than community-dwelling adults. The Centers for Medicare & Medicaid Services (CMS) defines “homebound” as the inability to leave home without considerable and taxing effort. A person who is homebound may leave home for medical treatment or short, infrequent absences for nonmedical reasons, such as a trip to attend religious services or a wedding (CMS, 2015). It is estimated that there are about 2 million homebound Americans, which is larger than the current nursing home population (Ornstein et al., 2015). In a 2015 study by Musich and colleagues (2015) factors associated with being homebound include self-reported memory loss, being older (>75 years), having multiple chronic conditions (three or more) resulting in multiple hospitalizations (two or more) in the past year and taking many prescription drugs (seven or more). Adults who never leave their home are three times more likely to become frail (Xue, 2011). Homebound older adults who have fallen or who are at risk for falls may be appropriate for the Otago exercise, which has been proven to reduce fall incidence in this population by up to 35% (Shubert, Smith, Jiang, & Ory, 2018; Thomas, MacKintosh, & Halbert, 2010). Developed and tested in New Zealand from 1997 to 2003, Otago was implemented more recently in the United States. Otago focuses on improving strength and balance with a simple, easy-to-implement, homebased exercise
program (Shubert et al., 2018). The homebound older adult, who is typically frailer than non-homebound adults, receives a visit from a home health nurse or physical therapist, along with telephone calls to provide support and guidance throughout the program. The program’s original, evidence-based plan includes 12 months of strengthening and balance exercises with tapering of onsite clinician visits across the program and monthly calls. The first 8 weeks includes five to six visits in the home. A follow-up visit takes place, if possible, at 6 and 12 months. Walking for endurance is added when the person is deemed ready by a skilled clinician. Although not every adult who could benefit from Otago is homebound, the best results appear to be in older, more frail adults living at home (Shubert et al., 2018). An affordable, 3-hour online Otago training for therapists can be accessed at http://www.med.unc.edu/aging/cgec/ exercise-program. Although several thousand physical therapists have completed the training, implementing the program duration and billing has been difficult with many persons being discharged after 8 weeks without follow-up phone calls. Program delivery innovations are being studied to address these issues, including the use of virtual rehabilitation technologies (Shubert, Basnett, Chokshi, Barrett, & Komatireddy, 2015), with hopeful modifications to come.
BRINGING FALL PREVENTION PROGRAMS TO YOUR COMMUNITY
By now, it should be clear why bringing fall risk screening and programs to the community is a crucial step in improving the health, function, and mortality rate of older adults at risk for falls. The STEADI program developed by the CDC offers a comprehensive program that is available online, in multiple languages, and free of charge (http://www.cdc.gov/steadi/). STEADI online resources include fall risk surveys, fall risk screening forms, educational handouts on a variety of fall risk factors, and a home safety checklist, just to name a few. The STEADI program can be easily disseminated to lay persons at local community centers, YMCAs, health departments, and hospital systems to reach as many older adults as possible. A link to STEADI resources can be found in the Resources section. Communities often choose to implement a fall risk screening on Falls Prevention Awareness Day, which is on the first day of fall in September every year, and is sponsored by NCOA. In 2018, NCOA will have promoted this event for 10 years with an annual Case study Irene is an 85-year-old woman who lives with her 87-year-old husband, Dwight, in a retirement community. Irene is referred to home health physical therapy due to multiple falls. Irene and Dwight have lived in their own apartment on the third floor for 7 years, where they must negotiate 300 feet to the elevator, a 20-foot ramp from their apartment building to their car, and an occasional curb or threshold, depending on how close they can park to the entrance. Irene uses a cane crafted out of PVC pipe by her home health physical therapist, who treated her after her first fall 2 years ago. Irene spends most of her time sitting in her favorite chair, reading, watching some TV, or sleeping. She has difficulty with community ambulation due to unsteady gait, poor endurance, and fear of falling (ABC score 55/100). Irene’s past medical history includes: ● Hypertension for 25 years controlled by medication. ● Corrected vision. ● Type 2 diabetes mellitus diagnosed 15 years ago, also requiring medication. ● CABG x 3 10 years ago. ● Osteoporosis for an undetermined length of time. ● A recurring case of horizontal canal benign paroxysmal positional vertigo (BPPV). ● Five medications (Lipitor, Metformin, Anti-vert, Xanax, and Fosamax). Irene has had multiple falls over a 2-year period, mostly in the bathroom or bedroom, but none resulting in more than a bruise
theme, fall prevention promotional materials, and a PowerPoint presentation, video contest, and media toolkit (http://www. ncoa.org). Both the STEADI and NCOA websites have extensive resources needed to get started. In addition to the existing screening protocols, many of the community-based programs described here can be implemented in any community. Collaborating with local senior services, YMCAs, or community centers can assist the clinician in implementation and execution of these vital programs. However, even before structured programs are in place, all physical therapists should ask their older patients the three basic screening questions: 1. Have you fallen in the past year? 2. Can you tell me the details surrounding the fall(s)? 3. Do you have difficulty walking or balancing? This is a great place to start for addressing the health emergency of falls. or scrape. The local emergency medical system must assist Irene from the floor each time she falls, as her husband is unable to transfer her from the floor. Irene is referred to physical therapy secondary to a fall 3 days ago in her bathroom while being assisted into the shower by her husband. She spent 1 day in the hospital and was released to home 2 days ago with a sprained right wrist and bruised right hip. Irene’s personal history includes being retired for 20 years from bookkeeping, being a mom to four grown children (none of whom live nearby), and attending church semiregularly until she started falling. She enjoys reading and playing cards. Irene’s goal: Be as independent as possible, stop falling, accompany her husband into the community as much as possible. Functional status ● Self-care: ○ Dresses while sitting at edge of bed, minimal assist for bathing, reaching in standing. ○ Husband does all laundry, cooking, bills, driving. ○ Verbal cues for consistent and thorough hygiene. ● Mobility: ○ Independent for bed mobility and short sitting balance. ○ Independent sit-to-stand transfers using upper extremities and needing multiple attempts, unable to get up from floor.
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