As our population ages, fall injuries and deaths in North Carolina (NC) are an increasingly serious public health issue. Falls are the fourth third leading cause of unintentional injury death for North Carolinians of all ages, and in every year from 1999 to 2017, the number one cause of injury death for individuals 65 and older. In 2018, there were 1241 unintentional fall-related deaths, over 19,000 hospitalizations, and over 100,000 falls-related emergency department (ED) visits among adults age 60 and older.
The Centers for Disease Control and Prevention (CDC) reports that more than one out of four OAs fall each year, but less than half tell their doctor. Falls are serious and costly with 20% of falls resulting in a serious injury such as fractures or traumatic brain injuries. In 2015, the Centers for Medicare and Medicaid Services (CMS) paid 75% of the $50 billion in medical costs due to falls.3 In 2018, the mean hospital discharge fee for NC residents age 60+ admitted for a fall was $48,837, a 160% increase from $18,800 in 2007. The total hospital discharge fees for North Carolinians age 60+ due to falls in 2018 was over $942 million dollars. Hospital charges account for a portion of the cost of a fall. Falls result in costs due to work loss and follow-up treatment. In 2018, 82.4% of unintentional fall hospitalizations were among people 60+. Of the 19,296 people age 60+ hospitalized following fall-related injuries in 2018, 61% were discharged to a skilled nursing facility, 13% required home health services, and 6% went to inpatient rehabilitation.
NCCHW established Healthy Aging NC as the state’s network hub for evidence-based programs (EBPs) in January 2016, with the goal of centralizing support for technical assistance, data management, data reporting, and communication. Since its inception, HANC has: centralized statewide coordination for programs and data collection/analysis; supported the expansion and continuum of chronic disease management programs, walking programs, and evidence-based falls prevention programs like A Matter of Balance and Tai Chi for Arthritis for Fall Prevention; and increased EBP visibility. This centralization has been progressing toward providing support for healthcare investments. The staff supports the integrated and sustainable EBP network in a way that didn’t exist before HANC. Centralized statewide data collection provides a sharper image of EBP impact, while dedicated staff improves responsiveness to program needs. In addition, our well-designed communications platforms such as www.healthyagingnc.com have received national recognition through media honors such as the Gold 2016 Marcom Award.
IGNITE COMMUNITY INITIATIVES
The North Carolina Center for Health and Wellness (NCCHW), housed at UNC Asheville, falls within the university’s Academic Affairs department. The mission of NCCHW is to develop equitable opportunities that lead to healthy NC communities. We impact policy, build capacity, and ignite community initiatives by working through a web of cross-sector relationships organized around building healthier places throughout the state.
The Falls Prevention Project Manager serves as the point person for day-to-day activities of the Heatlhy Aging NC Falls Prevention effort and manages subcontracts, prepares reports, and coordinates communication among partners. In addition to working closely with the High Country AAA for Tai Chi for Arthritis for Falls Prevention fidelity and tracking efforts, the Project Manager serves as the Executive Director of the NC Falls Prevention Coalition. Under their leadership, the NC Falls Prevention Coalition is undergoing a statewide strategic planning process to identify goals, objectives, and action items to guide the Coalition’s work for the next five years. Falls Prevention goals focus on three primary areas: advocacy and awareness, the continuum of care, and collaboration and coalition building. Partners engaged in this work include AAAs, state Department of Health and Human Services agencies such as the NC Division of Aging and Adult Services and the NC Division of Public Health, community-based organizations, and many health professionals. Through the 2017 ACL Falls Prevention grant, opportunities for community paramedicine, a fracture prevention clinic, a FQHC, and the largest hospital trauma department to link to EBFPPs in both formal and informal ways were created.
The NCCHW Data Manager manages data collection, entry into a national falls prevention program database (housed by the National Council on Aging), storage, and reporting for evidence-based falls prevention programs. The Data Manager is also responsible for managing the Healthy Aging NC website and e-mail account, regularly updating class information and registration online, and supporting the inquiries and online referrals for programs.
NCCHW Healthy Aging NC efforts are supported by the Director of State and Community Collaboration and the Director of Partnership and Evaluation. These additional staff members collaborate with state, regional, and local leaders to prioritize community needs, develop collaboration opportunities, expand efforts and evaluate efforts.
To continue and advance the work of the Healthy Aging NC Resource Center, the Division of Public Health’s Injury and Violence Prevention Branch included the Resource Center in their CDC CORE Injury funding request. As a result, the NCCHW has been awarded five years of funding to enhance the connections between Healthy Aging NC, the NC Falls Prevention Coalition and to promote the falls prevention screening and referral efforts using the evidence-based CDC Stopping Elderly Accidents, Deaths, and Injuries (STEADI) framework.
NCCHW embeds strategies that improve quality measures, raise awareness among clinicians and the public, and result in fewer fall related injuries and deaths among North Carolinians.
By 2025 it is projected that 90 of NC’s 100 counties will have more population age 60 and older than ages 0-17. This substantial increase of older adults in NC will likely result in a drastic rise in deaths, hospitalizations, and ED visits due to unintentional falls. Additional challenges are that community health improvement processes often lump fall related concerns in with “physical activity” or that awareness of the burden of falls in one’s area is unknown and the issue is not represented well in community or hospital assessments processes. Physicians, hospital staff, and other clinicians are often siloed from community-based organizations (CBOs), creating gaps in patient care.
We also have the challenge of changing public perception that falls are a preventable demise and not a normal part of aging.
Map of the Counties Impacted by Falls Prevention Trainings (Updated January 2020)
Systematically offering evidence-based falls prevention programs to populations at greatest risk of falls can offer significant healthcare cost savings by addressing many of the risk factors for falls, including medication use/misuse, vision problems, poor footwear, poor balance, home hazards, and others. Anticipated savings, or positive return on investment, has been documented by the Centers for Medicare and Medicaid Services for the A Matter of Balance (AMOB) and Tai Chi for Arthritis for Falls Prevention (TCA/FP) programs. AMOB “was associated with total medical cost savings, and cost savings in the unplanned in-patient, skilled nursing facility, and home health settings. AMOB participation was associated with a $938 decrease in total medical costs per year”. TCA/FP, previously referred to as the Arthritis Foundation Tai Chi Program, “estimated total cost savings of $1,111” in the report.” Both AMOB and TCA/FP are supported by the Healthy Aging NC (HANC) network hub, located within the NCCHW.
Additionally, we embed data collection and reporting systems for the various programs into the Statewide Falls Prevention Resource Center within Healthy Aging NC. We conduct data collection and dissemination for Administration for Community Living and Centers for Disease Control and Prevention grant reports as requested. Programs are promoted and delivered through the establishment or reinforcement of Regional integration committees and leveraging the successes of various Fall Prevention Coalition activities in the state, as well as through the Fall Prevention grant Clinical-Community Integration Committee and a variety of partners.
NC AAAs have been offering EBFPPs since 2007, and all currently send EBP data to NCCHW HANC. All 16 AAAs have delivered or built capacity to deliver EBFPPs, with metropolitan AAAs offering 20-30 workshops per year. NCCHW documents an average of 2000 enrolled participants in EBFPPs annually in NC since 2016. Most of these are AMOB participants (average of 1500 participants per year). NCCHW began supporting the statewide delivery of TCA/FP in 2017 and only supports programs that are offered for a minimum of 20 hours. To improve completion rates, NCCHW and NC DAAS (as part of OAA, Title IIID monitoring) require a minimum of 20 hours of program delivery to improve the TCA/FP completion rate (16 hours).
NCCHW’s completer rates (attendance of 5/8 AMOB sessions and 16/20 TCA/FP programs) are on par with national AMOB averages and better than national TCA/FP averages. We anticipate consistent enrollment of participants in programs through our robust and successful network of AAAs offering programs with administrative support from NCCHW’s HANC.
NC Division of Aging and Adult services
These state partners are integral part of the efforts to create more access and visibility of fall prevention strategies and evidence-based programs in North Carolina. We work with them to disseminate information and updates about Resource Center activities and the Senior Center Network among the aging network partners. We also collaborate with them to make strategic choices and create guidance for the state on how to disseminate and operate evidence-based programs.
NC DHHS, Division of Public Health, Injury and Violence Prevention Branch
This group provides up to date data on the state of fall death and injury in the state and provide access to partners with whom we share our resources. To continue and advance the work of the Healthy Aging NC Resource Center, the Division of Public Health’s Injury and Violence Prevention Branch included the Resource Center in their CDC CORE Injury funding request. As a result, the NCCHW was awarded $25,000 per year for 5 years to enhance the connections between Healthy Aging NC, the NC Falls Prevention Coalition and to promote the CDC STEADI initiative.
NC Association of Area Agencies on Aging (NC4A)
16 Area Agencies on Aging are responsible for a variety of health promotion and aging services in North Carolina and primary implementers of the A Matter of Balance and Tai Chi for Arthritis and Fall Prevention programs. We provide technical assistance and expansion support to alleviate many of their administrative burdens. Five Western NC AAAs have a direct contract with NCCHW for evidence-based falls prevention programs. Thirteen of 16 AAAs have a direct contract for Healthy Aging NC activities.
YMCA Alliance of NC/ YMCA of WNC
The YMCA of WNC and YMCA Alliance of NC are the disseminators of the YMCA: Moving for Better Balance Tai Chi and Enhance Fitness programs. The YMCA Alliance of NC and YMCA of WNC are active members of the NC Falls Prevention Coalition. The YMCA of WNC and the Land of Sky Area Agency on Aging have partnered to explore strategies for supporting program participants on a continuum of care and partnered to offer A Matter of Balance.
NC DHHS, Office of Rural Health
UNC Chapel Hill
UNC Chapel Hill houses the Carolina Geriatric Education Workforce Enhancement Program which is an integral leader in expanding education around the Otago Exercise Program to physical therapists throughout the nation.
Home Health Agencies
Various home health agencies partner with state and local fall prevention coalitions and historically are interested in championing programs and being the eyes and ears of their communities to implement fall prevention strategies.
Mission HCA is committed to the health and wellness of the 18 western most counties in North Carolina. NCCHW staff work together with Mission staff to embed evidence-based programs as part of the standard of care for the aging population in Western North Carolina.
Regional and State Fall Prevention Coalitions
NCCHW serves on and works in conjunction with the state and several regional coalitions where fall prevention information and best practices are shared among various community stakeholders.
NC Physical Therapy Association
Multiple agencies that support Older Adults (senior centers, geriatric case managers, care transition teams, independent living facilities, etc.)
All of these partners are further potential for increasing the visibility of our services and resources.