Development of Evidence-Based Practice Change Proposal I

Applied Nursing Research 57 (2021) 151392

Available online 26 November 2020 0897-1897/© 2020 Elsevier Inc. All rights reserved.

Promoting older adult fall prevention education and awareness in a community setting: A nurse-led intervention☆

Tiffani Chidume, DNP, RN, CCRN, CHSE *

Auburn University School of Nursing, United States of America

A R T I C L E I N F O

Keywords: Fall prevention Older adult Elderly Fall awareness Fall safety Fall education

A B S T R A C T

Background and objectives: Falls are costly and one of the most expensive medical conditions to treat. The implementation of fall prevention toolkits (FPTs), such as fall risk screenings and fall prevention education (FPE), have become progressively important in reducing fall incidences. Nurses have a greater role and responsibility to care for the aging population. The purpose of this project was to implement a FPT to adults age 65 and older that attended mobile IPE community clinics. Research design and methods: This project used quantitative pretest-posttests and an open-ended participant feedback survey. The Missouri Alliance for Home Care 10-question survey and components of the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) FPE were used to assess and educate participants on fall risks and fall prevention. An initial baseline fall assessment and fall education score was obtained at the mobile IPE clinics. Follow-up assessments occurred one month after the initial assessment and compared to the initial fall assessment and fall education scores with an additional open-ended participant survey. Results: In both fall risk assessment tools, lower scores indicated a lower fall risk; both fall risk assessment tool mean scores decreased over the one-month period. Discussion and implications: Future FPE implementation projects should consider providing needed resources the participants may need so there is no delay in increasing fall prevention and safety measures. The follow-up time period should also be increased to fortify FPE and keep participants engaged in fall prevention safety.

1. Identification of the problem

“I’ve fallen and I can’t get up,” a memorable quote from a 1989 Life Alert commercial, is still recited with updated versions being aired daily. Though used to promote various emergency medical alert devices, it also highlights the dangers and incidence of falls in the older population. Bergen et al. (2016) reported one in four older adults, ages 65 and older, fall each year. In 2017, unintentional falls in persons age 65 and older were the leading cause of nonfatal injuries in the United States (US), accounting for 63.3% of the total number of unintentional falls (National Center for Injury Prevention and Control (NCIPC), 2017a). For the same time period and population, falls were the most contributing factor of unintentional injuries and the seventh leading cause of death in the US (NCPIC, 2017b).

Falls are costly and one of the most expensive medical conditions to treat, costing more than $50 billion in 2015 alone (Centers for Disease

Control and Prevention [CDC], 2019). The Centers for Disease Control and Prevention (CDC) estimates the financial burden for older adults may reach $67.7 billion in 2020 (2019). As older adults continue to age, falls are more common, take longer to recover from, and cost more to treat, likely due to prolonged hospital stays (Bergen et al., 2016; Frith, Hunter, Coffey, & Khan, 2019). Declining sensory disorders [eyesight, hearing, sensation, etc.], polypharmacy, and weakness are only a few of the possible causes of falls (Frith, Hunter, Coffey, & Khan, 2019). One fall incident increases the likelihood of subsequent falls (CDC, 2019). Fall risk prevention methods are key factors in care, regarding efforts of healthcare providers and caretakers to increase the safety of the older adult as well as decrease falls and costs associated with falls.

Currently, Auburn University (School of Nursing, School of Phar- macy, College of Liberal Arts (Social Work), College of Human Sciences (Nutrition)) conducts mobile Interprofessional education (IPE) com- munity clinic visits to various sites that have an established partnership.

☆ The author reports no conflicts of interest involving this project or manuscript to declare.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

* 710 South Donahue Drive, Auburn University, AL 36849 E-mail address: [email protected].

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Applied Nursing Research

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https://doi.org/10.1016/j.apnr.2020.151392 Received 9 May 2020; Received in revised form 28 August 2020; Accepted 21 November 2020

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A community social worker coordinates which sites the mobile clinic will visit based on the needs of the community. The mobile IPE com- munity clinic was commenced to assist older adults in the community with little or no access to healthcare obtain some form of access to healthcare. Clients receive free health screenings, education, and re- sources from the IPE groups.

The older adult is the largest population that historically attended the clinics, as many of the clinics occured in senior centers or low- income housing units. At the clinics, client medications and diagnoses are reviewed and care plans are formulated by IPE teams. However, prior to the implementation of this fall prevention project, there was no fall risk assessment being completed. The mobile IPE clinic is often the most patient-centered care provided to those that attend and many are already a high risk for falls. For aging adults with possibly declining faculties, fall prevention and awareness should be assessed to decrease and possibly prevent falls.

The purpose of this project was to implement a fall prevention toolkit (FPT) to older adults that attended mobile IPE community clinics. There were no fall prevention assessments or education provided along with the health, social, and nutrition assessments. The FPT included two fall risk assessments as well as fall safety and prevention education. The intent was to reduce falls and increase older adult knowledge about fall safety and prevention. The care disparity in this population required immediate attention. The FPT was intended to improve the health out- comes of older adults in the community.

2. Background

Falls in any population can affect a persons’ mobility and quality of life. In the older adult, multiple factors, including vision impairment, environmental hazards or weakness, may contribute to falls (Bergen et al., 2016). For adults age 65 and older, the estimated falls that occur each year is 29 million; the equivalent of someone age 65 and older falling each second, every single day (Bergen et al., 2016; Sarmiento & Lee, 2017). Pohl et al. (2015) collected data on a qualitative focus group regarding older community-dwelling adults and fall precautions the participants were aware of and practiced. The study advised fall risk awareness should be introduced using various strategies and should be reinforced. The same study revealed that becoming aware of one’s increased fall risk can evoke different emotions in the elderly, often affecting pride and self-confidence (Pohl et al., 2015).

The aging population may have reservations speaking with health- care providers about declining mobility and falls, but healthcare pro- viders should be screening and assessing for fall risks annually (American Geriatrics Society, 2011; Moncada & Mire, 2017). Further- more, healthcare providers should use fall risk scores as guidelines to decrease patient-specific fall risk problems, rather than using generic fall risk interventions (Titler et al., 2016). For instance, if a patient’s fall risk assessment reveals fear of falling as a trigger, strengthening exercises as well as the psychological root of why there is a fear of falling should be addressed. There should also be an evaluation for the [possible] need for an assistive device.

Fall risk prevention awareness, assessments, and education are needed to improve healthcare outcomes in the aging population, opti- mally, to increase safety and decrease falls. The American Geriatrics Society/British Geriatrics Society (2011) developed clinical practice guidelines for the prevention of falls in older persons–with the under- standing that fall risk assessments are a vital element in reducing falls in the elderly population. Many fall prevention screening, awareness, and assessment tools are now available in response to numerous fall pre- vention/reduction initiatives (Moncada & Mire, 2017). Grealish et al. (2019) suggests, based on new evidence, that the focus should be concentrated on how fall prevention guidelines are utilized in conjunction with individualized corrective measures for the older adult.

For some older adults, there is little or no perceived risk of falling; for others, there are hindrances to learn fall prevention tactics or even

acknowledge a gradual decline in mobility and/or loss of functions (Bulsara et al., 2016; Pohl et al., 2015). The implementation of FPTs, such as fall risk screenings, home safety assessments, and FPE, have become increasingly important in reducing fall incidences (CDC, 2019; Olij et al., 2018). Research indicates that multifactorial screenings and assessments are preferred, considering no single aspect may be respon- sible for falls, but consider multiple issues that could be [responsible for falls] (American Geriatrics Society, 2011; Stevens & Phelan, 2013). The United States Preventive Services Task Force (USPSTF) (2018) recom- mends clinicians and older adult patients evaluate injury versus well- being regarding fall prevention measures. The evaluation of various medical diagnoses, fall history, and patient preferences may make a difference in the success of fall prevention of these community-dwelling elders (USPSTF, 2018).

In early 2019, researchers found that sharing FPE information where older adults congregate and frequent has value and decreases barriers to learning about fall prevention (Kiami et al., 2019). Older adults in the community setting that have received increased FPE have the propensity to maintain independence and safer living conditions (Minnier et al., 2019). Fall prevention screening checklists are vital initial tools in identifying at-risk individuals, but should be validated before use (Chacko et al., 2017). Lusardi et al. (2017) found that most fall pre- vention screening and assessment tools are predictive in identifying older adults at higher risks for falling. The most significant predictor indicators are “medical history questions, self-report measures, and performance-based measures” (Lusardi et al., 2017, p. 33).

Another recent study showed community-nurse recruitment for fall prevention activities in older community-dwelling adults, along with healthcare provider and researcher collaboration, played an integral part in the success of the study (Olij et al., 2019). Nurse-led FPE was also shown to have a greater impact on fall prevention behavior in the elderly population (Uymaz & Nahcivan, 2016). Even better results have been achieved with IPE teams collaborating with fall prevention awareness, assessments, and education implementation initiatives (McKenzie et al., 2017; Sullivan et al., 2015; Taylor et al., 2019). Concerning nursing care and the profession of nursing, nurses will have a greater role and re- sponsibility to care for, screen, and teach fall prevention methods to the aging population (Patton, 2018).

3. Conceptual framework and application to project

Boykin and Schoenhofer’s Nursing as Caring Theory served as the theoretical underpinnings for the development and presentation of the assessments, education, and follow-up interactions. This grand theory is an in-depth analysis of what caring is, how caring has multiple mean- ings, and how caring affects everyone differently (Smith & Parker, 2015). The nursing as caring theory has a multidimensional framework, as it integrates assumptions and components from its theory and that of the nursing metaparadigm (Masters, 2015).

The tenets of the nursing as caring theory relate to the imple- mentation of an FPT in the elderly population in various ways. The elderly may become forgetful, but they are not forgotten. The nursing as caring theory applies to this project because the aging population is, in fact, the focus. The IPE community clinics are a means of older adults in the community gaining access to healthcare through free screenings and healthcare collaborations. The clinics also provide an environment for members of the community to congregate; “community” in a true sense of the word. Through interviewing and providing education, a nurse provided a form of caring. The follow-up phone communications in the subsequent month emphasized the notion that someone cares and is proactive in attempts to help decrease falls and increase fall risk awareness and education in the aging population.

3.1. Project methodology

A design consisting of a quantitative pretest-posttest and an open-

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ended participant survey design was utilized. The project was consid- ered a practice change model in a specific type of setting (community clinics), and for a specifically aged population. The project setting occurred in various community settings in Lee County, Alabama and surrounding counties. The mobile IPE community clinics occurred on Fridays in low-income housing communities, assisted living facilities, community centers, and other rural settings.

Participant criteria included being 65 or older, English speaking, with no exclusion for race or gender. The sample was n = 30. Partici- pants consisted of mostly women (73.3%), doubling the number of male participants (26.6%). Fifty percent of the participants lived indepen- dently in the community, 26.7% lived in an assisted living facility, and 23.3% lived in low-income housing. Physical mobility of the various participants included total ambulatory (requiring no assistance), mostly ambulatory (the use of assistive devices at times), and very limited (dependent on a motorized or manual wheelchair).

3.2. Intervention

The intervention was the implementation of fall risk assessments and fall prevention education, the FPT, to older adults that attended IPE community clinics. The mobile IPE community clinic visits were scheduled, and the project advertised weeks in advance of actual IPE mobile clinics to gain possible participant interest. This was accom- plished by displaying flyers with project information in the various fa- cilities 1–2 weeks before implementation. Some word of mouth recruitment also occurred at the mobile IPE clinical sites.

Upon arrival at the mobile IPE community clinical sites, interest was confirmed with self-identified participants who met the inclusion criteria. Prior to visits to the clinical sites, FPT packets were prepared, which included the consents, assessments, and educational resources. If the inclusion criteria were met, the participants were read the informed consent script regarding the project. All interested parties were provided instructions and signed an informed consent form. Participants also provided contact information for follow-up communication. Partici- pants were assigned by the number in which their assessment occurred and ushered to a quiet area by the nurse in order to provide privacy during the implementation of the FPT.

Once the participants were seated and ready to proceed, the first fall risk assessment, the MAHC- 10, was evaluated. Once the individual baseline fall risk scores were obtained via the MAHC-10 assessment, a self-reported fall prevention safety education assessment, “Stay Inde- pendent”, was completed and calculated. Comparisons between the two fall risk assessment types will be discussed later. Next, a fall safety checklist with safety guidelines “Check for Safety”, were reviewed with the participants. Each question yielded an intervention to improve fall prevention safety and knowledge. For areas of improvement based on the “Check for Safety” guidelines, more time was spent teaching the participants how and why certain changes were needed to improve their safety.

Lastly, a fall prevention educational pamphlet, “What You Can Do to Prevent Falls” was read to the participants and specific areas of improvement were circled on the pamphlet. The pamphlet was given to the participants to keep for reference. The participants were notified of exercises, such as Tai Chi and yoga, to improve balance and strength. The nurse emphasized the importance of the participants slowing down and making intentional movements, like counting to three between taking steps. Each project participant session took 30–50 min depending on participant need. Participants were given a copy of the informed consent for reference and contact information for the nurse and Insti- tutional Review Boards in case there were questions or concerns after the intervention.

One month after the initial assessment, the two fall risk assessments were re-administered and the “Check for Safety” guidelines re-evaluated to assess if suggested improvements were made by the participants. The project-specific five-question follow-up survey was also completed

during the follow-up. The follow-up questions requested additional in- formation on possible changes the participants made, as well as their evaluation of the FPE provided.

3.3. Instruments

The first instrument used in this project is the Missouri Alliance for Home Care 10-question survey (MAHC-10). The MAHC-10 was devel- oped to assist home health agencies’ compliance with Centers for Medicare and Medicaid Services’ (CMS) Outcome and Assessment In- formation Set Criteria (OASIS-C) for home health patients (Calys et al., 2012). The MAHC-10 is multifactorial, standardized, and has been validated as a single tool to assess fall risks (Missouri Alliance for Home Care (MAHC), 2012). The validation study was a 2010 (July–October) four-month retrospective review of nine home health agencies located in Missouri. The sample size for the study was n = 2247. The MAHC-10 includes a fall risk assessment tool (survey), a fall report form, and a Microsoft Excel data entry form (MAHC, 2012).

The 10-question assessment tool requires information such as age, comorbidities, medical, and fall history. A numerical value was assigned for each question. The tally of the questions was combined, resulting in the MAHC-10 fall risk score. The fall prevention benchmarking initiative was tested in 2010. The construct validity of MAHC-10 differentiates between “fallers” and “nonfallers” (Calys et al., 2012). Also, on the MAHC-10 fall prevention tool, “prior history of falls” is defined as, “An unintentional change in position resulting in coming to rest on the ground or at a lower level” (MAHC, 2012). The fall risk factors are consistent with the literature (Calys et al., 2012). “Fallers,” individuals that are high-risk for falls, are considered to have a fall risk score of 4 or more (Calys et al., 2012; MAHC, 2012). However, researchers suggest that each agency alter the fall risk score for their specific needs and indications. Individuals with scores of less than four were less likely to fall according to their medical histories and MAHC-10 assessments (Calys et al., 2012).

The next instruments used in this project, “Stay Independent”, “Check for Safety”, and “What You Can Do to Prevent Falls,” are components of the Center for Disease Control and Prevention’s Stopping Elderly Acci- dents, Deaths, and Injuries (STEADI) initiative. The STEADI initiative was designed specifically for healthcare providers that cater to the older populations, which is especially important for patients who have fallen or are at risk for falling (Lee, 2017). The three essential STEADI com- ponents are screening, assessing, and appropriate interventions (CDC, 2016). The CDC’s intent with the STEADI initiative was to develop varying levels of resources for healthcare providers, resulting in improved health outcomes in the older adult (CDC, 2016).

The STEADI fall prevention toolkit offers a wide range of fall pre- vention materials that are free to use, customizable, and may be downloaded. There is also an option to purchase components of the toolkit, printed by the CDC, instead of downloading and printing on-site. Materials include fall prevention screening materials, teaching mate- rials, care planning booklets, fact sheets, checklists, and exercise pocket guides. Anyone may use any part of the toolkit or the entire toolkit at the discretion of the user. The CDC also offers training classes on how to implement STEADI into practice as well as case studies. “Frequently Asked Questions” are also available on the website.

For this project, the following STEADI components were utilized: a self-reported fall prevention safety education assessment, “Stay Inde- pendent”, a fall safety checklist with safety guidelines, “Check for Safety”, and a fall prevention educational pamphlet, “What You Can Do to Prevent Falls”, which the participants were given to keep. “Stay Independent” is a validated self-risk assessment brochure that brings awareness to risks of falling. The “yes” and “no” questions translate to numerical values to be tallied. Like the MAHC-10, a fall risk score of 4 or greater indicates a higher fall risk. “Check for Safety” is a home safety brochure that aids in identifying and correcting potential fall risks in the home setting. “What You Can Do to Prevent Falls” is an additional informational brochure that

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includes effective strategies to prevent and/or reduce falls (CDC, 2016). The STEADI initiative and materials were tested extensively for

validity and reliability by various healthcare providers and using various methods, such as interviews and focus groups. Members of the focus group (n = 18) commented on how useful the tool was because the initiative did not focus on the patients only after falls, but is useful as a preventative measure for falls (Stevens & Phelan, 2013). The STEADI materials were found to be valid and considered to demonstrate empirical evidence in a 2017 study that used the 2011–2015 National Health and Aging Trends Study data. The sample size in the aforemen- tioned study was n = 7392 and consisted of adults age 65 and older (Lohman et al., 2017). Additionally, the STEADI initiative follows the American and British Geriatrics Societies’ Clinical Practice Guidelines (CDC, 2016).

The project-specific, five-question follow-up survey was developed by the nurse with input from colleagues. The survey was completed during the follow-up phone call with participants. The follow-up ques- tions requested additional information concerning possible changes the participants made after the FPT implementation, if they had fallen since the FPE, as well as their evaluation of the FPE provided. The last ques- tion on the survey, “Is there anything else you would like for me to know,” allowed for participants to express additional feelings and con- cerns regarding fall prevention awareness, safety, and knowledge.

3.4. Data collection

All data were collected by the nurse. Data and forms were trans- ported by the nurse in a locked travel bag. No identifiable information was included during the data analysis. All data were systematically logged on paper forms, tabulated, and evaluated using descriptive sta- tistics and parametric analysis (interviews and questionnaires). The data were entered in the Statistical Package for the Social Sciences (SPSS) version 24. Completed surveys and informed consent were placed in a locked file cabinet where they will be retained and accessible only by the nurse for five years.

The MAHC-10 assessment tool was administered upon recruitment and obtained consent from older adult participants. The MAHC-10 fall risk assessment requested information such as the patient’s age, medi- cal, and fall history. Points were assigned for each assessment question. The numerical total of the points for each MAHC-10 assessment was the baseline fall risk assessment score. The numerical total of the points for each “Stay Independent” checklist, was the baseline FPE score.

After one month, follow-up phone communication with participants occurred. The nurse communicated with the participants using the contact information given during the initial assessment. Participants were queried by reassessing the MAHC-10 fall risk and the “Stay Inde- pendent” self-reported checklist. Scripted follow-up questions were also asked. Over the six-week project period, 33 participants were obtained for the initial assessment and FPE. Of the 33 initial participants, 30 were available for the reassessment and follow-up questions.

3.5. Data analysis

Statistical analysis of the project data was conducted using SPSS Version 24. The baseline fall risk assessment scores, FPE scores, and descriptive statistics were entered and analyzed in SPSS. After the follow-up phone call, new scores were tabulated, entered into SPSS, and analyzed. Prior to the FPE, the participants’ overall MAHC-10 score was (μ = 4.87, (SD = 1.978)); after receiving FPE, that level decreased to (μ = 4.83, (SD = 1.821)) in a month. Prior to the FPE, the participants’ overall “Stay Independent” score was (μ = 5.67, (SD = 3.977)); after receiving FPE, that level decreased to (μ = 5.53, (SD = 4.158)). See Table 1. The MAHC-10 fall risk assessment pre and post scores were statistically insignificant (p = 0.662, α = 0.05). The MAHC-10 paired t- test was (t = 0.441, p = 0.662) supports the fall prevention education to be statistically insignificant. The “Stay Independent” fall risk assessment

pre and post scores were statistically insignificant (p = 0.255, α = 0.05). The “Stay Independent” paired t-test was (t = 1.161, p = 0.255). See Table 2.

3.6. Findings

The overall scores of the thirty participants that completed both the initial and follow-up assessments did not change significantly in one month. The mean MAHC-10 initial assessment score was μ = 4.87 and the reassessment mean was μ = 4.83. The “Stay Independent” Fall Risk initial assessment produced a mean of μ = 5.67, with a follow-up mean of μ = 5.53. In both fall risk assessment tools, lower scores indicated a lower fall risk; both fall risk assessment tool means decreased over the project period.

Upon reassessment via the follow-up phone call, a specific question regarding recent falls was used to evaluate if client falls decreased and to what degree, by comparing the baseline and reassessment scores. The question asks if there has been a fall in the past three months. In the initial assessment, six of the 30 participants admitted to falling in the past three months. There were two reported falls in the one month following the education. Because of the difference in time periods, no conclusion can be drawn.

The home safety brochure, “Check for Safety,” aided in identifying potential fall risks in the home setting and guided individualized teaching points for the participants. Many of the questions focused on if there were stairs in the dwelling, how well-lit were the commonly used areas, and possible environmental hazards. During the follow-up phone call, specific areas of concern were reassessed to note any changes and improvements in the home environment. For example, for the question, “Do you have throw rugs on the floor,” participants were educated on removing the rugs or obtaining non-skid mats to go under them and explained why the rugs are a fall hazard. While none of the “Check for Safety” questions demonstrated statistical significance per the paired samples correlations, one of the questions produced noteworthy safety improvements; “Is the light near the bed hard to reach.” Participants were educated on possibly moving the lamp closer, keeping a flashlight near them to prevent straining, purchasing a battery-operated portable LED light, or utilizing a nightlight to provide additional visibility.

Additionally, a five-question follow-up survey was completed after the reassessments and knowledge scores. The questions revolved around changes the participants made, if any, and if there were suggestions to improve the delivery of the fall prevention information. Twenty-eight of the thirty participants responded they had not fallen since the FPE and two participants had fallen. Of the six participants that had fallen within the three months before the initial assessment, none of the initial six participants had fallen since the baseline assessment and education. Ott

Table 1 Paired samples statistics for the MAHC-10 and “Stay Independent” fall risk assessments.

Mean N Std. deviation

Std. error mean

Pair 1

MAHC fall risk score initial 4.87 30 1.978 0.361 MAHC fall risk score reassessment score

4.83 30 1.821 0.332

Pair 2

Stay independent fall risk initial score

5.67 30 3.977 0.726

Stay independent fall risk reassessment score

5.53 30 4.158 0.759

Note. Prior to the FPE, the participants’ overall MAHC-10 score was (μ = 4.87 (SD = 1.978)); after receiving FPE, that level decreased to (μ = 4.83 (SD = 1.821)) in a months’ time. This is a 0.157 reduction (improvement in the overall mean score). Prior to the FPE, the participants’ overall “Stay Independent” score was (μ = 5.67 (SD = 3.977)); after receiving FPE, that level decreased to (μ = 5.53 (SD = 4.158)) in a months’ time. This is a 0.14 reduction (improvement in the overall mean score).

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(2018) also found an expansion in fall risk knowledge and techniques in community members after the implementation of fall prevention educational sessions.

Interestingly, though both fall assessment tools were developed by different entities, both use a score of four or greater to indicate fall risks. This unique project produced comparisons between the two fall-risk assessment types and measured the accuracy of the tools. The most notable difference between the two assessment types was the MAHC-10 focused almost solely on concrete medical information; the “Stay Inde- pendent” assessment included other factors, such as perceptions of un- steadiness, fear of falling, as well as feelings of depression. Both the MAHC-10 and “Stay Independent” scores for the initial six participants that had fallen were above four, indicating a higher risk for falls; how- ever, neither of the assessment tools indicated a fall risk score (a score of four or above) for the two participants that fell after the FPE.

The findings of this project were consistent with the current litera- ture concerning this population. A merging of the two fall risk tools utilized, MAHC-10 and STEADI, or one that incorporates individual medical information and perceptions may be optimal for this type of project. Nithman and Vincenzo (2019) also used the STEADI fall risk toolkit in community-dwellers and noted the difficulty in the tool identifying fallers. In the same study, the recommendation was also made that multiple tools be used for identifying fall risks in individuals. Callis (2016) identified twenty significant fall risk factors and deter- mined that there is not a comprehensive fall risk tool that addressed them all. Though both the MAHC-10 and STEADI provided valuable information to indicate fall risks, a fall risk assessment tool that does not mutually exclude medical information and/or personal perceptions may be better suited for this type of project. A more comprehensive tool would take both types of factors listed previously into account and possibly capture those who did not fall in the fall risk category of the two different assessment types used.

According to participant feedback collected in the follow-up assess- ments, many participants voluntarily stated that they enjoyed the follow-up assessment and conversation. One of the faculty involved in the mobile IPE clinic conducts two-week follow-ups. Therefore, the participants involved in the mobile IPE clinics and the FPE imple- mentation project received two follow up assessment phone calls in a month. The participants said the follow-ups gave them a true sense that someone cares about them and they are somehow being “looked after.” Some participants even relayed that they also improved their behavior because they knew there would be a follow-up and wanted to be able to give a good report. Follow-ups over a longer period may create the desire to continue the “good reports” and affect fall prevention and safety for older adults in the community. Radulescu et al. (2016) cites other research and reiterates positive reinforcement reward systems, [in the case of this project, follow-up phone call assessments, and conver- sation], continue to play a role in behavior changes.

3.7. Discussion

There are many concentrated research efforts focused on fall pre- vention and fall safety in older adults. Mobile IPE community clinics require support and efforts from multiple stakeholders including the University, community partners, and community members. This project continued these efforts and discovered additional factors to help make fall prevention education implementation projects successful. A fall risk assessment and a self-risk assessment, both validated, were used to calculate fall risk scores in the older adults that attended the mobile IPE community clinics. The older adults in the community were assessed for fall risks, educated on how to prevent falls and how to make their homes safer. The Auburn University IPE program observed the benefit of the FPE and are considering implementing their own fall prevention initiative, possibly using components of this project.

3.8. Implications

Only one mobile IPE clinic occurred before realizing key elements that would have made this project more effective: necessary resources and additional time. During the initial assessments and education, par- ticipants were encouraged to obtain essential resources to increase their safety and prevent falls, as guided by the “Check for Safety” list. Many of the participants fell in the low-income economic category and qualified for low-income housing, hence the need for free assessments by the mobile IPE clinic. During the follow-up assessments and questionnaire, the participant feedback revealed some participants could not improve fall safety in their home environment. Materials, such as non-skid mats or double-sided tape for rugs or portable lights to increase visibility, were not purchased because some participants did not have the re- sources to obtain them. Resources include monetary funds, devices, as well as transportation to attain the devices. Future projects could also include grant funding. Having resources on hand to provide the partic- ipants during the initial assessments may have led to a greater impact in this population by ensuring the resources were received.

Additional time would be needed to continue projects of this type. Along with the conversation and educational components of the project, increased time may have allowed for supplementary interventions such as demonstrations of safe balance and strengthening exercises. Where possible, group exercise sessions by certified instructors, focusing on balance and strength, could have produced a project with increased efficacy. Other helpful strategies, such as a concentrated focus on walking using actual step measurement and purposeful arm swinging may also have been beneficial (Cheng et al., 2014; de Melker Worms et al., 2017). Implementing this project over a longer period of time may have allowed for a larger sample size. Follow-ups with the participants in three months and assessing the recall of falls after the education was provided may also be valuable.

Table 2 Paired samples test for the MAHC-10 and “Stay Independent” assessments.

Paired differences t df Sig. (2- tailed)

Mean Std. deviation

Std. error mean

95% confidence interval of the difference

Lower Upper

Pair 1

MAHC fall risk initial score - MAHC fall risk reassessment score 0.033 0.414 0.076 − 0.121 0.188 0.441 29 0.662

Pair 2

Stay independent fall risk initial score - stay independent fall risk reassessment score

0.133 0.629 0.115 − 0.101 0.368 1.161 29 0.255

Note. A statistically significant difference is present if the ???? ≤ 0.05. The 0.157 mean reduction in the MAHC-10 fall risk assessment is statistically insignificant since the p-value of 0.662 is greater than the specified α level of 0.05 (p = .662, α = 0.05). The MAHC-10 paired t-test (0.441 = p = .662) using a 0.05 alpha level also supports the fall prevention education to be statistically insignificant; suggesting that the education had little or no effect on the participants’ reassessment answers. The 0.157 mean reduction in the “Stay Independent” fall risk assessment is statistically insignificant since the p-value of 0.255 is greater than the specified α level of 0.05 (p = .255, α = 0.05). The “Stay Independent” paired t-test (1.161 = p = .255) using a 0.05 alpha level also supports the fall prevention education to be statistically insignificant.

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A 2017 study determined that assisted living communities and fa- cilities should utilize fall prevention protocols and flowcharts to decrease falls in their residents (Coughlin et al., 2019). Two of the initial six fallers lived in an assisted living facility [26.7% of the project par- ticipants] possibly indicating improved fall prevention measures of the facility, as indicated in the Coughlin et al. (2019) study. One of the assisted living facilities where participants resided, offered fall alert/ alarm devices and mandated that all bathroom shower and toilet areas had handrails installed. The researchers agree that additional explora- tion is needed to develop and implement a fall prevention process that is comprehensive enough to decrease falls for all (Coughlin et al., 2019).

Results from this project indicate more studies are needed to develop a comprehensive fall risk assessment and intervention tool that can be used for all ages, especially the older adult. The data showed various participants with similar fall risk scores to be fall risks for different reasons. A score of five on the MAHC-10 could be due to age, previous falls, polypharmacy, stroke, and the need to wear glasses; whereas the same score of five on STEADI’s “Stay Independent,” could be the result of previous falls, using an assistive device, and worrying about falling.

The CDC’s STEADI comprehensive tool kit for health care pro- fessionals includes many components, such as screening tools, assess- ments, balance tests, and referral forms, but were not implemented in this project due to time restrictions. While using two assessment tools for this project, future data collection will include a more inclusive assess- ment tool including medical history, co-morbidities, previous falls, polypharmacy, psychological and psychosocial issues, access to re- sources, with appropriate interventions and continuous follow-up. Another important aspect of the comprehensive assessment tool would be one that categorizes the levels of risk. For example, scores 0–3 low fall risk, 4–7 medium, and 8–12 high, with additional interventions and prevention measures implemented with increasing scores, much like STEADI’s screening tool. As a result, identifying those at higher risks for falls and interventions to address them could occur sooner.

3.9. Limitations

Project implementation and mobile IPE clinics occurred in a small region in Alabama and findings may not be generalizable to the public or other similar participant groups. Ideally, the sample size would be larger. There were 33 initial participants, but three were excluded from follow-up due to the inability to contact them. More thorough assess- ments could have occurred if access was granted to visit the actual living space of the participants. Other barriers that impacted this project and the participation rate were the short follow-up period, lack of additional interventions, deficient time intervals of the IPE clinics, age limitation, time of day, weather, and specific dates.

Due to project time constraints, significant changes about decreased falls were difficult to measure. The brief follow-up period with partici- pants was one month, which was not adequate to assess significant changes regarding decreased falls in this population. Following the assessment and evaluation of FPE scores, education was the interven- tion. Although participants were educated and given information via the CDC (2016) pamphlet, “What You Can Do to Prevent Falls”, on the importance of balance and strengthening exercises, these exercises could have been demonstrated, given more time. Future projects could incorporate exercise sessions with a trained professional as an inter- vention, with additional assessments pre and post this certain intervention.

The setting and time of the mobile IPE clinics was a limitation that could not have been predicted. The IPE clinics occurred once a week for a few hours and each participant session took 30–50 min, which contributed to the time constraints for these additional interventions. More frequent clinics or longer clinic hours could solve this constraint. The setting and time of the clinics were also restricted by the IPE faculty that run the clinics. The IPE faculty clinic organizers plan the clinics during times all involved disciplines can attend, each with a group of

students. Training and educating IPE faculty members of other disci- plines about the FPT was similarly hindered by time, but could have contributed to a more significant project and likely, a larger sample size. Future planning could include buy-in from the other IPE faculty stake- holders. Therefore, the project, like the clinics, would be interprofes- sional and beneficial to all partners.

Since the mobile IPE clinics occurred in some low-income housing developments, some individuals may have benefited from the FPE that did not meet the age requirement of 65 or older. Some participants felt the IPE mobile clinics occurred too early in the day, which may have resulted in the low turnouts at some of the sites. The weather was un- predictable months ahead of the IPE clinical time, therefore, rainy days may have resulted in a lower turnout. The lowest participation turnout day for the mobile IPE clinic and the project occurred on Friday the 13th. One of the participants who had been involved in the clinics in the past recognized the lower turnout as well and provided a possible rationale, "Oh, some are very superstitious over here. They won’t even come out of their house today so nothing bad will happen to them.

4. Conclusion

Falls are more common and more costly as one ages. In the older adult, once a fall occurs, there is an increased likelihood that another fall will ensue. Fall prevention and awareness should be assessed to decrease and possibly decrease falls in all ages. The mobile IPE community clinics provided health, social, and nutrition assessments, but none were spe- cific in addressing fall risks or safety education. The purpose of this project was to implement a fall prevention toolkit (FPT) to adults age 65 and older, that attended mobile IPE community clinics. There were no fall prevention assessments or education being provided in conjunction with other assessment types by the IPE team. The intent was to improve the health outcomes of the older adults in the community. Two validated fall risk assessment tools were utilized, the MAHC-10 and the CDC’s STEADI. Fall risks were assessed by interviewing community members age 65 and older at the mobile IPE community clinic sites. The project was evidence-based, concerning the development and implementation of a FPT. The overall scores of the thirty participants that completed both the initial and follow-up assessments did not change significantly in one month. Continued follow-ups, reinforcement of FPE, and resource availability would be key in enhancing this type of project. This project was designed to be replicated in other populations/areas. Additional research using multiple fall risk assessment tools combined with FPE and interventions are needed to determine if the combination would be beneficial.

Acknowledgements

For mentorship and assistance with this project, I would like to thank Dr. Lori Lioce of The University of Alabama in Huntsville, my project chair, and Dr. Sarah Watts of Auburn University, my project member. A special thanks to the Auburn University IPE team as well.

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