In February 2007, in conjunction with several aging and chronic disease related grants on which the North Carolina (NC) Division of Aging and Adult Services (DAAS) and the NC Division of Public Health (DPH) were partnering, the two Divisions entered into a written memorandum of agreement, formalizing their respective commitments to each other and the intent to partner on future projects. Both Divisions were also working on a grant with the Institute on Aging (now defunct) at the University of North Carolina (UNC) at Chapel Hill. As a result of ensuing dialogue between all three agencies, they quickly recognized shared concerns over the high morbidity and mortality associated with falls in the older adult population that would, without significant intervention, increase substantially as baby boomers aged. All three agencies were also aware of interest being generated on the national level around falls prevention.
While establishing a Falls Prevention Coalition by any one of these organizations might have proven a daunting task, this group, enhanced by the addition of the UNC Center for Aging and Health, provided a strong core of agencies with diverse strengths, funding sources, and networks that combined into a successful partnership.
The first NC Falls Prevention Coalition (NCFPC) meeting was held April 30, 2008. Interest was very high, with numerous key leaders and stakeholders present from a multitude of organizations. The need was agreed upon and the Coalition mission and goals were identified. At the second coalition meeting in July 2008, Coalition members began to address strategies to meet the goals and objectives.
The Coalition’s mission is to bring together researchers, planners, health care providers, housing specialists, aging services providers, and many others to work together to reduce the number of falls and fall-related injuries for North Carolinians.
The founding goals for the Coalition include the following:
- Create and maintain a statewide structure to better coordinate falls reduction efforts
- Ensure that organizations and communities throughout NC have access to resources to reduce falls
- Raise awareness of the magnitude of the falls problem and the potential of various strategies to reduce falls
- Provide falls prevention education to older adults, caregivers, the community, health care professionals, industry, social service professionals, and policymakers
- Ensure that older adults are routinely screened for falls
- Increase availability of evidence-based and best practice falls prevention interventions and resources
- Advocate for policy changes and resources to reduce falls
- Consider strategies to improve data collection and analysis to identify fall risks, health care cost data, and protective factors
In 2008, when the North Carolina Institute of Medicine (NCIOM), in collaboration with the NC DPH, convened a Task Force to develop a prevention action plan for the state, falls prevention was a key topic in conjunction with unintentional injuries, which are among the 10 preventable risk factors contributing to the leading causes of death and disability in the state. The Coalition secured its first Governor’s Proclamation for Falls Prevention Awareness Week (FPAW) in 2009 and has obtained that proclamation every year since then.
The Coalition’s first action plan was created in 2012, with most stated objectives accomplished by 2014. Six workgroups evolved to address the following: infrastructure development and maintenance; community awareness and education; provider education; risk assessment and behavioral intervention; surveillance and evaluation; and advocacy for supportive policies and environments.
In 2014, the NC DAAS received its first Administration for Community Living (ACL) grant to disseminate evidence-based falls prevention programs in the state and establish a centralized falls prevention “hub” (healthyagingnc.com) at UNC Asheville’s NC Center for Health and Wellness (NCCHW). NCCHW then received an ACL falls prevention grant in 2017 along with supplementary Centers for Disease Control and Prevention (CDC) funds from the NC DPH to expand the dissemination and infrastructure of evidence-based falls prevention programs and continue improving the Healthy Aging NC hub, which also houses the NC Falls Prevention Coalition website.
Despite minimal funding over the years, coalition growth remained steady and has been growing in the last few years. Falls prevention activities also have increased, with the state coalition currently consisting of approximately 70 member organizations, 170 individuals and eight regional coalitions. Much of this work has already resulted in increased attention to falls. In 2019, the Coalition’s Steering Committee identified the need to develop a new action plan, and funding to support the process was provided by the NC Division of Public Health, NC Center for Health and Wellness, and UNC Center for Aging and Health.
The NC Falls Prevention Coalition hosted a retreat to initiate the next strategic planning process. The retreat planning and steering committee members wanted to have a variety of perspectives represented in the planning process, so brainstormed a list of professions/areas of focus from which to seek representation. These included the following fields: physical therapy, occupational therapy, pharmacy, accountable care organizations, primary care providers, housing and home modification, advocacy, faith-based, intellectual/developmental disabilities, emergency management/paramedics, hearing impairment, vision impairment, traumatic brain injury, trauma centers, parks and recreation/community wellness, city planning, area agencies on aging, home health, fire, university, and public health. Once the list was created, the steering committee identified professionals from within each field, and this became the potential participant list. This list was prioritized based on several criteria, such as: expertise, geographic coverage area represented (statewide, east, central, west), and number of different fields a single candidate might represent. The goal was to create as diverse a stakeholder group as possible, while keeping the number of attendees manageable for the retreat process at about 20-25 people. After the invitation list was finalized, the steering committee began inviting professionals based on the above priorities. If a first choice was not available, an alternate was contacted. This was repeated until the steering committee felt it had exhausted all options and had achieved a multi-sector and geographically representative stakeholder group.
The NC Center for Health and Wellness (NCCHW) based at UNC Asheville has two primary initiatives: Culture of Results (COR) and Healthy Aging NC (HANC), which leads the state Administration for Community Living Falls Prevention grant. With input from the FPC Steering Committee, Healthy Aging NC and Culture of Results colleagues partnered to lead the strategic planning retreat on April 4, 2019.
Through the Culture of Results Initiative, the NCCHW works with local, regional, and state partners to assess impact, strengthen coordination, and improve programs and systems statewide. Culture of Results provides evidence-based training and technical support to state-wide and regional initiatives, as well as local public health departments, hospitals, clinics, universities, and community providers and groups. COR applies key aspects of empowerment evaluation — providing evaluation as part of an ongoing planning process to support client self-determination and empowerment and organizational capacity building. Clients are participants who develop the skills and capacity to evaluate their own services to adapt, improve, expand, and communicate the impact of their work and their contribution to the health and wellbeing of the population.
Culture of Results team members engage partner organizations in learning and using Results-Based Accountability (RBA) and its evidence-based, common sense tools to plan and evaluate their projects and services. RBA is a framework for moving from talk to action quickly and methodically. RBA has been recognized by the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and departments and agencies across North Carolina as an effective practice for evaluation and planning.
The RBA “Whole Distance” exercise is a facilitated process to help stakeholders with the following: co-creating a result statement; identifying key measures for tracking impact; discussing current and potential strategies; understanding the story behind what is helping and hurting the work; and prioritizing next steps. An overview, summary and detailed description of the RBA process and questions used at the retreat, along with pictures and notes, and a list of the organizations that participated in the retreat, and those areas of representation that were missing, can be found here: https://ncfallsprevention.org/resources/action-plans/
At the end of the retreat, we had our agreed upon “headline” community indicator, the vision of what this experience would look like if we achieve our desired results, along with identified and prioritized strategies and partners to move forward with this work.
Headline Community Indicator: Reduce the number of injuries and deaths due to falls among older adults and adults at risk for falling.
The steering committee described the retreat process and results at the quarterly NC FPC meeting on May 22, 2019 and distributed summaries via the Coalition listserv for input to ensure all members had a chance to provide feedback on the headline community indicator and the top five strategies that were identified at the retreat, and to identify any possible missing plan elements or voices. All Coalition members were invited to lead and/or join one of three work groups identified from the prioritized retreat strategies. An Action Plan Steering Committee was formed consisting of two co-chairs of the overall process along with six co-chairs of the three Work Groups. The Work Groups met from August 2019 – October 2020, with the Action Plan Steering Committee meeting in between each Work Group meeting to reassess and adjust as needed. Work Groups presented to the full Coalition at various times for input and feedback along the way. It is important to note that the final months of this action planning process occurred during the COVID-19 pandemic. This presentation provides more information on the action planning process.
The following shared values and guiding principles shape the planning, implementation, and evaluation of our action plan and need to be integrated and considered at each step. A self-assessment checklist based on these shared values and guiding principles guides their integration into each action step, and it also will serve as a tool to evaluate how well that step adhered to the principles as it is completed.
Studies have shown that the greatest impacts to health are outside of traditional health care settings (i.e. the physician’s office or hospital). People’s ability to thrive is based on where they live, work, play, pray, and learn. The Robert Wood Johnson Foundation (RWJF) reports that 20 percent of a person’s health is based on clinical care, the remaining 80 percent rests upon social and economic factors, health behavior and the physical environment. However, when communities lack resources or face other barriers, including the quality of those resources, it is more difficult for people to live their best and healthiest lives.
This plan defines health equity as every person having the opportunity to “attain his or her full health potential,” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” (CDC, https://www.cdc.gov/chronicdisease/healthequity/index.htm, retrieved 5-22-20). Equity and equality are not synonymous. Equity is about fairness and justice, whereas equality strives to ensure everyone has the same resources regardless of need, an approach that benefits individuals and communities that are already better resourced and leaves behind or even increases the gaps for historically marginalized communities.
Planning to prevent and improve falls outcomes requires an intentional focus on the individuals most impacted by negative health outcomes. Overwhelmingly, these individuals have fewer resources, are geographically isolated or lack access to services, face gender-related challenges, and are members of racial and ethnic minority groups. All strategies and plans for falls prevention must bear in mind these factors so that marginalized individuals and communities are better served, are centered in discussions, and are not further harmed through unintended consequences of the plan. These priorities have been elevated further by the COVID-19 public health pandemic which has revealed the historic and systemic racism that has resulted in inequities and gaps in the social and economic sectors of our society and resulting disparities in health outcomes of marginalized communities. Neglecting and overlooking health equity will only contribute to the perpetuation of these systemic gaps and inequities. It is the intention of this plan to codify those actions that acknowledge the use of strategies that promote health equity.
This guiding principle is one aspect of equity that will shape the development of educational opportunities and materials as well as stakeholder engagement. In order to ensure that the plan’s activities and strategies are accessible, all materials and activities must consider appropriate communication channels, format, and health literacy. Resources such as advocacy, training, and educational materials need to be available at an appropriate literacy level (e.g., basic for the general public and more technical for providers) and in multiple languages. Resource development in multiple languages may need to be tasked to local and regional coalitions so they may determine the languages most spoken/read in that region/county. People with sensory disabilities also should have access to materials that are best suited for them (e.g., braille, large font, close captioning, American Sign Language, etc.).
One important aspect of equity is sharing decision-making power with the community by engaging and including members of the communities and affected populations we wish to reach in the NC and regional falls prevention coalitions and on work groups/committees for planning and implementation. Focus groups, surveys, and interviews are other important ways to gather feedback and input, but these methodologies are not a substitute for inclusion in decision-making, planning, and program development.
This plan recommends several new or adapted resources, advocacy efforts, training, and educational materials. In order to promote a comprehensive and coordinated body of work and increase broad understanding of the issues related to falls prevention, it is critical to ensure consistent falls prevention messaging (e.g., that falls are not a normal part of aging and can be prevented) across stakeholders, materials, and audiences (eg., medication management, vision/hearing checks, home safety, physical activity, etc.). Once this messaging is developed and agreed upon by the Coalition membership, it will be used to guide all communications.
The Coalition will strive to utilize the best available data for decision-making and to apply best practices. Data will also be disaggregated and used to identify disparities and work towards ensuring health equity in falls prevention efforts.
The continuum of care describes the many settings older adults and adults at risk for falling participate in and interact with when they are learning to prevent, are at risk for, or have recently had, a fall. Inclusion of multidisciplinary and diverse stakeholders within and serving the aging community across multiple community and clinical settings is essential to achieving our headline indicator. Partnerships in the continuum of care may include, but is not limited to:
- Clinical/Health Care Providers: primary care providers, nurses, physician specialists, rheumatologists, orthopedic and other specialists, physical and occupational therapists, physical and occupational therapist assistants, home health providers, long term care providers, audiologists, ophthalmologists, diabetes educators, 24-hr adult residential facilities to be inclusive of adult care homes, multi-unit assisted living, specialists working with any specific health needs, conditions, or abilities
- Community and Faith-based Organizations: social services and other agencies that address social determinants of health, faith communities, housing authority, Council on Aging, Area Agency on Aging, senior centers, evidence-based program providers, senior centers, YMCA, fitness centers, environmental and home modification agencies
- Government Agencies: NC Department of Health and Human Services, Division of Adult and Aging Services, NC Division of Public Health
- Bridge/Transitional Care: community paramedics, home care agencies, navigators, health coaches, peer educators, and/or community health workers, community center/neighborhood associations
- Home connections: family members, including those who provide direct care, caregivers
Along the continuum of care, decision points can guide individuals, families, and providers through key health decisions, considering medical information along with personal values to help to make a wise health decision with the best fit. Prevention and intervention can occur at any point in the continuum.
Primary prevention are steps that are taken before a fall has occurred, or involvement in practices to prevent a fall. Secondary prevention is the immediate care after a fall has occurred, or processes to deal with short-term outcomes. Tertiary prevention is comprised of the long-term consequences or processes defined after a fall has taken place.
Sample partners at each level of prevention:
- Primary: Community and Faith Based Organizations
- Secondary: Hospitals, First Responders/ Urgent Care
- Tertiary: Caregiving/Home Health Agencies/Rehabilitation/Long-Term Care Facilities
Falls coalitions, resource hubs, and referral networks can facilitate navigating the continuum of care and communication between the individual, family, community, and clinical networks. Through the identification of resources, referrals, and coalition networking, decision points and steps of prevention or intervention become easier to pinpoint and integrate, and likewise as prevention and intervention steps are acknowledged, referrals and references are identified.
The SRPF framework is an approach that shifts the focus from the health outcomes that need to be prevented to more upstream (i.e., root cause) factors that contribute to those outcomes. Please see The Centers for Disease Control and Prevention guidance document, that introduced this framework in the context of violence prevention. While there is not yet an equivalent guide for falls prevention, the basic tenets of the approach can be applied.
Risk Factors: A set of behaviors and/or conditions associated with a greater likelihood of falls
Protective Factors: A set of behaviors and/or conditions that may reduce or buffer against the risk for falls.
Shared Risk and Protective Factors: Different types of health outcomes are connected and often share the same root causes, risk factors and protective factors. They can all take place under one roof, in the same community or neighborhood, at the same time, or at different stages of life. Understanding the overlapping causes of falls and the factors that can protect people and communities can help us better prevent negative health outcomes simultaneously.
Why Focus on SRPF’s? This framework or approach may help to:
- Break down the “silos” dividing programs and the prevention of health conditions
- Prevent multiple negative health outcomes simultaneously
- Develop new partnerships
- Leverage resources/funding streams
- Increase efficiency of efforts
- Consider a larger pool of strategies and program options
- Increase reach and scale up impact of programs and strategies
An example of SRPFs in Falls Prevention:
- Risk factor: social isolation is a risk factor for falls as well as for suicide and substance use disorder, and/ medication misuse. Protective factor: community connectedness is a protective factor for each of these issues. How can we think about falls prevention strategies that can be done in a way that also builds community connectedness? What potential partners or sectors might be working on decreasing social isolation and/or building community connectedness that may become interested in falls prevention work? Are there evidence-based strategies for building community connectedness that can be wrapped around falls prevention programming? For example, adding in a component before or after a Moving for Better Balance class? Or ensuring that classes are planned in a setting that also decreases social isolation? What about reaching folks who are the most isolated – can we try to link up with mental health services?
Falls increase the risk of traumatic brain injuries (TBIs) and TBIs themselves increase the risk of falls. How can we think about prevention of both factors simultaneously? Are there some common root causes across linked topics that can be our focus rather than each condition separately?
- As noted in each objective and action step, to implement this plan, we will embrace and encourage inclusivity and adaptability. We will invite different subject matter experts, different regional representatives, stakeholders and those directly impacted, to serve on work groups for each goal and to help tell and understand the story behind the data. We will expand virtual connections and geographical inclusion. Examples include reaching out for input from senior center focus groups for implementation steps and increasing virtual capacity during and after COVID to build social connection and prevent falls in older adults. We plan to live out the shared values and include and evaluate throughout the process to ensure that this plan remains a living document that adapts as needed.
- Timeline for evaluation, work groups and action steps:
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- Launch background, goals and objectives on website September 2020
- Continue three work groups for each goal to start implementation in 2021.
- Create an evaluation work group to identify process and outcome indicators that are feasible and realistic for the Coalition to track. This group will lead the creation of the Shared Value/Guiding Principle Checklist Sept – December 2020
- Conduct an annual review of progress, revisit goals and objectives on a yearly basis. Action steps will be refined, continue to evolve, and be operationalized annually. This annual review will be integrated with Obj. 1A.
- Disseminate on ncfallsprevention.org similar to interactive model which can be updated annually online: https://whb.ncpublichealth.com/phsp/