1. Ciance, Karin L. DNP, RN


Falls are the leading cause of fatal and nonfatal injuries among adults 65 years and older. Each year, one in three older adults experiences a fall, and people who fall are more likely to fall again. According to the National Council on Aging (2017), instituting evidence-based falls prevention programs can significantly decrease falls. The purpose of this article is to describe a pilot study that examined the impact of the Sure Steps(R) Fall Prevention Program on incidence of falls among adults 65 and older living in their home. A convenience sample of 10 community-dwelling participants aged 65 and older was recruited. After the Sure Steps(R) Fall Prevention Program was implemented, participants were contacted by telephone monthly for 1 year. None of the participants reported falls during that time. Based on the findings of this pilot study, the Visiting Nurse Association implemented the Sure Steps(R) Fall Prevention Program into their other four clinical sites.


Article Content

Falls are a major threat to the health and independence of older adults. When someone falls there is also a significant decline in quality of life, which is often difficult to quantify. According to Brenoff, approximately one-quarter of seniors who sustain a hip fracture from a fall die within 1 year. Each year, one in three adults aged 65 and older experiences a fall, and people who fall once are two to three times more likely to fall again (CDC, 2016a). Falls are the leading cause of fatal and nonfatal injuries among adults 65 years and older and 10,000 people in the United States turn 65 every day (CDC, 2016a). According to the U.S. Census Bureau (2014), one in five Americans will be 65 years or older by 2030, and this population is predicted to double from 43 million in 2012 to 84 million in 2050. One out of 10 falls causes a serious injury, such as a hip fracture or head injury, which requires hospitalization (CDC, 2016a), and one of the main reasons seniors are admitted to extended care facilities is because of fall-related injuries (Brenoff, 2012). Each year, at least 25,000 older adults in the United States die as a result of falls and this rate has been rising steadily over the past decade (CDC, 2016a). Fall injuries are among the 20 most expensive medical conditions with an average cost of $35,000 per episode and total cost of $34 billion in 2013 (CDC, 2016b).

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Falls are preventable, but people are living longer and falls will increase without a serious commitment to providing effective fall prevention programs. There are many risk factors associated with falls such as: medical/fall history, polypharmacy, visual deficits, home environment, improper footwear, muscle strength, balance deficit, and gait abnormality (American Geriatrics Society [AGS], 2010). According to the National Council on Aging (2017), instituting evidence-based falls prevention programs can significantly decrease falls. Robertson and Gillespie (2013) concluded that fall rates in community-dwelling people were reduced by instituting fall prevention exercise programs, home safety interventions, and individually targeted multifactorial interventions. Falls and accidents typically occur in the home and many times can be reduced by 50% by fall proofing a home according to the National Council on Safety (Brenoff, 2012). Hill et al. (2011) examined whether elders were prepared to engage in fall prevention strategies after discharge from the hospital and found they had a low level of knowledge about appropriate fall prevention strategies. The purpose of this article is to describe a pilot study that examined the impact of the Sure Steps(R) Fall Prevention Program on incidence of falls among adults 65 and older living in their home.


Description of Sure Steps(R)

The Sure Steps(R) Fall Prevention Program is a multifactorial fall prevention intervention developed in 2001 by Jane Mahoney, MD, and Terry Shea, PT, which was adapted from evidence-based guidelines published by the AGS, British Geriatrics Society, and the American Academy of Orthopedic Surgeons (2010 Sure Steps - SlideShare, 2010). Home healthcare nurses screened patients who were at risk of falls or who had suffered a fall for willingness to participate in the program and perform exercises. The Sure Steps(R) Guidebook served as a workbook and resources for clinicians as well as participants. Participants were assessed by a nurse and a physical therapist and an individualized treatment plan was developed (Sure Steps(R), 2012). Participants received a thorough in-home assessment by a registered nurse (RN) or physical therapist (PT), which included an evaluation of medications, home environment, risky behaviors, vision, cognition, balance, and mobility. An in-home follow-up visit by the RN provided the participants with written recommendations to decrease their risk of falls. The primary care provider also received results of the evaluation and recommendations regarding fall prevention. The four-step process of the program included:


Step 1: Assessment

Areas assessed included: medical/falls history, polypharmacy, visual deficits, home environment, improper footwear, muscle strength, balance deficit, and gait abnormality. The following standardized tools were used: Falls Efficacy Scale; Tinetti Performance Oriented Mobility Assessment Test; Timed Up and Go Test; and Functional Reach Test. Each participant was then assigned a numeric value that identified their risk for a fall and was provided an objective plan for treatment and progress. Results were incorporated into the patient assessment system, which also contained a predictive model for hospitalization risk.


Step 2: Treatment Plan

The AGS (2010) recommended the following activities be included in an effective fall risk reduction plan: an exercise component for balance, gait, and strength training; environmental adaption by a healthcare professional to reduce risk factors in the home and in daily activities; managing foot and footwear problems; providing education and resources; simplifying medications; and managing vision deficits. For each risk factor covered in Sure Steps(R), the RN and/or PT administered a combination of clinical assessments, patient education, and exercises designed to work together to reduce the patient's fall risk.


Step 3: Progress

Both AGS guidelines and the Centers for Disease Control and Prevention (CDC) concur that home modification and exercise programs can improve balance, mobility, and gait and reduce the fear of falling. CDC's collaborative studies with the Administration on Aging stress the importance of education when it comes to implementing a course of action. Older adults need to know risk factors, protective behaviors, and how they can adopt changes to reduce risk. With that in mind, Sure Steps(R) provides patients with updates on their progress that help maintain motivation between sessions and give the patient and clinician a common goal. As the progress of a patient is monitored, it becomes evident where he/she has progressed and where there is still room for improvement (Sure Steps(R), 2012).


Step 4: Results

On the last visit with the patient, the clinical team repeated the assessment tests made on the first visit. The goal is for the patient to maintain improvements in identified fall risk factors, such as better management of medications, visual deficits, and environmental hazards. The PT also gave the patients a progressive home exercise plan addressing muscle strength, balance deficits, and gait abnormalities they can continue once discharged from the program after 1 year.



A pilot study was conducted at a Visiting Nurse Association (VNA) in New England to implement and evaluate the Sure Steps(R) Fall Prevention Program. In phase I, the agency staff implemented the first four steps of the program previously described. In phase II, participants who were enrolled in the Sure Steps(R) Fall Prevention Program received a monthly follow-up telephone survey. The participants were asked if they were following the personalized treatment plan and utilizing the Sure Steps(R) Guidebook.


The sample consisted of 10 community-dwelling, older adults who were referred to the VNA from a nearby medical office. The sample size of 10 was determined after consultation with the clinical education director and rehabilitation manager due to a desire to introduce the program with a small cohort. Inclusion criteria included one or more of the following:


* Adults aged 65 and older without cognitive impairment.


* Carry Atrius and Medicare for insurance.


* Medical history may include conditions that are stable but affect mobility, such as: heart disease, diabetes, arthritis, Parkinson's disease, pain, osteoporosis, and depression.


* History of fall(s) with or without injury.


* Taking medication(s) that increase fall risk such as: benzodiazepines, antidepressants, sedatives, antihypertensives, analgesics, and diuretics.


* Unsteady gait, requiring assistance to leave home.


* Needs to be an active participant in the Sure Steps(R) program.



Five RNs and PTs who are trained in the Sure Steps(R) fall prevention program made the initial home visit. The RN performed the initial assessment, completed the admission, and reviewed the medications. The participants completed the medication log and symptom log by the second visit, which was then faxed to the pharmacy for their input. The PT conducted the home assessment. Each participant was seen two to three times a week for 3 to 4 weeks depending on patient needs.


A data collection worksheet was used to collect the following demographic information: sex, age, marital status, medical diagnoses, medications, history of any falls in the last year, any injuries sustained when fall occurred, living conditions, how many hours of support each day, status of stairs in the home, identified risk factors, and type of home. In addition, a telephone follow-up survey of the participants who were enrolled in the program was developed to collect data on a monthly basis.


The VNA's administration granted approval for the pilot study. Guidelines and a care map were included in the staff development training for all the staff using the Sure Steps(R) Fall Prevention Program. As advocated by the program, participants received monthly phone contact for 1 year to evaluate the program's effectiveness During this conversation, the participants were asked a series of questions developed from the original research by Tinetti et al. (1990) from the Falls Efficacy Scale (FES). The FES measures fear of falling based on the operational definition of fear as low perceived self-efficacy at avoiding falls during essential, nonhazardous activities of daily living. The reliability and validity of the FES were assessed in two samples of community-living elderly persons. The FES showed good test-retest reliability (Pearson's correlation = 0.71). Participants who reported avoiding activities because of fear of falling had higher FES scores, representing lower self-efficacy or confidence, than subjects not reporting fear of falling (Tinetti et al.).


According to the Rehabilitation Measures Database Team (2013), the FES instrument is still an effective scale being utilized by organizations. The questions are used to predict the level of confidence on a scale from 1 to 10 that a person has in performing these activities. The total score denotes the Falls Efficacy Score. A score of 1 denotes extreme confidence and 10 denotes no confidence at all in performing these activities. Each participant was monitored for up to 1 year after being discharged from the program. A follow-up telephone survey was administered and participants were asked:


1. Have you fallen since completing the Sure Steps(R) Program or from our last telephone call? Yes/No


2. Do you feel you are progressing toward your long-term goal you identified? Yes/No


3. Are you continuing to follow your exercise plan? Yes/No



The author then asked each participant about the 10 activities found on the FES tool (see below). The question posed was "On a scale of 1 to 10 (1 being very confident and 10 being not confident at all), how confident are you that you can do the following activities without falling?"


1. Getting dressed


2. Getting on and off the toilet


3. Preparing (simple) meals


4. Taking a bath or shower


5. Getting in and out of a chair


6. Getting in and out of bed


7. Answering the door, getting to the telephone


8. Walking around the house


9. Reaching into cabinets or closets


10. Personal grooming (washing face)



(Reprinted with permission, Mary E. Tinetti, M.D. (C) copyright, 2006.)



The average age of the 10 participants was 76 years, and all were over age 67 years. Seventy percent were female, and of those 71% were widowed and 29% were single. Among the male participants, 67% were married and 33% were widowed. All female participants reported living alone; 57% in an apartment and 43% in a house. All male participants reported living in a house; 67% lived with their spouses and 33% live alone. Eighty percent of the total participants reported they had a history of a fall prior to participation in this pilot study.


Polypharmacy was an identified risk factor in all the participants. According to the Sure Steps(R) Guidebook (2012), polypharmacy was defined as having four or more prescription medications associated with falls. For example: antidepressant, antihypertensive, antianxiety, anticholinergic, hypoglycemic, sedatives, and tranquilizers. One participant was identified as a low fall risk, five participants were identified as a moderate fall risk, and four participants were identified as a high fall risk.


FES scores of the participants improved or remained the same, indicating that none of the participants' risk for falling increased after being discharged from the program after 1 year. Participants in this pilot study continued the exercise program on a routine basis. None of the participants reported falling when contacted by telephone for monthly follow-up over a 1-year time frame. Participants reported continuing to work on attaining their long-term goals that included:


* Being progressively more physically active.


* Preventing future falls.


* Improving walking and balance.


* Sleeping better at night.


* Being able to drive again and continuing to live at home independently.



Based on the positive findings of this pilot study, the VNA implemented the Sure Steps(R) Fall Prevention Program into their other four clinical sites. A mandatory training in-service on the Sure Steps(R) Fall Prevention Program for PTs and RNs was developed and presented to the staff. A total of 30 staff members received the training at the home office. After implementing the pilot study and evaluating the process, a care map was developed for the RNs and PTs. There were four mandatory in-service trainings provided to the second clinical office in another town to begin implementing the program. A total of 45 staff members received the training. A PowerPoint presentation on the Sure Steps(R) Fall Prevention was developed and the findings of the pilot study were presented to the following stakeholders at the VNA: chief executive officer, clinical directors, quality improvement specialists, rehabilitation managers, nurse managers from across the network, vice president of human resources, chief information officer, and the clinical education director. The program was well received and within the next 2 months the remaining three clinical offices received the in-service training.



Falls affect all aspects of life-physical, emotional, psychosocial, and financial. Reducing the number of falls increases quality of life and decreases burden on the healthcare delivery system. The Sure Steps(R) program was found to be effective in providing a small sample of community-dwelling adults aged 65 years or older with a safer environment and an ongoing exercise program to reduce risk of falls. The success of this pilot study has led to wider implementation of the Sure Steps(R) Falls Prevention Program within this VNA. The results of this pilot study are not generalizable due to the small sample size. Additional research is needed using a larger, randomized sample to further examine the effectiveness of the Sure Steps(R) program on falls reduction.


Home care clinicians are in an optimal position to assess community-dwelling patients for fall risk and implement fall reduction measures. Noted risk factors for falls are: history of falls, polypharmacy, visual deficits, home environment, improper footwear, muscle strength, balance deficit, and gait abnormality. Medication reconciliation and consultation with the primary care provider should be conducted to reduce risks related to polypharmacy. Referrals should be made for physical therapy evaluation should assessment reveal history of falls, problems with muscle strength, balance, or gait. Finally, patient and caregiver education is an integral part of fall risk reduction. See Box 1 for topics that should be included in education to decrease fall risk.

Box 1 - Click to enlarge in new windowBox 1. Topics for Patient Education



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