Summary of Recommendations

Improve Public Policy Response and Medicare Coverage for Fall Prevention and Intervention
July 2010

Developed by the American Occupational Therapy Association under a contract with the National Center for Injury Prevention and Control (2009-Q-11452)

Every 15 seconds, an older adult ends up in a US emergency room due to a fall. That’s nearly 2 million older adults—in one year—injured in a fall. Another 15,000 died as a result of their injuries. In other words, every 35 minutes, an older adult dies from a fall injury -- the equivalent to nearly 6 major airplane crashes a month.

The Centers for Disease Control and Prevention (CDC) estimates that direct medical costs of falls totaled nearly $20 billion for the non-fatal —and that was in 2000. Falls are the leading cause of death and disability among older adults. More than half of these falls occur in the home. Falls take a toll on health, independence, finances-and they can be deadly. As the aging population grows and the fall rates increase with them, the health care industry struggles to care for the ever increasing burden of fall-related injuries.

What the Research Tells Us

This is not a hopeless situation. There are proven strategies that can reduce the risk of falling in older adults. This year, The American Geriatrics Society and British Geriatrics Society released fall prevention recommendations based on the best current evidence. A few of these recommended interventions include:

  • An exercise program incorporating balance, gait, and strength training, such as Tai Chi or physical therapy;
  • Adaption or modification of home environment by an occupational therapist to reduce identified hazards, tailored to the individual with appropriate follow-up provided;
  • Provision of Vitamin D supplements of at least 800 IU per day; and
  • Medications should be reviewed with a physician or other medical provider to minimize the number and types of medications being taken.

When these interventions are incorporated into healthcare provided to older adults, their risk of falls decreases as compared to care that does not include these services. When total costs of falls are considered, resulting savings could be considerable. How Medicare Can Help:

The first step in treatment is assessing the risk. Medicare currently addresses fall risk in assessments mandated for home health services and skilled nursing facility care. The ‘Welcome to Medicare’ Exam, also includes fall risk assessment. The Physician Quality Reporting Initiative also incentivizes certain providers to assess fall risk and to create a fall prevention plan if a risk is identified.

Falls risk is a concern for older adults on an ongoing basis. There is a need for more education of Medicare providers about fall prevention and about evidence-based interventions that should be provided as part of routine and ongoing care. There is a need for education among Medicare beneficiaries of the importance of addressing falls through the Medicare and other systems.

Proposed Changes:

Quality Metrics: Incidence of falls, provision of falls prevention services, and related falls measures should be primary indicators of success in programs such as Independence at Home, accountable care organizations, medical home systems and other efforts to coordinate care. Increased attention should be paid to incidence of falls following acute and post-acute care (e.g., 30-60 days post home health discharge) in gathering data and promoting quality. Prevention of falls should be a key item to be addressed in

Durable Medical Equipment: Modify current coverage policy to include DME items which improve mobility and decrease falls risk. Currently, DME used in the bathroom (e.g. bath benches, grab bars) are classified as “presumptively non-medical,” but from a falls risk/benefit perspective, should be considered medically necessary for those who have an assessed falls risk. Similarly, there should be concurrent coverage for more than one mobility device (e.g. cane or walker) for use on different levels or different area of the home. The cost of including these items to at-risk elders is minimal compared to the cost of treating fall-related injuries, and certainly less than the cost of permanent disability and loss of independence. Services could also be targeted as medical nutrition therapy is targeted.*

Vitamin D: Vitamin D deficiency is a risk factor for falls and falls-related injury. The solution is very low-cost and low-risk- Vitamin D supplements. However, these are not covered under any Medicare Part D plan. Given the very low cost of Vitamin D and the significant cost benefit in reducing falls risk and falls-related injury, coverage should be considered which would ensure that at least SNF residents who are at risk have access to Vitamin D and promote availability of Vitamin D for community dwelling beneficiaries who are at risk.

LCD Consistency: In Medicare, Medicare contractors decide whether a service is reasonable or necessary (in accordance with the Social Security Act) by means of a Local Coverage Determination (LCD). Across the country, there are differences and inconsistencies in coverage of assessments and interventions shown to reduce falls risk and recognition of the ICD-9-CM falls risk code. Some contractors deny coverage of an occupational or physical therapy evaluation if the resulting intervention includes non-covered services or items, even if the items are covered by a non-Medicare payer. This restriction limits practitioners from making fully appropriate intervention plans and limits beneficiaries from accessing all available fall prevention strategies. If it results in a recommendation for an intervention Medicare does not cover (like bathroom safety equipment or attending a community program for balance). This prevents the practitioner from making appropriate recommendations or for providing direction on how to obtain coverage, e.g., through Medicaid. A National Coverage Determination in the area of fall prevention could be done and should be based on the latest quality research such as the recommended interventions that the AGS/BGS guidelines suggest.

Establish a Coordinated Fall Prevention Benefit: The three most highly recommended interventions based on evidence are that of a home safety assessment by an occupational therapist with modifications, provision of vitamin D in those with proven deficiency, and physical therapy or programs such as Tai Chi for exercise for balance, strength and gait training. (. A Medicare benefit entitled “Fall Prevention Services” should be established that would “bundle” these and other services such as a medication review by a pharmacist in a manner that assures coordination among service providers, follow through by patients and providers and linkage to community programs. This benefit, like the current nutritional counseling benefit*, could be targeted to individuals with a determined high risk for falls.

Increased Education of Providers and Beneficiaries: Provider and beneficiary education through Medicare is an effective means of spreading innovations, promoting best practice and raising awareness. Increased attention to fall prevention, including suggestions for referrals to covered and non-covered services, recommendations for a followup schedule, and recognition of the effectiveness of fall prevention interventions should be included in the description and training related to the “Welcome to Medicare” visit, the new annual wellness visit, and in the Medicare and You booklet mailed to beneficiaries every year.

*Medicare Part B covers medical nutrition therapy services by a Medicare-certified nutritionist, registered dietitian, or other Medicare-approved nutrition professional as part of doctor-prescribed diabetes care.