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The Forum
The Gerontologist
Copyright 2006 by The Gerontological Society of America
Vol. 46, No. 6, 717–725
Fall-Risk Evaluation and Management:
Challenges in Adopting Geriatric
Care Practices
Mary E. Tinetti, MD,
1
Catherine Gordon, RN, MBA,
2
Ellen Sogolow, PhD,
3
Pauline Lapin, MHS,
4
and Elizabeth H. Bradley, PhD
1
One third of older adults fall each year, placing them
at risk for serious injury, functional decline, and
health care utilization. Despite the availability of
effective preventive approaches, policy and clinical
efforts at preventing falls among older adults have
been limited. In this article we present the burden of
falls, review evidence concerning the effectiveness of
fall-prevention services, describe barriers for clini-
cians and for payers in promoting these services, and
suggest strategies to encourage greater use of these
services. The challenges are substantial, but strategies
for incremental change are available while more
broad-based changes in health care financing and
clinical practice evolve to better manage the multiple
chronic health conditions, including falls, experi-
enced by older Americans.
Key Words: Falls interventions, Falls prevention,
Fall-risk evaluation, Medicare, Preventive approaches
Despite the high prevalence and adverse effect of
falls among older adults, prevention receives little
attention in clinical practice. This neglect reflects, in
part, a health care system focused on the episodic
diagnosis and treatment of individual diseases rather
than ongoing evaluation and management of the
multiple simultaneous conditions experienced by
many older adults (Berenson & Horvath, 2003;
Tinetti & Fried, 2004; Wagner, Austin, & von Korff,
1996). The widespread incorporation of fall-preven-
tion services into practice would require the adop-
tion of new or modified services on the part of health
care providers, payers, and older adults. The
perspective of older adults, including the lack of a
common language concerning falls and fall conse-
quences, has recently been described in the literature
(Zecevic, Salmoni, Speechley, & Vandervoort, 2006).
In this article, we focus on the perspectives of pro-
viders and payers.
Our objectives are to (a) summarize the evidence
revealing the burden of falls and supporting the
effectiveness of fall-prevention services for older
Americans living in the community; (b) delineate
the barriers to promoting fall-prevention services
from the perspectives of health care providers and
payers in the United States; and (c) present strat-
egies that could be implemented in the near term
to improve the delivery and financing of care for
The findings and conclusions described in this article are those
of the authors and do not necessarily represent those of the Centers for
Disease Control and Prevention and the Centers for Medicare and
Medicaid Services.
Address correspondence to Mary E. Tinetti, MD, Gladys Phillips
Crofoot Professor of Medicine, Public Health and Epidemiology, Yale
University School of Medicine, 20 York St., TMP15, New Haven, CT
06504. E-mail: mary.tinetti@yale.edu
1
Departments of Internal Medicine and Epidemiology and Public
Health, Yale University School of Medicine, New Haven, CT.
2
Office of the Director, Centers for Disease Control and Prevention,
Washington, DC.
3
National Center for Injury Prevention and Control, Centers for
Disease Control and Prevention, Atlanta, GA.
4
Office of Research, Development, and Information, Centers for
Medicare and Medicaid Services, Baltimore, MD.
Vol. 46, No. 6, 2006
717
community-living older Americans at risk for falls.
The key groups of health care providers relevant to
fall-risk evaluation and management include physi-
cians, nurses, rehabilitation providers (i.e., physical
and occupational therapists), and home care agen-
cies. Our focus is on the fee-for-service component of
Medicare, which covered 87% of Medicare benefi-
ciaries in 2002.
such as rushing further increase the risk of falling
and experiencing a serious injury (Studenski et al.,
1994). The risk of falling increases as the number
of these factors increases, suggesting that falling
is a multifactorial health condition that results from
the accumulated effects of coexisting conditions
and their treatment (Nevitt et al., 1991; Tinetti
et al., 1988).
The Burden of Falls
Prevalence and Morbidity of Falls
One third, or approximately 30%, of community-
living adults who are older than 65 years of age
fall each year; the proportion increases to 50%
among those aged 80 years and older (Bergland &
Wyller, 2004; Burt & Fingerhut, 1998; Hornbrook
et al., 1994; Sattin, 1992). Approximately 10%
of these falls result in a serious fall injury such
as a fracture, serious soft-tissue injury, or head
injury (Finkelstein, Fiebelkorn, & Binder, 2004;
Nevitt, Cummings, & Hudes, 1991; Sattin; Tinetti,
Doucette, Claus, & Marottoli, 1995). More frequent
falling is an independent predictor of the likelihood
of experiencing a serious injury such as a hip fracture
(Schwartz, Nevitt, Brown, & Kelsey, 2005). Epide-
miological studies suggest that fall events are direct
and independent contributors to restricted activity,
functional decline, and skilled nursing facility
placement, rather than merely markers of poorer
health status (Gill, Desai, Gahbauer, Holford, &
Williams, 2001; Kosorok, Omenn, Diehr, Koepsell,
& Patrick, 1992; Tinetti & Williams, 1997, 1998).
Fear and poor self-confidence are probable mecha-
nisms explaining the loss of function following falls
without serious injury (Tinetti & Williams, 1998;
Yardley & Smith, 2002). Recognizing falls’ fre-
quency, morbidity, and effect on functioning, quality
of life, and health care utilization, the Depart-
ment of Health and Human Services declared
injury prevention, including fall prevention, one
of the 10 leading health indicators in Healthy
People 2010 (Department of Health and Human
Services, 2005).
Cost Estimates of Falls and Fall Injuries
Among Older Americans
Falls account for approximately 10% of visits to
an emergency department and 6% of hospitaliza-
tions among Medicare beneficiaries (Englander,
Hodson, & Terregrossa, 1996). Rizzo and colleagues
(1998) reported that, relative to the cost for
community-living older adults of similar health
status who had not fallen, the average additional
health cost of experiencing a fall-related injury
requiring hospitalization was $16,000 ($24,330 in
2002 dollars), after adjustment for age and other
comorbidities such as heart disease associated with
hospitalization (see also Bishop et al., 2002). This
estimate included Medicare-covered hospital, home
health care, emergency department, and subsequent
nursing home costs. According to data from the
National Electronic Injury Surveillance System—
All Injury Program (Centers for Disease Control and
Prevention [CDC], 2003), in 2002, approximately
388,200 people aged 65 years and older were hos-
pitalized after being treated in emergency depart-
ments for fall-related injuries. Multiplying this
number by the cost estimate derived by Rizzo and
colleagues provides a $9.4 billion estimate in addi-
tional fall-related health care costs to the system
in that year. The CDC similarly estimated the
added health costs at $3,560 for the 1.6 million
adults aged 65 years and older who required fall-
related care in an emergency department but were
not hospitalized (CDC, 2005b), resulting in an
additional $5.7 billion in health care costs. This
gives a total of $15.1 billion in fall-related health
care costs to the system that year. In an economic
analysis conducted by the CDC using incidence
data and actual medical payments, the direct cost of
fatal and nonfatal fall injuries in 2000 was estimated
at 19.5 billion dollars (Finkelstein, Chen, Miller,
Corso, & Stevens, 2005). The CDC findings ex-
tended the earlier estimates by adding outpatient and
physician visits to emergency department and
hospital treatments. These figures are of necessity
based only on those falls that came to medical
attention. Furthermore, existing estimates do not
include caregiver time, nonmedical expenditures,
decreased quality of life, or loss of functional capa-
city, all of which are potentially avoidable fall-
related costs.
Etiology of Falls
Conditions known to increase the risk of falling
among community-living older adults include im-
pairments in balance, gait, cognition, vision, and
muscle strength; the use of four or more prescrip-
tion medications, particularly psychoactive medica-
tions; depressive symptoms; postural hypotension;
and arthritis (Bergland & Wyller, 2004; Sattin, 1992;
Tinetti, Speechley, & Ginter, 1988; Tinetti et al.,
1995). Environmental hazards such as stairs and
obstacles in the walking path and unsafe behaviors
718
The Gerontologist
Effectiveness of Fall-Risk Evaluation and
Management as a Preventive Approach
Effectiveness at Reducing Falls
A compelling body of evidence, including more
than 60 randomized trials, supports the effectiveness
of various health-care-based and community-based
approaches at reducing the prevalence of falls,
although most of the trials have not been large
enough to assess the effect on the most serious fall
injuries such as hip fracture (Gillespie et al., 2003). A
methodologically rigorous review of clinical trials
concluded that, although some interventions are of
unknown effectiveness, the evidence supporting
health-care-based multifactorial strategies among
community-living older adults was convincing (Gil-
lespie et al.). Evaluation and management, involving
assessment of the multiple known risk factors for
falls followed by treatment strategies targeting the
identified risk factors, has proved to be the most
consistently effective strategy among community-
living older adults. It is associated with a 37%
reduction in the rate of falls per person-month
(Chang et al., 2004). Components of effective
evaluation and management strategies studied in
the clinical trials included reducing psychoactive
medications; reviewing and reducing other medica-
tions; using home- or facility-based physical or oc-
cupational therapy, including progressive balance,
gait, and strength training, and instruction in the
proper use of mobility assistive devices such as canes
and walkers; management of blood pressure drops
on standing, referred to as postural hypotension;
attention to visual impairment and other medical
conditions; and home safety environmental adapta-
tion and modifications.
Complementing these effectiveness studies, there
have been a limited number of cost-effectiveness
studies of fall-prevention services (Englander et al.,
1996; Gillespie et al., 2003; Miller & Levy, 2000).
Although the determination of net savings from fall-
prevention services is sensitive to multiple assump-
tions about the prevalence of risks, effect sizes, and
service-related costs, studies have uniformly indi-
cated that such services have net-cost savings for
older adults at high risk of falls.
Evidence-based clinical guidelines recommend
that community-living older adults who present for
medical attention because of a fall, who demonstrate
difficulty with balance or walking, or who report
recurrent falls in the past year receive fall-risk
evaluation and management performed by clinicians
with appropriate skills and experience (American
Geriatrics Society, British Geriatrics Society, &
American Academy of Orthopaedic Surgeons Panel
on Falls Prevention, 2001). The guidelines did not
specify which groups of health care providers should
perform the various components of the fall-risk
evaluation or management, although in practice the
components are variously under the purview of
physicians, advanced practice registered nurses, re-
habilitation specialists, and home care providers.
The Evidence–Practice Gap
Despite the existing evidence and guidelines, the
proportion of at-risk Medicare beneficiaries who
presently receive fall-risk evaluation and manage-
ment is unknown; it has not been a topic of bene-
ficiary surveys and no traceable billing code exists. A
survey conducted in primary care practices in several
areas of the country found that most older adults
are not even asked about falls (Wenger et al., 2003),
suggesting that fall prevention, including fall-risk
evaluation and management, remains largely ignored
in clinical practice.
Barriers to Providers Offering Fall-Risk
Evaluation and Management Services
The challenges and barriers described here have
been reported in the literature by individuals who
have attempted to disseminate fall-related evidence
(Baker et al., 2005; Reuben, Roth, Kamberg, &
Wenger, 2003), or they are consistent with the
authors’ clinical and research experience with
providers and payers concerning the adoption of
evidence-based fall-prevention services (see Table 1).
The barriers and challenges to diffusing any
evidence-based service or innovation into practice
have been well chronicled (Berwick, 2003; Bradley,
Webster, Baker, Schlesinger, & Inouye, 2005; In-
stitute of Medicine, 2001; Rogers, 1995; Timmer-
manns & Mauck, 2005). Some of the challenges
facing fall-risk evaluation and management, such as
time constraints and competing demands, are similar
to those facing other services, although they are
perhaps of a greater magnitude for fall prevention
because of the personnel-intensive nature of the
services. Other challenges and barriers, such as
knowledge and skills deficits, are somewhat unique
to geriatric conditions that do not fit the disease
model of clinical care and reimbursement.
Time Limitations and Competing Demands
The time required to perform the total package
of currently recommended preventive services in
primary care is prohibitive (Yarnall, Pollak, Ostbyte,
Krause, & Michener, 2003). In clinical encounters,
pressing problems, such as exacerbation of conges-
tive heart failure, usually take precedence over
preventive issues. Fall-related interventions such as
checking and managing postural blood pressure and
medication review and adjustment are particularly
time consuming. Fall-risk evaluation and manage-
ment is not yet a focus of quality assurance initiatives
Vol. 46, No. 6, 2006
719
that encourage or mandate attention to specific
health conditions even in the face of limited time and
competing demands in clinical encounters (National
Committee for Quality Assurance, 2003).
Table 1. Provider and Payer Barriers in Promoting Fall-Risk
Evaluation and Management for Older Americans
Health care providers
Time limitations
Competing demands from coexisting conditions
No mandate to address falls
Lack of knowledge and skills
Geriatric conditions not part of professional training or
practice; providers not familiar with multifactorial
geriatric health conditions
Complexity caused by the multifactorial nature of
fall evaluation and management
Focus is on diagnosing and treating individual diseases;
providers not skilled in weighing tradeoffs
among multiple health conditions
Fragmentation and lack of coordination
Need to coordinate and refer across settings and
provider groups
Provider groups do not understand each other’s
roles and skills
Components within and outside of the health care system
Reimbursement and financial concerns
Perceived lack of, or inadequate, reimbursement
Provider confusion concerning what is prevention of
falls (not covered) versus management of the
risk conditions (covered)
Coordination services not covered by Medicare
Health care payers – Medicare (fee for service)
Potential cost of services
Concern about fraud and abuse
Statutory limitations on coverage (Medicare was
developed for acute episodes of care)
Complex financing structure
Centers for Medicare and Medicaid Services not
accustomed to multiprovider, multisetting model of
fall-risk evaluation and management
Component services are processed by different types of
Medicare contractors
Variable interpretation of Medicare policies among
carriers and intermediaries
Knowledge and Skills Deficits
Fall-risk evaluation and management, like all
multifactorial geriatric health conditions, involves
complex decision making and behavioral interven-
tions. Neither traditional professional education nor
practice patterns among the relevant provider groups
includes sufficient attention to these geriatric health
conditions. Many providers thus lack the necessary
knowledge, skills, or experience to care for older
adults with these conditions. Knowledge of the types
of balance exercises known to improve stability
and prevent falls, for instance, has not yet widely
permeated clinical practice. Furthermore, when
making clinical decisions, many providers who are
used to diagnosing and treating individual conditions
separately are not accustomed to weighing several
competing morbidities simultaneously. Decision
making for medications, for example, presently is
predicated on attaining disease-specific outcomes
rather than on weighing the benefits and harms of
medications to reduce fall risk without compromis-
ing other health conditions.
Fragmentation and Lack of Coordination
Even when providers are willing and able to
perform fall-risk evaluation and management, the
fragmentation of care among providers and across
settings is a barrier to effective patient care. Fall-risk
evaluation and management requires coordination
and referral among several providers with comple-
mentary skills, including physicians, home care
nurses, physical therapists, and occupational thera-
pists. The more components and providers involved,
however, the harder it is and the longer it takes for
practice changes to diffuse (Bradley et al., 2004).
Inadequate awareness of the skills of other provider
groups exacerbates the difficulty; the roles of
physical therapists and occupational therapists, in
particular, are poorly understood by some providers.
As a result, for instance, home care nurses may not
recognize that some individuals might benefit from
rehabilitation, and medical providers may fail to
prescribe these services.
The challenge of coordinating patient care among
health care providers is compounded by the need to
coordinate such care between health care and non-
health-care settings. Some components of fall-risk
management are within the purview of medical care,
such as medication reduction and physical therapy,
whereas others, such as environmental safety outside
the home, and physical activity or exercise, are not.
The straddling of responsibility within and outside
Notes
: Health care providers = physicians, nurses, reha-
bilitation specialists, and home care agencies; health care
payers =Medicare (fee for service).
the health care setting further compromises co-
ordination and limits accountability.
Reimbursement and Financial Concerns
Whether accurate or not, reimbursement for fall-
related clinical activities is perceived by the relevant
health care provider groups as inadequate; inade-
quate reimbursement is considered a disincentive
for providing fall-risk evaluation and management
(Baker et al., 2005).
In addition to the perceived inadequacy of reim-
bursement, there is confusion among providers of
what is or is not covered. This confusion results, in
part, from the fact that Medicare covers treatment but
not preventive services. On the one hand, fall-risk
720
The Gerontologist
evaluation and management could be considered a
preventive service for which coverage must be spec-
ified by changes in the Medicare statute. These chan-
ges would require legislation. On the other hand,
although fall prevention per se is not covered, the
evaluation and management of contributing con-
ditions and the treatment of individuals who have
already fallen are services covered at least to some
extent.
Even when the issue of prevention versus treat-
ment is resolved, there are still financial barriers. For
instance, most of the physician-provider components
of fall evaluation and management (e.g., counseling
about medications) are covered by Evaluation and
Management (E and M) codes, used for documenting
the nonprocedural components of the visit. Criteria
for assigning E and M codes are vague; some pro-
viders consider documentation cumbersome; and
coverage decisions are open to variable interpreta-
tion among local health insurance carriers.
Furthermore, Medicare specifically provides no
additional payments for coordination among pro-
viders as a covered service. Although the components
of fall-risk evaluation and management may be
allowable under Medicare, there is no incentive for
the multiple providers involved in the delivery of
these services to coordinate their care. As a conse-
quence, components may be duplicated, omitted, or
performed inadequately (see Table 1).
system for home health care. The act also imposed
caps on outpatient rehabilitation services; these
caps have recently been reinstated after a period of
moratorium. The CMS is also concerned about
possible billing for nonevidence-based methods to
evaluate falls, such as the use of expensive machines
to assess equilibrium. Fall-risk evaluation and
management services will have to address concerns
about fraud and abuse, perhaps by setting up
outcome-driven criteria for eligibility or by limiting
the duration of services, such as the existing cap on
outpatient rehabilitation services.
Statutory (Legislative) Limitations
The complexity of Medicare payment and cover-
age policies contributes to the barriers facing not
only providers but also the CMS itself in financing
fall evaluation and management services. Fall risk
is a recurrent problem with predictable and frequent
use of services. Medicare, created in 1965, has its
historic roots in indemnity insurance. It was de-
veloped primarily for unpredictable and infrequent
use of acute services and not for frequent use of
chronic services (Radovsky, 1968). Legislative bar-
riers, resulting from the limits on what decisions the
CMS can make on its own, make it challenging to
address chronic conditions and geriatric conditions
such as falls. These conditions require ongoing,
coordinated approaches across multiple providers,
settings, and payment systems.
Barriers to Fee-for-Service Medicare Coverage for
Fall-Risk Evaluation and Management Services
Potential Cost of Services
The cost benefit of fall-risk evaluation and man-
agement theoretically provides an incentive to the
Centers for Medicare and Medicaid Services (CMS)
to ensure adequate reimbursement (Miller & Levy,
2000). Given the prevalence of fall risk among Medi-
care beneficiaries and the multiple providers who
would require payment, however, the costs of fall-
risk evaluation and management services could be
substantial. From the perspective of the CMS, there
is no guarantee that these costs will be offset by the
reduced CMS expenditures for treating fall-related
consequences.
Complex Financing Structure
Fee-for-service Medicare is more accustomed to
the single-provider, single-setting model than to the
multiprovider, multisetting approach necessary for
optimal fall-risk evaluation and management. Dif-
ferent providers deliver fall-risk evaluation and
management services in a variety of settings and bill
Medicare Part A or B, depending on the circum-
stances. Insurers that process Medicare hospital
claims, generally under Part A, are called
intermedi-
aries
, whereas those that process Medicare physician
claims, generally under Part B, are called
carriers.
However, the situation is more complex than that.
Home health care, for instance, may be covered
under either Part A or B. Hospital-based outpatient
rehabilitation services are financed under Part B, al-
though the bills are sent to fiscal intermediaries.
Outpatient physician and freestanding outpatient
rehabilitation services, in contrast, are paid for under
Part B, with the bills sent to carriers. The CMS
contracts with private insurers to process claims for
Medicare beneficiaries. Adding to the complexity and
confusion, different models of payment are used in
different settings. This complexity is illustrated by
home health payments, which are generally provided
under the prospective payment system, rather than
fee-for-service reimbursement.
Concern About Fraud and Abuse
The CMS has a long-standing concern about
fraud and abuse in the evaluation and treatment of
conditions that are difficult to define and may be
relatively common. Relevant to fall-risk evaluation
and management, for instance, is that home care and
rehabilitative services, both of which often entail
multiple visits in nonmedical settings, have come
under careful scrutiny. At least in part to control the
potential for abuse, the Balanced Budget Act of
1997 required payment under a prospective payment
Vol. 46, No. 6, 2006
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