase. The difference in rates of hospitalization between these three groups was not statistically significant (P = .06).
DISCUSSION Interventions in primary care practices focused on physician decision support, medical record prompts, and patient education materials have documented improvement in rates of assessments and development of plans of care in individuals who reported falling.26 The data from the current study also indicate improvement in assessment using similar office-based supports. The falls PQRS screening
75 76 76 76 76 72 74 74 74 74 74 74
60 50 Percent
the 17 who screened positive, seven were assessed, four had a documented plan of care, and one adhered to a plan of care.
Goal
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59
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30 29
20 17
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Figure 1. Physician Quality Reporting System measure #154: Percentage of patients screened and assessed (n = 2,021).
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$16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $-
Hospital Admission
ED Visit
T1: 2010-11
All Visits
T2: 2012-13
Figure 2. Average expected hospital payment for fall-related care according to visit type before (T1) and after the intervention (T2; n = 2,021). Mann–Whitney analysis, P > .05. ED = emergency department.
protocol was designed and implemented in primary care practices, and risk assessments were completed according to the PQRS requirements. Developing a plan of care— referring patients for appropriate assistive devices and for exercise programs focused on improving balance, flexibility, and strength—was less effective. The majority of individuals who fell and were seen in ED or hospital after the PQRS intervention (T2) had not previously indicated that they had fallen when screened in primary care. It is possible that self-report of falls during the office-based screening may not be totally accurate— people may underreport falls. Underreporting of falls may be attributed to individuals not being seen in the office after falls, not recognizing or acknowledging that a trip is a fall, not remembering a fall (cognitive dysfunction), or purposefully withholding falls history hoping to avoid a higher level of care (e.g., move from independent living to assisted living).12 A region-wide intervention composed of academic detailing to physicians and a robust county-wide fall prevention program resulted in 9% fewer overall serious injuries and 11% less fall-related use of health services than in regions of usual care in Connecticut.27 The baseline rate of falls in Connecticut was 31.9 per 1,000 person-years—similar to the current study’s rate of 33.3 per 1,000 personyears, although the current study lacked the region-wide interventions. No decrease in incidence or overall costs of falls requiring visits to the ED or admissions to the hospital from T1 to T2 was detected, although a nonsignificant trend toward fewer hospitalizations for falls was found in individuals who were fully assessed, had a plan of care, and adhered to the plan of care than for those who did not adhere to their plan. It may be that the clinical components of fall prevention (screening, assessing, and developing plans of care)—all that is required under PQRS—are necessary but not sufficient.
A drop in the falls rate may have been expected too soon after the intervention was implemented because it may take time for referrals and completion of exercise programs that improve balance and strength, such as tai chi.28 The Connecticut Falls Interventions Study compared a baseline period from October 1999 to September 2001 with an evaluation period of October 2004 to September 2006, leaving a 3-year period in between for implementation of the intervention.27 The current study’s intervention period was only 1 year, and this might have been too short to ensure adequate assessment and treatment for individuals who self-admitted to falling. Furthermore, relatively few fallers required hospital care, resulting in limited power to study change in incidence. The current cohort was 2 years older during the postintervention phase than in the preintervention period and thus potentially at more risk of falls. Overall, the percentage of recurrent fallers, even at 2 years older, was 20.2%. This rate, at the low end of reported recurrent falls in community-dwelling older adults (range 10–69%), suggests that a low-risk population was targeted for screening and assessment.29–32 Over the duration of this project, greater public awareness of the problem with falls may have led more families and care providers in older adult homes to seek assessment in the ED for minor falls, although there was no shift to a higher percentage of falls-related ED visits in T2. Alternatively, ED and hospital professionals may have more accurately reported and coded the encounters as fall related.
Lessons Learned A number of important lessons can be gleaned from this CQI project that may assist other primary care practices or healthcare systems as they try to implement the PQRS falls measures. Even though screening for falls can be
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perceived as additional nursing work, staff such as medical assistants and licensed practical nurses will follow protocols for screening and recording information into the EHR. The screening questions can be incorporated into the usual flow of gathering information from individuals before they see a physician. The protocol also instructed nursing staff to perform TUG tests, vision assessments, and home safety assessments and to measure orthostatic vital signs once a person screened positive, before the clinician saw the person. These additional services added at least 10 minutes to preparing the individual and quickly resulted in complaints from nursing staff and physicians because they interrupted the flow of patient care. Physicians found that adding the unanticipated but required PQRS falls assessment and plan of care to a more-extensive historical information and physical examination dictated by good clinical care easily added 30 minutes to a visit. To address this, physicians were asked to schedule people for return appointments to complete the PQRS fall risk assessment and plan of care, but after a few months of monitoring the data, this did not adequately increase the numbers of patients being assessed; physicians felt they were too busy and did not want to add this assessment even for future appointments, so the special falls clinic, run by a geriatric physicians’ assistant, was started. Although this relieved the nursing staff and the physicians from same-day and future risk assessments and care planning, it too required an additional visit. Scheduling staff reported patient complaints (e.g., they had just seen their physician, so they did not need a recheck; falls happen and cannot be reduced), and some people refused to schedule another visit for the PQRS falls assessment. Nursing staff and clinicians would require flexibility in their schedules so that the screening, assessment, and plan of care can be performed during the same visit. The PQRS falls measures require substantial coordination, time, and effort by many staff to implement the protocol successfully. Providers have many PQRS measures from which to choose. Falls is the hardest one that has been adopted in our practices; it is no longer being reported on as of 2013. The PQRS falls measures do not follow the AGS or CDC STEADI recommendations for screening older adults. PQRS does not require risk assessments outside of a TUG and one other item; the AGS and CDC STEADI tool recommend a broader risk assessment. If the current PQRSrecommended office-based intervention was expanded based on the AGS and CDC recommendations, the numbers who screen positive and are then assessed would increase considerably.1,8,9,26,33 Furthermore, PQRS does not require documentation of any other assessment of osteoporosis risk, functional ability, fear of falling, cognitive impairment, neurological functioning, urinary incontinence, cardiovascular examination, or depression, although these are all included in a proper evaluation of individuals who fall. PQRS also does not require documentation that individuals adhere to the plan of care and are no longer falling or are falling less often. PQRS falls measures miss individuals who are at risk of future falls as evidenced by the majority of individuals who went to the hospital for falls and had not reported previous falls.
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If the AGS or CDC screening recommendations were implemented in primary care, the TUG tests and a fear of falling survey would be added resulting in a longer screening to be completed annually on everyone; it is likely that the screening rate would be lower than in the current study. Furthermore, a greater percentage of individuals would be considered “at risk,” so more would require risk assessments and referral. Expanding the screening questions to follow the AGS or CDC recommendations would create even more work for primary care practices and more chances of problems with implementation, although it would be helpful to determine whether adhering to the AGS or CDC recommendations would lead to fewer falls.
CONCLUSIONS Implementing the PQRS falls measures into fee-for-service primary care is feasible but challenging. No reduction in serious falls occurred over the ensuing 9 months in the aging cohort that was screened in primary care. The PQRS-recommended office-based screening, assessment, and plan of care, as implemented in this program, was not robust enough to generate significant changes in injury rates. The lack of effectiveness of this falls prevention program may have resulted from inadequate implementation of the management component of the program.
ACKNOWLEDGMENTS The authors thank Susan Sutherland, PhD, for providing the hospital raw data on fall-related use and anticipated hospital payment. Paper presented at the American Geriatrics Society National Meeting, May 2013, Grapevine, Texas. Conflict of Interest: Dr. Landis received partial support for the project through a Centers for Medicare and Medicaid Services Innovation Award during 2012. Author Contributions: Landis: study idea, study design, conduct of study, interpretation of data, preparation of manuscript. Galvin: data abstraction, data analyses, interpretation of data, preparation of manuscript. Sponsor’s Role: The sponsor had no role in the design, methods, subject recruitment, data collections, analysis, or preparation of the paper.
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Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx Accessed November 4, 2013. Schwarz M, Landis SE, Rowe JE. A team approach to quality improvement. Fam Pract Manage 1999;6:25–30. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. The Timed Up and Go (TUG) test. 2001 August [on-line]. Available at http://www.cdc.gov/homeandrecreationalsafety/pdf/ steadi/timed_up_and_go_test.pdf Accessed November 4, 2013. Bohl AA, Fishman PA, Ciol MA et al. A longitudinal analysis of total 3-year healthcare costs for older adults who experience a fall requiring medical care. J Am Geriatr Soc 2010;58:853–860. U.S. Healthcare Costs Rose 5.58% Over 12-Months Ending May 2011 According to the S&P Healthcare Economic Indices. July 21, 2011. PRNewswire, United Business Media [on-line]. Available at http://www.prnewswire. com/news-releases/us-healthcare-costs-rose-558-over-the-12-months-endingmay-2011-according-to-the-sp-healthcare-economic-indices-125947913.html Accessed November 4, 2013. Annual Growth Rates Decelerate in November 2012 According to the S&P Healthcare Economic Composite Indices. January 17, 2013. PRNewswire, United Business Media [on-line]. Available at http://markets.financialcontent.com/stocks/news/read/23225898/ Accessed November 4, 2013. Kumaranayake L. The real and the nominal? Making inflationary adjustments to costs and other economic data. Health Policy Plan 2000;15:230– 234. Wenger NS, Roth CP, Hall WJ et al. Practice redesign to improve care for falls and urinary incontinence: Primary care intervention for older patients. Arch Intern Med 2010;170:1765–1772. Tinetti ME, Baker DI, King M et al. Effect of dissemination of evidence in reducing injuries from falls. N Engl J Med 2008;359:252–261. National Council on Aging. Tai Chi Moving for Better Balance. 2004 [on-line]. Available at http://www.ncoa.org/improve-health/center-forhealthy-aging/tai-chi-moving-for-better.html Accessed November 7, 2013. Shumway-Cook A, Ciol MA, Hoffman J et al. Falls in the Medicare population: Incidence, associated risk factor, and impact on health care. Phys Ther 2009;89:324–332. Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: A prospective study. J Gerontol 1991;46:M164–M170. Pluijm SM, Smit JH, Tropm EA et al. A risk profile for identifying community-dwelling elderly with a high risk for recurrent falling: Results of a 2year prospective study. Osteoporos Int 2006;17:417–425. Tinetti ME, Speechley M. Prevention of falls among the elderly. N Engl J Med 1989;320:1055–1059. Schubert TE, Smith ML, Prizer LP et al. Complexities of fall prevention in clinical settings: A commentary. Gerontologist 2014;54:550–558.
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Fall prevention strategies for older adults are underused in primary care. A study was designed to examine the Centers for Medicare and Medicaid Services Physician Quality Reporting System (PQRS) fall measures and to reduce injuries and costs from falls by 10%. This quality improvement project using a pre/post design was implemented in four primary care practices with 2,021 patients aged 65 and older in Asheville, North Carolina. The project used a patient registry, electronic templates, standardized care protocols, a falls clinic to evaluate individuals who reported falling, and patient resource materials. Data were collected from medical records on processes of care, fall-related injuries, and anticipated payments. Individuals billed for at least one outpatient visit from July 2011 through June 2012 (n = 2,021) constituted the cohort for the intervention and for analysis of injuries from falls requiring hospital visits (before the intervention (T1): July 2010 to March 2011; after the intervention (T2): July 2012 to March 2013). Practice sites properly screened 68.8% of older adults for falls, assessed 87% of those who reported falling, and documented the PQRS required plan of care in 23%. Only 20% self-reported falls. Numbers of falls requiring a visit to the hospital were small overall and did not decrease (T1, 2.4%; T2, 2.9%; P = .32); 61% of individuals seen in the hospital for fall-related injuries had not reported previous falls. Incorporating the PQRS fall measures into primary care was challenging, and the program was not robust enough to reduce serious falls and hospital costs. J Am Geriatr Soc 62:2408–2414, 2014.
Key words: fall prevention; older adults; quality improvement; Physician Quality Reporting System
From the *Mountain Area Health Education Center, Asheville; and Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina. †
Address correspondence to Suzanne E. Landis, Mountain Area Health Education Center, 121 Hendersonville Road, Asheville, NC 28803. E-mail: [email protected]
O
ne in three adults aged 65 and older fall annually, and one in three of those who fall sustain a moderate to severe injury.1 Morbidity from falls includes fractures of the hand, arm, leg, hip, pelvis, and spine; traumatic brain injuries; and death. Medical costs for falls in the United States in 2010 exceed $30 billion annually.1,2 For these reasons, our national public health priorities, Healthy People 2020, include fall prevention objectives.3 In addition, the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) has established various indices that physician practices may choose to report by 2015; falls screening is one option.4 Evidence-based strategies to successfully implement the PQRS fall measures have not been published for primary care providers.
BACKGROUND AND KNOWLEDGE Although there are at least 22 effective community-based fall prevention programs, the adoption of provider components in clinical settings has been slow.5–7 Variation in recommendations for providers confound the issue. The American Geriatrics Society recommends that physicians ask patients yearly whether they have had two or more falls, had an acute fall, or have difficulty with walking or balance.8 The Centers for Disease Control and Prevention (CDC), through their Stopping Elderly Accidents, Deaths, and Injuries tool (STEADI), recommends that primary care physicians screen patients annually for falling in the past year, feeling unsteady when standing or walking, worrying about falling, and scoring four or more on the Stay Independent survey.9 The PQRS screening requirement is limited to self-report of falling in the past 12 months as a trigger for the risk assessment and subsequent plan of care as needed.10,11 The PQRS measures require a falls risk assessment (#154) and falls plan of care (#155).10,11 A falls risk assessment requires the reporting of the “percentage of patients aged 65 years and older with a history of falls who had a Risk Assessment for falls completed within 12 months.”10 A falls plan of care requires the reporting
DOI: 10.1111/jgs.13137
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of the “percentage of patients aged 65 years and older with a history of falls who had a Plan of Care for falls documented within 12 months.”11 How physicians incorporate these risk assessments and plans of care into their practices is left up to them. Physicians are also responsible for developing methods of tracking and reporting the percentages of their patients with documented risk assessments and plans of care. In addition to the burden of systems development and implementation, physicians reported that screening for falls increases the difficulty and length of a patient encounter.12 Reports of quality improvement (QI) methods in the physician office setting applied to implementing the PQRS falls measures have not been found. An opportunity was seen to apply QI to develop, implement, and test a falls screening, assessment, and plan of care program in which the items necessary for PQRS would be collected and reported. In addition, the opportunity was seen to incorporate the assessment of the intervention’s outcomes, including whether individuals sustained fewer falls with injuries over time and whether costs related to fall-related injuries decreased. The addition of these two outcomes allows for the integration of PQRS objectives into those of the Institute for Healthcare Improvement’s Triple Aim Initiative: improved patient experience of care, improved health of populations, and reduced per capita costs of health care.13,14
LOCAL PROBLEM According to the North Carolina Falls Prevention Coalition, the leading cause of injury deaths for older adults in 2011 was falls. On an average day in North Carolina, there are 531 visits to emergency departments (EDs), 69 individuals admitted to the hospital, and two fall-related fatalities. North Carolina medical costs associated with falls in 2011 were $806 million.15 In 2012, western North Carolina, the western-most 16 counties, had higher rates of older adults (12.9% vs 19%) and injury-related deaths due to unintentional falls (47% vs 52%) than the rest of North Carolina.15–17 Thus, effective interventions in western North Carolina have the potential to effect substantially the morbidity, mortality, and costs of fall-related health care in older adults.
STUDY QUESTION Could a falls screening, assessment, and plan-of-care intervention in primary care for individuals aged 65 and older, patterned after the PQRS falls measures to achieve Triple Aim objectives, be implemented? Specifically, the objectives were to implement this intervention successfully to reduce injuries from falls by 10% and per capita costs from fall-related injuries by 10%.
METHODS Ethical Concerns The Mission Health institutional review board in Asheville, North Carolina, approved this project.
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Setting Four primary care practice sites operated by the Mountain Area Health Education Center Division of Family Medicine and located in Asheville, North Carolina (population ~70,000), in Buncombe County (population ~240,000)18 encompass two continuous care retirement communities (CCRC) with approximately 800 residents with an average age of 82, a rural site with 4,000 patients of all ages, and an urban family medicine residency with 10,000 patients of all ages; more than 2,000 patients are aged 65 and older. All practices have received the National Committee for Quality Assurance’s Patient Centered Medical Home level three recognition.19 Faculty physicians, family medicine residents, geriatric fellows, and midlevel providers operate in a fee-for-service environment providing more than 35,000 patient visits annually. The Mountain Area Health Education Center payer mix is 32% Medicare, 29% Medicaid, 28% commercial insurance, 9% self-pay, and 2% indigent.
Planning the Intervention A 25-month continuous quality improvement (CQI) process engaged a team including family medicine residents, physicians, nursing staff, and patients beginning in March 2011. Using the Find a process to improve; Organize a team; Clarify current understanding; Understand variation; Select an intervention; Plan-Do-Study-Act (PDSA) process improvement model, the team set about understanding variations in clinical processes across the four practices, selecting interventions, and using rapid-cycle PDSAs to check on small tests of change.20 The CQI team designed the intervention, which included a clinical protocol, a falls evaluation clinic, patient self-management resources, a falls registry, and an electronic health record (EHR) template. The protocol detailed the assessment and development of care plans for individuals who reported falls based on the PQRS falls measures. Assessment (#154): nursing staff asked patients annually during check-in whether they had fallen in the past 12 months. If they had not fallen or had fallen once without sustaining injuries requiring a visit to a physician, no further assessment was required. If they had fallen two or more times or had one fall requiring a visit to a physician, PQRS required a risk assessment and a plan of care. The risk assessment includes a gait and mobility assessment such as the Timed Up and Go (TUG) test21 and one of the following: orthostatic vital signs, vision check, home safety assessment, or documentation of use of high-risk medications.10 The plan of care includes proper use of or referral for an assistive walking device and referral for appropriate exercise program.11 PQRS falls measures do not require documentation or reporting of the specific management of individuals who have fallen except for the above mentioned items, although good medical care requires investigating other contributory factors such as inadequate footwear and cardiac, neurological, and orthopedic problems; if an expanded risk assessment was performed, this information was also recorded in the EHR. Likewise, the PQRS does not require
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documentation and reporting of follow-up, including adherence to a plan of care. A geriatric physicians’ assistant, trained in the clinical protocol by one of the authors (SEL), started falls evaluation clinics at three of the four practices. Self-management resources included lists of local tai chi and other appropriate exercise programs. The CQI team developed a falls registry to monitor the PQRS measures monthly and report to physicians quarterly whether their patients were screened and assessed if self-reporting falls and had a plan of care— referred for evaluation for an assistive device and exercise programs. A nurse proactively managed the registry by calling individuals who had not been screened or who screened positive but had not been assessed to schedule further evaluation. A falls template was designed and inserted into the EHR to capture all of the important clinical and PQRS-required data fields.
Planning the Study of the Intervention While this model of the PQRS falls measures was established through multiple practice-wide trainings, an evaluation plan with process and outcome measures was concurrently implemented. The objectives were to track and describe progress toward successful implementation of the PQRS falls measures and compare rates of actual falls and fall-related hospital expenses in a cohort of individuals before and after implementation of this intervention. The intervention was initiated in July 2011.
Methods of Evaluation A pre/postimplementation study was designed, and a cohort of individuals who had been seen at least once in the practices during the intervention period from July 2011 through June 2012 was selected (n = 2,021). The preintervention period (T1) was July 2010 through March 2011, and the postintervention period (T2) was July 2012 through March 2013.
Measures Process measures that PQRS required were (i) the percentage of individuals aged 65 and older screened for selfreported falls and, if they reported falling (≥2 times or one fall with an injury requiring a visit to a physician), were properly assessed in the primary care practice using the TUG test and one of orthostatic vital signs, vision assessment, home safety check, and use of high-risk medications (PQRS #154) and (ii) the percentage of this cohort who screened positive who had a documented plan of care focused on proper use of, or referral for, an assistive device and referral for proper exercise program (PQRS # 155).10,11 PQRS #154 includes the individuals who were screened and reported that they did not fall and those screened who reported that they had fallen and were properly assessed. PQRS #155 requires both elements of the plan of care to be in place. Individuals with limited mobility or who were bed ridden, immobile, confined to chair, or wheelchair bound were exempt from the risk assessment and documentation
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of a plan of care. All these data for the PQRS measures were collected electronically from the EHR. Process measures were calculated and reported according to month for the entire 25 months of the CQI process. Outcome measures were injuries in the cohort of older adults associated with unintentional falls requiring an ED visit or a hospital admission and anticipated payments for those visits. International Classification of Diseases, Ninth Revision, codes 800 to 848, 850 to 854, and 920 to 924 and E codes 880.0 to 886.9 and 888 for injuries from unintentional falls were used to determine causes of ED visits and hospitalizations.22 Outcome data were extracted electronically from hospital databases for T1 and T2. Follow-up data were extracted from the EHR for individuals whose records contained documentation of PQRS risk assessments to determine what percentage of individuals adhered to their plan of care and whether postintervention hospitalizations were related to exposure or follow-up to the PQRS-based intervention. Follow-up data included completion of referral appointments to physical therapy, physician specialists, and other fall-specific follow-up documented in the EHR.
Analysis Data for the cohort of 2,021 individuals over the 12month intervention period were combined, and annual rates for the PQRS measures were calculated. Inpatient and observation admissions were combined as hospitalizations. Follow-up data were categorized as adherence to the plan of care or none. The incidence of falls treated at the hospital was reported per 1,000 people. The rates of individuals who fell in T1 and T2 were compared using the McNemar test. Changes in types and durations of hospitalizations were examined using Chi-square and Mann-Whitney analyses, respectively. To determine changes in anticipated payments to the hospital, an increase in hospital Medicare costs (S&P Healthcare Economic Hospital Medicare Index) of 1.03% in 2010–11 and 2.61% in 2011–12 was assumed.23,24 Anticipated payments to the hospital were adjusted using costs for 2012 as the base rate: [Costs2010 + (Costs2010 9 1.03%)] +[(Adj Costs2010 for 2011 9 2.61%)] = Adj Costs for 2012.25 Changes in hospital costs for treating falls were examined using Mann–Whitney tests. Percentage of hospitalizations for individuals with full exposure to the intervention and appropriate follow-up (assessment, plan of care and adherence), with exposure without follow-up (assessment and plan of care but no adherence), and with inadequate exposure (not assessed and/or no plan of care) was compared using chi-square analysis. SPSS version 21 (SPSS Inc., Chicago, IL) was used for analysis, with significance at P < .05.
OUTCOMES Process Measures PQRS Measures Assessed Monthly Although steady improvement in the rate of screening and appropriate assessment of individuals seen each month
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was demonstrated, the goal of 80% was not attained, with 76% reached during the final months of the CQI process (Figure 1). The intervention was not successful in ensuring that individuals needing a plan of care (according to PQRS) had one documented; at best, only 29% were reached in any of the months during the CQI process.
PQRS Measures for Intervention Cohort (n = 2,021) The annual rate of screening for the cohort of individuals seen during the intervention year was 68.8% (n = 1,391). This included individuals who were screened and reported that they did not fall (n = 1,135), those screened who reported that they fell and then were properly assessed (n = 204), and those who screened positive but were too immobile to assess (n = 52). Only 31 (13.2%) who should have been assessed were not.
Outcome Measures Falls Requiring Hospital Visits The rate of falls in this cohort increased slightly from 25 (95% confidence interval (CI) = 17.9–31.6) per 1,000 people to 33 (95% CI = 26.3–40) per 1,000 people. The rate of frequent falls (≥2 falls within 9 months) increased from 1 (95% CI = 0.03–5.6) in 1,000 people to 4 (95% CI = 1.1–10.2) in 1,000 people. During T1, 48 (2.4%) individuals experienced 50 falls requiring an ED visit or hospitalization, compared with 60 (3.0%) people with 67 falls during T2 (P = .32); four individuals fell in both time periods. ED visits made up 60.0% (30/50) of the total visits in T1 and 61.2% (41/67) in T2 (P > .99). Median length of stay for hospitalizations was not significantly different over the two time periods (T1 = 3 (interquartile range (IQR) 1–9) vs T2 = 3 (IQR 1–9); P = .66). Of the 60 individuals who fell in T2, 47 (78.3%) had been screened for falls before their hospital visit. Of those who had been screened, 36.2% (17/47) reported one fall with injury or two or more falls within the past year. Of
80
Anticipated Payments The total expected hospital payments for fall-related care increased 8.6%, from $201,330 in T1 (adjusted to 2012 dollars) to $293,063 in T2. The average expected adjusted payment per fall to the hospital was $4,027 5,006) in T1 and $4,374 6,228 in T2 (P = .94; See Figure 2).
Follow-Up to Plan of Care Of the 204 individuals who had risk assessments, 77 had documentation in their charts of all of the PQRS assessments (TUG, orthostatic vital signs, vision, home safety, high-risk medications) and were healthy enough to participate in a plan of care; 40 (51.9%) had been seen in the falls clinic, and 56 (72.7%) had a properly documented plan of care. Of the 56 with a plan of care, 34 (60.7%) had documentation that they had followed through with their plan of care; only one (2.9%) was seen in the hospital for a fall after the intervention. Of the 22 who had no documentation about adherence to the plan of care, three (13.6%) were seen in the hospital for falls (P = .26). Of the 21 with no plan of care documented, three (13.6%) had hospital care for a fall-related event during the postintervention phase. The difference in rates of hospitalization between these three groups was not statistically significant (P = .06).
DISCUSSION Interventions in primary care practices focused on physician decision support, medical record prompts, and patient education materials have documented improvement in rates of assessments and development of plans of care in individuals who reported falling.26 The data from the current study also indicate improvement in assessment using similar office-based supports. The falls PQRS screening
75 76 76 76 76 72 74 74 74 74 74 74
60 50 Percent
the 17 who screened positive, seven were assessed, four had a documented plan of care, and one adhered to a plan of care.
Goal
70
55
59
63
67
49
40
42 37
30 29
20 17
10
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Figure 1. Physician Quality Reporting System measure #154: Percentage of patients screened and assessed (n = 2,021).
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$16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $-
Hospital Admission
ED Visit
T1: 2010-11
All Visits
T2: 2012-13
Figure 2. Average expected hospital payment for fall-related care according to visit type before (T1) and after the intervention (T2; n = 2,021). Mann–Whitney analysis, P > .05. ED = emergency department.
protocol was designed and implemented in primary care practices, and risk assessments were completed according to the PQRS requirements. Developing a plan of care— referring patients for appropriate assistive devices and for exercise programs focused on improving balance, flexibility, and strength—was less effective. The majority of individuals who fell and were seen in ED or hospital after the PQRS intervention (T2) had not previously indicated that they had fallen when screened in primary care. It is possible that self-report of falls during the office-based screening may not be totally accurate— people may underreport falls. Underreporting of falls may be attributed to individuals not being seen in the office after falls, not recognizing or acknowledging that a trip is a fall, not remembering a fall (cognitive dysfunction), or purposefully withholding falls history hoping to avoid a higher level of care (e.g., move from independent living to assisted living).12 A region-wide intervention composed of academic detailing to physicians and a robust county-wide fall prevention program resulted in 9% fewer overall serious injuries and 11% less fall-related use of health services than in regions of usual care in Connecticut.27 The baseline rate of falls in Connecticut was 31.9 per 1,000 person-years—similar to the current study’s rate of 33.3 per 1,000 personyears, although the current study lacked the region-wide interventions. No decrease in incidence or overall costs of falls requiring visits to the ED or admissions to the hospital from T1 to T2 was detected, although a nonsignificant trend toward fewer hospitalizations for falls was found in individuals who were fully assessed, had a plan of care, and adhered to the plan of care than for those who did not adhere to their plan. It may be that the clinical components of fall prevention (screening, assessing, and developing plans of care)—all that is required under PQRS—are necessary but not sufficient.
A drop in the falls rate may have been expected too soon after the intervention was implemented because it may take time for referrals and completion of exercise programs that improve balance and strength, such as tai chi.28 The Connecticut Falls Interventions Study compared a baseline period from October 1999 to September 2001 with an evaluation period of October 2004 to September 2006, leaving a 3-year period in between for implementation of the intervention.27 The current study’s intervention period was only 1 year, and this might have been too short to ensure adequate assessment and treatment for individuals who self-admitted to falling. Furthermore, relatively few fallers required hospital care, resulting in limited power to study change in incidence. The current cohort was 2 years older during the postintervention phase than in the preintervention period and thus potentially at more risk of falls. Overall, the percentage of recurrent fallers, even at 2 years older, was 20.2%. This rate, at the low end of reported recurrent falls in community-dwelling older adults (range 10–69%), suggests that a low-risk population was targeted for screening and assessment.29–32 Over the duration of this project, greater public awareness of the problem with falls may have led more families and care providers in older adult homes to seek assessment in the ED for minor falls, although there was no shift to a higher percentage of falls-related ED visits in T2. Alternatively, ED and hospital professionals may have more accurately reported and coded the encounters as fall related.
Lessons Learned A number of important lessons can be gleaned from this CQI project that may assist other primary care practices or healthcare systems as they try to implement the PQRS falls measures. Even though screening for falls can be
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perceived as additional nursing work, staff such as medical assistants and licensed practical nurses will follow protocols for screening and recording information into the EHR. The screening questions can be incorporated into the usual flow of gathering information from individuals before they see a physician. The protocol also instructed nursing staff to perform TUG tests, vision assessments, and home safety assessments and to measure orthostatic vital signs once a person screened positive, before the clinician saw the person. These additional services added at least 10 minutes to preparing the individual and quickly resulted in complaints from nursing staff and physicians because they interrupted the flow of patient care. Physicians found that adding the unanticipated but required PQRS falls assessment and plan of care to a more-extensive historical information and physical examination dictated by good clinical care easily added 30 minutes to a visit. To address this, physicians were asked to schedule people for return appointments to complete the PQRS fall risk assessment and plan of care, but after a few months of monitoring the data, this did not adequately increase the numbers of patients being assessed; physicians felt they were too busy and did not want to add this assessment even for future appointments, so the special falls clinic, run by a geriatric physicians’ assistant, was started. Although this relieved the nursing staff and the physicians from same-day and future risk assessments and care planning, it too required an additional visit. Scheduling staff reported patient complaints (e.g., they had just seen their physician, so they did not need a recheck; falls happen and cannot be reduced), and some people refused to schedule another visit for the PQRS falls assessment. Nursing staff and clinicians would require flexibility in their schedules so that the screening, assessment, and plan of care can be performed during the same visit. The PQRS falls measures require substantial coordination, time, and effort by many staff to implement the protocol successfully. Providers have many PQRS measures from which to choose. Falls is the hardest one that has been adopted in our practices; it is no longer being reported on as of 2013. The PQRS falls measures do not follow the AGS or CDC STEADI recommendations for screening older adults. PQRS does not require risk assessments outside of a TUG and one other item; the AGS and CDC STEADI tool recommend a broader risk assessment. If the current PQRSrecommended office-based intervention was expanded based on the AGS and CDC recommendations, the numbers who screen positive and are then assessed would increase considerably.1,8,9,26,33 Furthermore, PQRS does not require documentation of any other assessment of osteoporosis risk, functional ability, fear of falling, cognitive impairment, neurological functioning, urinary incontinence, cardiovascular examination, or depression, although these are all included in a proper evaluation of individuals who fall. PQRS also does not require documentation that individuals adhere to the plan of care and are no longer falling or are falling less often. PQRS falls measures miss individuals who are at risk of future falls as evidenced by the majority of individuals who went to the hospital for falls and had not reported previous falls.
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If the AGS or CDC screening recommendations were implemented in primary care, the TUG tests and a fear of falling survey would be added resulting in a longer screening to be completed annually on everyone; it is likely that the screening rate would be lower than in the current study. Furthermore, a greater percentage of individuals would be considered “at risk,” so more would require risk assessments and referral. Expanding the screening questions to follow the AGS or CDC recommendations would create even more work for primary care practices and more chances of problems with implementation, although it would be helpful to determine whether adhering to the AGS or CDC recommendations would lead to fewer falls.
CONCLUSIONS Implementing the PQRS falls measures into fee-for-service primary care is feasible but challenging. No reduction in serious falls occurred over the ensuing 9 months in the aging cohort that was screened in primary care. The PQRS-recommended office-based screening, assessment, and plan of care, as implemented in this program, was not robust enough to generate significant changes in injury rates. The lack of effectiveness of this falls prevention program may have resulted from inadequate implementation of the management component of the program.
ACKNOWLEDGMENTS The authors thank Susan Sutherland, PhD, for providing the hospital raw data on fall-related use and anticipated hospital payment. Paper presented at the American Geriatrics Society National Meeting, May 2013, Grapevine, Texas. Conflict of Interest: Dr. Landis received partial support for the project through a Centers for Medicare and Medicaid Services Innovation Award during 2012. Author Contributions: Landis: study idea, study design, conduct of study, interpretation of data, preparation of manuscript. Galvin: data abstraction, data analyses, interpretation of data, preparation of manuscript. Sponsor’s Role: The sponsor had no role in the design, methods, subject recruitment, data collections, analysis, or preparation of the paper.
REFERENCES 1. Centers for Disease Control and Prevention. Falls among older adults: An overview. 2013 September [on-line]. Available at https://www.cdc.gov/ homeandrecreationalsafety/falls/adultfalls.html Accessed October 24, 2013. 2. Stevens JA, Phelan EA. Development of STEADI: A fall prevention resource for health care providers. Health Promot Pract 2013;14:706–714. 3. U.S. Department of Health and Human Services. Healthy People 2020: Injury and Violence Prevention. 2013 August [on-line]. Available at http://www. healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=24 Accessed October 24, 2013. 4. Centers for Medicare and Medicaid Services. Physicians Quality Reporting System. February 2012 [on-line]. Available at http://www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/PQRS/2011-PhysicianQuality-Reporting-System-Items/CMS1254515.html?DLPage=1&DLSort=0 &DLSortDir=ascending Accessed March 2, 2011. 5. Campbell AJ, Robertson MC. Implementation for multifactorial interventions for fall and fracture prevention. Age Ageing 2006;35(Suppl 2):60–64. 6. Stevens JA. A CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults, 2nd Ed., 2010 [on-line].
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