Rehab

Therapists: Secure a fall prevention program in your facility

Rehab Regs, May 22, 2003

Source: Briefings on Outpatient Rehab Reimbursement and Regulations, June 2002

Whether you have a large geriatric patient population or not, a fall prevention program is a good thing to have in your arsenal of therapy weapons. Falls account for a high percentage of fractures and disability in the elderly. Creating a prevention program can broaden your facility and help the older population in your community.

"Fall prevention programs are a real up-and-coming area for PTs to look at," says Cathy Ciolek, PT, GCS, clinical therapist at Kendal-Crosslands Communities facility in Kennett Square, PA. "With a lot of older adults, there is a definite need for this."

Buoyed by the information that the direct cost of fall injuries for people age 65 and older is expected to rise $32.4 billion in 2020, Senator Tim Hutchinson (R-AR) introduced the Elder Fall Prevention Act in February 2202. The bill provides the resources needed for education, research, and demonstration projects that can reduce the risk of falls.

Who's at risk?

Fall prevention programs are designed for people considered to be at a high risk for falls. This determination requires the following tools:

  • Balance assessments, notably the Berg balance scale

  • The functional reach test, the score of which determines a patient's risk category

Fall prevention programs require little maintenance. You received most of the education needed for this program in your undergraduate therapy courses. To become an expert on falls, you can consult a number of resources and papers written on the subject, either on the Internet or at a local library.

For the most part, the equipment is low-tech. "There are lots of options," Ciolek says. "You can go anywhere from a $50,000 BalanceMaster machine to a $1.29 yard stick. The nice thing is that there are lots of options."

What to look for during your initial evaluation

Like other programs in your practice, this cannot be one-size-fits-all. "The form that a fall prevention program takes depends on the bias of the person running the program," says Anne Shumway-Cook, PT, PhD, associate professor for the department of rehabilitative medicine at the University of Washington in Seattle.

"Being a PT, I'm interested in physical activity, and exercise to improve balance and mobility is what I am going to focus on. Another individual might emphasize a multifactorial fall prevention program by working to reduce and control blood pressure and improving home environmental factors."

Many factors can cause balance problems. This means you'll have to assess your patients' home environment. The following are hazards Ciolek looks for:

  • Throw rugs

  • No grab bars in the bathroom

  • Incontinence (which may cause patients to run for the bathroom)

  • Insufficient lighting

  • Proper footwear

  • Pets, especially those that scamper under foot

  • Clutter

  • Narrow door frames that can obstruct equipment like walkers or crutches

  • Inaccessible bed, sofa, chairs, or toilet (without a raised seat)

"You get to be a bit of a sleuth to see why a person may be falling," Ciolek says. "After you make an assessment of these areas, you find out where to focus your fall prevention." Sleuthing gets harder when older patients can't tell you why they fell-simply because they can't remember. In these cases, Ciolek says she has to rely on her reasoning skills alone.

Shumway-Cook looks for falls that are related to impaired balance. You'll know whether to use her program or another after the initial evaluation. If you feel that a patient's balance is corrupted, multidimensional exercises use all the functions that contribute to balance. For example, if a patient is unsteady due to lower extremity muscle weakness, then strengthening exercise will be good for them.

How to get started

Fall prevention programs could help your practice in a number of ways. Setting up a free fall prevention screening tool at a mall, health fair, or assisted living facility can determine whether potential patients have balance issues. "The screening is a great marketing tool," Ciolek says. "Refer [patients] to their physicians if they need a referral [for] therapy."

Medicare does not reimburse for preventive programs, but therapists are compensated by Medicare for impairments that involve balance. If not covered by Medicare, therapists work on a fee-for-service basis. Depending on the severity of the impaired balance, a therapist can prescribe anything from a home program to office visits up to three times a week for eight weeks.

Balance assessment can be coded as a PT evaluation. Balance training can be coded as 97112 (nerve reeducation). If your patients lose their balance through transfer training, it is a therapeutic activity (code 97530). In some cases, gait training is required (code 97116).

Not just a physical problem

Getting your patient over the fear of falling is just as important as preventing the fall itself.

"What I try to emphasize is that falls aren't an inevitable part of aging," says Anne Shumway-Cook, PT, PhD, associate professor for the department of rehabilitative medicine at the University of Washington in Seattle. "You have to change people's attitudes that falls are a normal part of aging."

Your patients' quality of life suffer, and your work could be for naught as well. "If their balance is okay, but they are afraid, [patients] will self-limit," says Cathy Ciolek, PT, GCS, clinical therapist at Kendal-Cross lands Communities facility in Kennett Square, PA.

"Then they tend to get weak because they don't move around that much. This gets into a real cyclic activity."

Shumway-Cook says she doesn't see it as fall prevention. "I look at it as a maximizing balance and mobility function in order to prevent or minimize disability and maintain maximum safe activity levels."

Falling is more than an old-age problem

Cathy Ciolek, PT, GCS, of Kendal-Crosslands Communities facility in Kennett Square, PA, says her organization is geared toward a geriatric population, but she adds that many younger people have problems with balance and falling too. "Geriatrics aren't the only people who fall, but they do have a higher predominance," she says.

The main difference between younger and older people is that younger people are usually more aware of their environment. This means the fall prevention program will focus on education rather than where things are.

"There are a lot of different patient populations for whom falls are a problem," says Anne Shumway-Cook, PT, PhD, associate professor for the department of rehabilitative medicine at the University of Washington in Seattle.

"Fall risk increases in people who have had a stroke or have Parkinson's disease. Falls are a result of neurologic pathology, largely because it impacts the balance system. I see a lot of patients who are younger, but have some sort of neurological problems."

Besides the examples Shumway-Cook listed, other types of patients at risk for falls include the following:

  • Those with disabilities

  • People who have recently gone through surgery and whose blood pressure is not stabilized

  • Those who are on high doses of medication

  • Someone with weak knees or unstable joints

People with unstable joints go through an exercise program that is different from one that is prescribed for a geriatric patient. Their program focuses more on resistance exercise training, endurance, and strengthening exercises.

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