Background and Purpose
The growing number of seniors and elderly population comes with an increased amount of healthcare issues. They are usually faced with decline in physical and psychological health, increased risk is disability and dependency and increase in number of comorbidities. Fall has become one of the common issues that our seniors and elderlies had to deal with. It can lead to different injuries that can be debilitating to individuals.1 It is also a common cause of issues that we face in rehabilitation.
As per the US Census, Colby and Ortman (2015) reported that the percentage of the population that is aged 65 and over is expected to grow from 15% to 24%. 2 The population is projected to age over the coming decades, with a higher proportion of the nation's total population in the older ages (65 and over). 2 By 2029, when all baby boomers will be 65 years and over, more than 20% of the US population will be over the age of 65. 3 Centers for Disease Control and Prevention (CDC) reported that one-third of people 65 and older fall each year, with less than half of the Medicare beneficiaries who fell in the previous year talked to their healthcare provider about it.4 Even though not all falls cause injuries, one of five falls cause serious injury such as fracture or traumatic brain injury. 5
The government spends a huge amount of money for the seniors and elderly's healthcare. Medicare spends $31 billion dollar annually for the direct medical costs of fall injuries and two-thirds of the total goes to hospitalization cost. 6 Fall case treatment can be expensive especially with the age group and the comorbidities it comes with it. It is said that it is one of the 20 most expensive medical conditions in the United States.7 The medical cost only accounts for the fees that needs to be paid for which includes hospitalization, professional fees, rehabilitation, drugs, etc. On top of that, there are other expenses such as disability, dependency and reduced quality of life that needs to be considered as well. 8
With the growing population of the seniors and elderlies, it can be expected that fall rate will increase as well. The increase of fall rate will mean increase in expenditure in healthcare cost. Having in mind as well that the older the individual, the more susceptible they are in having a serious fall and the more complicated the injuries that they can get and the comorbidities that needs to be addressed as well. For this reason, preventing fall is the best way to address the issue. The government has been doing programs and has been encouraging healthcare providers to educate people on fall prevention. Research has also been made that focuses on fall and its prevention.
Like in any other case, it is important to know the risk factors that can call fall to older individuals so that we can deal with the issue directly and effectively. Primarily, it is important to do a fall risk assessment that is reliable and valid to be able to make a recommendation plan, prevention and treatment as well. 9 Certain risk factors such as decrease muscle strength, balance and gait problems can be modified and can be addressed by healthcare professionals to prevent fall.10
Balance plays an important role in fall prevention. Together with improved muscle strength. muscle power and gait, they are vital to be able to perform activities of daily living.11 A significant deficit in balance, muscle strength and power as well gait can all contribute in fall of the older adult population. An individual who has decrease muscle strength and power can lead to loss of balance that can cause fall. In the same case, someone who has a balance deficit will often rely on different strategies that involves their musculature to prevent a fall.12
Exercise program can address the issues on balance, strength and gait. Specific balance and strength training regimen can help the older adult population in preventing fall. Government agencies and different health organizations are promoting different approach in preventing fall. It is not only limited to educating the public and the healthcare professionals but they promote exercises in preventing fall. CDC has been doing research to prevent fall and resulting injuries among older population and American and British Geriatrics Societies also developed a clinical practice guideline for fall assessment and evidence-based interventions.13
Different researches has been found that exercise caused decline in rate falls and the risk of fall among older adult population. In the research done by Gshwind et al., studies showed that combined balance, resistance and power training promotes good effect on the older adult population's balance and strength, quality of life and functional performance which includes ADLs.14 In another study by Tomicki et al, a comparison of active elderly women doing regular exercises and sedentary elderly women showed a positive effect on balance maintenance and lower fall risks.15 An exercise program that specifically designed to address an older adult's physical impairments based on physical therapist evaluation is an effective way to promote increased strength, balance and fall prevention whether it is done in a facility or at home with supervision of a physical therapist.16
Physical Therapist can play an important role in preventing fall among older adult population. Physical Therapist can perform specific assessments and can create specific individualized interventions that can address balance as well as strength training. With the interaction of Physical Therapist with their patients in the facility, they are in a good position to recognize the needs of their patients in terms of balance and risk for fall. Fall prevention program specifically addressing balance concerns of patients can prevent incidence of fall and injuries related to fall. With that, healthcare costs can be reduced by reducing incidence of fall.
The purpose of this administrative case report is to describe the development of fall prevention program thru balance exercise and strength training in a Physical Therapy Facility that will be beneficial for the patients, the community, the payers and the company.
The need to establish a fall prevention program thru balance exercises was necessary due to the increase of fall incidents among seniors and elderly. Some of them are even unaware of their needs until an incident happen that leads to other condition that requires medical attention or when they are already having difficulties in their activities of daily living. Patients being seen in outpatient facilities usually comes for a musculoskeletal condition however, upon evaluation most of these patients have balance issues which makes them prone to falls.
The project aims to cater to older adult population ages 65 and older, who are most susceptible to falls as mentioned earlier. The outpatient private facility where the project will be implemented to is strategically located in a busy location in a city with a wide demographics of retirees. There are multiple senior apartments in the area and some senior centers as well as senior health facilities and skilled nursing homes. Currently, the facility has several seniors and elderly coming in for physical therapy. With the number of patients already being seen and its location, the program can be executed and established in the facility.
The program will be primarily implemented in the clinic. As the program becomes successful, it can be expanded to offsite areas such as the different senior centers or skilled nursing home facilities within the community thru physical therapy services. The program will assess the needs of the facilities or centers and the program will be introduced and applied for fall preventions of the seniors and the elderly.
Development of the Process
With the increase of patients in the facility that has issues with their balance, an exercise program that focuses on balance for fall prevention is designed. Balance program is beneficial to prevent injuries and to reduce the cost for providers. The balance exercise program is primarily designed for an outpatient facility that caters to different age group and cases. Patients are referred for physical therapy by an in house orthopedic doctor or physiatrist. Some patients are also referred by their primary physicians. Patients will be seen by physical therapist for evaluation and individualized treatment that includes exercise program that focuses on balance, strengthening and functional improvement. 15,16,17
The idea first came in to mind with an observation of the needs of the patients in the facility particularly a program that will focus on balance. Upon observation, a need arises to develop a balance exercise program because of a significant number of patients who are having problems with their balance that affects their normal way of life. Research on fall, prevention, evaluation, balance exercises and outcome measures were done.
Determining the program or the services that would be presented in the facility is the first part of the process. To strengthen the need for the new program, certain number of patients were interviewed. A meeting with the medical director/owner of the facility together with the general manager will be put in place. The need and the ideas for the balance program was presented to them as well as evidences that will support the project. In a study conducted by Li, et al., it was mentioned that not a lot of clinical practice address this common fall issues among the older adult population. The result of the study also showed the effectivity of an evidence-based program in reduction of fall with significant improvement from baseline in all outcome measures in an outpatient setting.18
Upon agreement, the program will start with an initial evaluation that includes strength and balance testing. Patients will also be given a questionnaire to know what functional limitations they have and to what extent are the limitations affect their daily living. Functional outcome measures will also be established for each patient to track their improvement and the effectivity of the program as well. Part of the program will be series of evidence-based strengthening and balance exercises that will be given to the patients. Patients will be seen at least 2-3 times a week for 6-8 weeks then a re-evaluation will be done. 19 Patients will be billed thru their health insurance, Medicare coverages or cash whichever will be applicable. CPT Codes for balance training and strengthening will be used to bill patients who will be billed thru insurance or Medicare. For those who will pay in cash, a per visit payment will be established. Payment plans will also be available.
The program will try to make use of available materials and equipment to lessen expenditures. A common balance standardized test will also be use by physical therapists which will not need any costly training. From the research done by Sibley, et al, it is emphasized that valid and reliable tests should be used in clinical assessment. 20 Physical therapists and physical therapist assistants who will be part of the program will only be paid an overtime pay from their hourly wage of $40 per hour and $28 per hour, respectively for meetings regarding the program which will include the development of the program and application, discussion about performing the standardized tests and ideas for balance exercise programs that will be used by patients. Once the program is set, all extra hours will also be compensated. It can be from doing extra hours for awareness classes inside and/or outside the facility or program evaluations. To keep up with technology and for easy access in documentation, 2 tablets will be purchased at a cost of $499 each for documentation. It will be pre-loaded with the test forms and charting for patients. This will minimize paper waste and easier communication within and outside the department including billing and insurance and health providers. Papers and printers which is already part of office supplies will also be used for other forms and printed materials for patient communication, marketing, etc. For the time being, existing exercise equipment will be use and exercises that are functional and use the patient's own body weight will be utilized. New and extra exercise equipment will be purchased as the program grows and more patients or clients will be participating. This is to ensure that capital will be utilized accordingly.
The effectivity of the program will be based on the improvement of patients/clients. Subjective reports of each patients will be noted and objective findings from balance testing and outcome measures will also be documented from initial evaluation, re-evaluation and upon discharge. Patients will be given survey forms to evaluate the program as well as the management and the rest of the team. Evaluation will be done every 6 months for assessment. The overall success of the program will not only be based on the clinical improvements of the patients but also in terms of patients' satisfaction, increased number of referrals and increased income of the facility.
As the program becomes successful through the expected outcomes which are not solely based on the clinical outcomes but also on the business aspects of it that includes increase revenues and referrals, a window of expansion will be considered by introducing the fall prevention program to different health institutions in the area as well as senior centers and facilities.
Application of the Process
The program will be first implemented in the outpatient facility. It will focus first on existing patients. To begin the process, a simple awareness program will be initiated by the facility. Physical therapists involved in the program will conduct a short talk on fall prevention. Simple handouts will also be provided to patients. Patients will also be asked to answer a checklist on fall risk which can be downloaded and printed from the Center of Disease Control and Prevention website. The survey will help patients determine their need for the program. It will also help the therapists in determining who will benefit in the program.
Patients who will be participating in the program will be evaluated by the Physical Therapists. Specific tests and measures appropriate for the patients will be performed. Data will be recorded in the tablet provided. This will also track the progress of patients and will also serve as communication to other health care provider as well for billing purposes. After the initial evaluation and specific problem areas have been determine, physical therapists will design a program that will include strength training and series of balance exercises. Patients will be seen 2-3x a week for 8 weeks with each session lasting from 45 minutes to 1 hour. Patients will also be given home exercise programs and safety reminders on fall prevention. The interventions should be individually tailored to challenge the patient based on level of his or her impairments.19
Patients will be re-evaluated after 8 weeks to check progress. The course of the program will run through a six-month period. Patient will be re-evaluated again. Patient will be discharged from the program when goals have been achieved and significant improvements are manifested. Patient will be put in a follow up program to track them after discharge. For those patients who still need therapy, another few weeks will be given and the same process will be followed.
Every after 3 months, surveys will be given to patients, managers, and physical therapy staffs to check and evaluate the program. This is will be an opportunity to know the strengths and weaknesses of the program. If the program is successful, it will then be marketed to different healthcare institutions, senior facilities and senior centers within the community.
With the success of the program, it will be an opportunity to market it outside the facility. The program will be introduced to different healthcare institutions, senior facilities and senior centers within the community. The company will market the program by conducting seminars on fall prevention. Possible participants which are the seniors will be asked to answer the same survey that was given to outpatient patients in the beginning of the process. That will enlighten them about the importance and the need for this program for safety and prevention. These probable patients can either get a referral from their primary doctors or can visit directly the facility for evaluation and treatment. Another way to market the program is to talk to primary doctors available in the community.
Again, with the success of the program, further expansion will be considered.
Patient's improvement will be one of the outcomes that will be measured. The improvements are expected to be manifested in the first eight weeks of the program considering at least 2-3x a week of Physical Therapy with 40 minutes to 1 hour per session. The whole duration of treatment will be at least six months. In the study by Shier et al (2016), the research noted that a program with least thirty minutes to one hour session that last for five months was deemed successful. 18 Outcomes for the patients will be measured with Timed Up and Go and Berg Balance Score. Both have been found to have good reliability and validity as noted by the research conducted by Mancini and Horak (2010).21 In the program, patient will be billed with at least 2-3 units using PT codes. For existing patients, this will mean additional billing codes if necessary. With new patients, additional codes for evaluation will be added on top of the minimum units necessary for revenues.
To be realistic, the program will aim for 3-4 new patients each month. One of the outcomes we expect is increase referrals in the facility. This can be primarily done by in house referral which will not add cost to the expenses. Another way to do it is to market the program by conducting small talks or awareness program. It will be best done in the facility in the beginning, where patients will invite their friends and family members to be educated on how to prevent fall. Then, the awareness program will be presented to different senior centers and facilities in the community. We can expect more patient referral with more exposure in the community. We also consider communicating to medical doctors in the area for referrals. Since the facility is in a very active community, joining local events can also be a venue for marketing. Physical Therapist who will be working extra hours for the awareness program will be paid with overtime pay with bonus as the revenue increases. I understand that marketing is challenging and with that I anticipate 6-12 months to promote the program. Evaluation will be done every 6 months to know the progress of the program.
As previously mentioned, I am looking in to expanding the program with its success in the outpatient facility by promoting it to other rehabilitation and nursing facilities in the community and its neighboring towns. This will require more work and responsibility but can also be a source of income for the company. It will only be initiated after the success of the outpatient program.
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