    [Senate Hearing 116-541]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 116-541

                               FALLS PREVENTION:
                             NATIONAL, STATE, LOCAL
                      SOLUTIONS TO BETTER SUPPORT SENIORS

    =======================================================================

                                    HEARING

                                   BEFORE THE

                           SPECIAL COMMITTEE ON AGING

                              UNITED STATES SENATE

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 WASHINGTON, DC

                                   __________

                                OCTOBER 16, 2019

                                   __________

                               Serial No. 116-13

             Printed for the use of the Special Committee on Aging

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                   __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    47-291 PDF                 WASHINGTON : 2022

    -----------------------------------------------------------------------------------

                           SPECIAL COMMITTEE ON AGING

                       SUSAN M. COLLINS, Maine, Chairman

    TIM SCOTT, South Carolina            ROBERT P. CASEY, JR., Pennsylvania
    RICHARD BURR, North Carolina         KIRSTEN E. GILLIBRAND, New York
    MARTHA McSALLY, Arizona              RICHARD BLUMENTHAL, Connecticut
    MARCO RUBIO, Florida                 ELIZABETH WARREN, Massachusetts
    JOSH HAWLEY, Missouri                DOUG JONES, Alabama
    MIKE BRAUN, Indiana                  KYRSTEN SINEMA, Arizona
    RICK SCOTT, Florida                  JACKY ROSEN, Nevada
                                  ----------
                Sarah Khasawinah, Majority Acting Staff Director
                     Kathryn Mevis, Minority Staff Director

                             C  O  N  T  E  N  T  S

                                  ----------

                                                                       Page

    Opening Statement of Senator Susan M. Collins, Chairman..........     1

    Opening Statement of Senator Robert P. Casey, Jr., Ranking Member     3

                               PANEL OF WITNESSES

    Peggy Haynes, Senior Director, Healthy Aging, MaineHealth,
      Portland, Maine................................................     5
    Virginia Demby, Advocate for Community and Older Adults, Chester,
      Pennsylvania; Accompanied by Ellen Wiliams, Health and Wellness
      Program Manager, County of Delaware Services for the Aging.....     7
    Kathleen A. Cameron, Senior Director, Center for Healthy Aging,
      National Council on Aging, Arlington, Virginia.................     9
    Liz Thompson, Chief Executive Officer, National Osteoporosis
      Foundation, Arlington, Virginia................................    10

                                    APPENDIX
                          Prepared Witness Statements

    Peggy Haynes, Senior Director, Healthy Aging, MaineHealth,
      Portland, Maine................................................    33
    Virginia Demby, Advocate for Community and Older Adults, Chester,
      Pennsylvania; Accompanied by Ellen Wiliams, Health and Wellness
      Program Manager, County of Delaware Services for the Aging.....    37
    Kathleen A. Cameron, Senior Director, Center for Healthy Aging,
      National Council on Aging, Arlington, Virginia.................    39
    Liz Thompson, Chief Executive Officer, National Osteoporosis
      Foundation, Arlington, Virginia................................    53

                           Statements for the Record

    National Safety Council..........................................    65
    Trust for America's Health.......................................    69
    Centers for Medicare and Medicaid Services.......................    72

                               FALLS PREVENTION:
                           NATIONAL, STATE, AND LOCAL
                      SOLUTIONS TO BETTER SUPPORT SENIORS

                                  ----------

                          WEDNESDAY, OCTOBER 16, 2019

                                           U.S. Senate,
                                    Special Committee on Aging,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 9:28 a.m., in
    Room 562, Dirksen Senate Office Building, Hon. Susan Collins,
    Chairman of the Committee, presiding.
        Present: Senators Collins, Hawley, Braun, Rick Scott,
    Casey, Blumenthal, Jones, Sinema, and Rosen.

                     OPENING STATEMENT OF SENATOR
                       SUSAN M. COLLINS, CHAIRMAN

        The Chairman. The Committee will come to order.
        Good morning. Each year, the Senate Aging Committee
    releases a bipartisan annual report on an issue affecting older
    Americans.
        Today's hearing on the prevention of falls is the subject
    of our report this year and represents the culmination of much
    work on this important issue.
        Nearly 200 organizations representing patients, clinicians,
    community service providers, and others have contributed
    valuable insights and recommendations on ways to reduce falls
    and related injuries. We will hear more about that this
    morning.
        Falls are the leading cause of fatal and non-fatal injuries
    for older Americans, often leading to a downward spiral with
    serious consequences. In addition to the physical and emotional
    trauma of falls, the financial toll is staggering. In the
    United States, the total cost of fall-related injuries is
    approximately $50 billion annually, and that is expected to
    double to $100 billion by the year 2030. Seventy-five percent
    of these costs are borne by the Medicare and Medicaid programs.
        While we tend to attribute falls to external factors like
    uneven sidewalks or icy stairs, clinicians also attribute them
    to such factors as medications, medical reasons, or muscle
    strength.
        One key cause is osteoporosis, which can be especially
    dangerous for people who are completely unaware that they
    suffer from low bone density.
        While Medicare covers bone density testing, reimbursement
    rates have been slashed by 70 percent since 2006, resulting in
    2.3 million fewer women being tested. As a result, it is
    estimated that more than 40,000 additional hip fractures occur
    each year, which results in nearly 10,000 additional deaths.
        I have introduced the Increasing Access to Osteoporosis
    Testing for Medicare Beneficiaries Act with Senator Ben Cardin
    to reverse these harmful reimbursement cuts.
        I would like to recognize Ann Elderkin, who is with us
    today, and has assisted us greatly with this legislation. She
    is the executive director of the American Society for Bone and
    Mineral Research and a resident of Cape Elizabeth, Maine.
        Another major risk factor for falls among seniors is
    medications. Ninety percent of older Americans take at least
    one prescription medicine, and 36 percent take five or more.
    Taking multiple prescription drugs can cause interaction
    problems that increase the risk of falls, like vision
    disturbances, confusion, and sleepiness.
        Certain frequently prescribed drugs themselves can also
    trigger side effects that increase the risk of falls. These
    medications often are not tested adequately in older adults.
        At my request, the Fiscal Year 2020 FDA funding bill
    directs the agency to assess the impacts of drug interactions
    and ensure that older adults are adequately represented in
    clinical trials.
        To address this risk factor, we must also encourage
    medication reconciliation in the Medicare Annual Wellness
    Visits.
        In addition to medical factors, the Committee heard from
    stakeholders about the importance of education and community
    interventions. For example, MaineHealth, my State's largest
    health care organization, developed a peer-led program called
    ``A Matter of Balance'' in 2003. It aims to increase activity
    levels, improve balance, and reduce the fear of falling for
    older adults.
        Let me provide an example. Ginny is 90 years old and lives
    alone in coastal Maine. Last winter, she slipped and fell down
    her front steps. She signed up for ``A Matter of Balance'' but
    was really unsure how it would help. Her improvements exceeded
    her expectations, including more than just physical progress.
        Over the course of the class, her confidence increased.
    Ginny shared that her fear of falling often kept her alone,
    essentially imprisoned in her own home. With the support from
    the group, she is now getting out and socializing, including a
    recent trip to an island off the Maine coast.
        Since 2006, more than 6,200 Mainers have participated in
    the program, which is now in 46 States across the Country.
        Home health, especially occupational therapy, is another
    falls prevention tool. I have introduced the Home Health
    Payment Innovation Act with Senator Debbie Stabenow that would
    give Medicare Advantage and Accountable Care Organizations
    flexibility to waive the antiquated ``homebound'' definition so
    that more people can receive these services.
        Senators Scott, Sinema, Burr, and Rosen have already
    cosponsored this bill. Medicare Advantage is starting to expand
    this benefit, which is a welcome first step.
        Home modification is another strategy to prevent falls.
    Senator King and I have introduced the Senior and Disability
    Home Modification Assistance Act to coordinate programs that
    provide home modification resources and to help people age in
    their own homes. As the Chair of the Transportations and
    Housing Appropriations Subcommittee, I recently created and set
    aside some grant funding for this very purpose.
        Last month, the Senate unanimously approved a resolution
    spearheaded by our Committee, marking the first day of fall,
    September 23d, as National Falls Prevention Awareness Day. We
    are a little bit late, but I hope that this hearing will also
    help to promote awareness. Now is the time and now is our
    opportunity to take action to prevent falls.
        Our report includes recommendations to key Federal agencies
    to take steps to reduce falls, and we will be following up with
    those agencies, so for everybody's benefit, here is a copy of
    our annual report on falls preventions. The Committee has given
    it its stamp of approval. It is bipartisan, and I am very
    pleased that we will be able to share this with everyone who
    has an interest.
        I now am pleased to turn to our Ranking Member, Senator
    Casey.

                     OPENING STATEMENT OF SENATOR
                  ROBERT P. CASEY, JR., RANKING MEMBER

        Senator Casey. Thank you, Chairman Collins, for holding
    this hearing and for the work done by you and by both staffs on
    this report.
        I am pleased that the Committee took up the issue of falls
    prevention this year. In order to inform our hearing today and
    release the Committee's annual report entitled ``Falls
    Prevention: National, State and Local Solutions to Better
    Support Seniors,'' the Committee solicited input from
    stakeholders, experts, academics, and Federal agencies.
        We received nearly 200 comments from stakeholders about
    falls prevention and responses from nearly every relevant
    Federal agency.
        There is good reason for that response. As the report
    finds, falls are a serious issue that affect a growing number
    of Americans each year.
        I will just give you two numbers--30 and 50. The first is
    30,000. In 2016, almost 30,000 older adults died from falls. In
    2015, falls cost the United States health care system 50
    billion--with a ``b''--$50 billion, as Senator Collins
    indicated, so, in 2016 and 2015, those two numbers, 30,000
    deaths, $50 billion in terms of cost.
        Those numbers are staggering, and they may not even tell
    the whole story because many older adults do not tell anyone
    when they fall. We must remove the stigma associated with
    falling so that our loved ones can get the help they need to
    age in place, where they want to be, in their homes and
    communities.
        As our report illustrates, there are steps that can be
    taken to make this a reality. I will start with one, physical
    mobility. That is a key. Staying active, walking, stretching,
    strength-training, all of that is proven to reduce risks, the
    risk of falling among older adults.
        Second, continuing to invest in the development,
    dissemination, and evaluation of proven interventions is
    critical. It is why Chairman Collins and I are working to get
    more resources for evidence-based programming for seniors
    through our efforts to reauthorize the Older Americans Act.
        Number three, home modifications can also help. Yet to a
    senior on a fixed income, even installing a grab bar in the
    shower may be out of reach due to cost.
        The research community also has a role to play by ensuring
    that older adults are part of clinical trials so that we know
    the prescription drugs they may need do not come with a dose of
    falling.
        Providers must be trained to screen patients for their
    falls risk and refer those in need of intervention to the
    appropriate service provider.
        A conversation that allows a provider to assess a patient
    should be part of every, every wellness visit.
        I am hopeful that our work over the past year, along with
    this hearing today and the release of this report, will do the
    following: 1) launch that type of dialog between patients and
    providers; 2) propel the research community to do more; 3) to
    get more dollars invested into supporting home modifications;
    and 4) encourage more older adults to be active.
        I am particularly interested in sharing this report with
    the relevant agencies and learning how the recommendations will
    be implemented. Not just put in a report. Implemented.
        I want to thank each of our witnesses for being here, and
    want to reiterate my thanks to Chairman Collins for holding
    this important hearing and for her leadership in releasing this
    report.
        Just to note for today in terms of my presence, I have to
    leave briefly to introduce a judicial nominee in the Judiciary
    Committee. They do not tell us when they are having these
    hearings, and they just happen to schedule it at the same time.
    I will be in and out but not too long.
        Thank you, Chairman Collins.
        The Chairman. Thank you very much, Senator Casey.
        I also want to acknowledge the presence of Senator
    Blumenthal, Senator Rosen, and Senator Jones. Thank you so much
    for your interest and for being here today.
        We will now turn to our panel of witnesses. First, I am
    delighted to introduce Peggy Haynes, who is the senior director
    of MaineHealth Partnership for Healthy Aging, where she leads
    MaineHealth's efforts to deliver quality aging and senior care
    of Maine seniors. Ms. Haynes' primary focus has been on
    MaineHealth, a highly successful A Matter of Balance program,
    which I described in my opening statement. She has led the
    successful translation and national dissemination of A Matter
    of Balance to a lay leader model. Under her leadership, the
    organization has received national recognition for
    accomplishments in health promotion and collaboration.
        I will now turn to our Ranking Member to introduce our
    second witness.
        Senator Casey. Thank you, Chairman Collins.
        I am pleased to introduce Virginia Demby of Chester,
    Pennsylvania. Virginia brings decades of experience as a nurse,
    to her testimony today, having talked to the patients she
    treated about the importance of staying active later in life.
    Now Virginia is putting into practice what she told patients
    all those years as a nurse.
        In addition to taking a falls prevention class offered
    through her local senior's center, Virginia is a regular at
    kickboxing and yoga. Virginia, some days around her, I would
    like to know how to kickbox.
        Senator Casey. Sometimes you can also find her dancing and
    even weightlifting. We will hear more about that later, I hope.
        As Virginia will explain, she has not stopped encouraging
    others to get moving either.
        Virginia is joined today by Ellen Williams, Health and
    Wellness program manager at the County of Delaware Services for
    the Aging.
        Ellen, thank you for being here as well.
        Virginia works with Ellen to encourage other seniors in
    Delaware County, Pennsylvania, to take these classes and to
    stay active.
        Thank you, Virginia, for being here and to let us in on
    your secrets to staying healthy, and thank you for your
    advocacy in your community.
        The Chairman. Thank you.
        I want to acknowledge that Senator Rick Scott of Florida,
    who has been a very loyal member of this Committee, has also
    joined us.
        Next, we will hear from Kathleen Cameron, a veteran health
    care professional in the field of aging. She has more than 25
    years of experience as a pharmacist, researcher, and program
    director focusing on falls prevention, geriatric
    pharmacotherapy, mental health, long-term services and
    supports, and caregiving. Since 2014, Ms. Cameron has been the
    senior director of the National Council on Aging's National
    Falls Prevention Resource Center, and last but certainly not
    least, we will hear from Liz Thompson, the chief executive
    officer of the National Osteoporosis Foundation, and again, I
    want to thank the foundation for working with me in my office
    on the legislation that we have introduced to reverse the
    harmful cuts in osteoporosis and bone density screening.
        Ms. Thompson has 30 years of experience. In 2018, she
    launched the National Bone Health Policy Institute, which seeks
    to spread greater awareness about the importance of bone
    health.
        I want to thank all of our witnesses for being with us
    today, and, Ms. Haynes, we will start with you. Thank you for
    being here, all the way from the great State of Maine.

              STATEMENT OF PEGGY HAYNES, SENIOR DIRECTOR,

              HEALTHY AGING, MAINEHEALTH, PORTLAND, MAINE

        Ms. Haynes. Thank you, Chairman Collins, Ranking Member
    Casey, and Committee members. I am Peggy Haynes. I am the
    senior director of Healthy Aging at MaineHealth. We are Maine's
    largest integrated health care delivery system.
        Our vision is to make our communities the healthiest in
    America, which led us to focus on fall prevention. Health care
    has a critical role to play in fall prevention, from screening
    for falls, assessing fall risk factors, reviewing medications,
    and referring to both medical and community-based
    interventions.
        Falls are multi-factorial, and a range of interventions are
    needed. We recognize this by becoming founding members of the
    Evidence Based Leadership Collaborative, promoting the
    increased delivery of multiple evidence-based programs.
        Today I am here to share our work with A Matter of Balance.
    In Maine, we took an evidence-based, clinically led program
    that was challenging to replicate and used Maine's experience,
    innovation, and common sense to create a program that is now
    reached across the country. A Matter of Balance reduces the
    fear of falling and increases activity levels in older adults.
    It is a small group program, where participants learn to view
    falls and fear of falling as controllable, set realistic goals
    to increase their activity, reduce their fall risk factors, and
    use exercises to gain strength and balance. Eight 2-hour
    classes include group discussion, problem-solving, and exercise
    training.
        A Matter of Balance was developed with funding from the
    National Institute on Aging through a randomized control trial
    at Boston University in the mid-'90's. We brought A Matter of
    Balance to Maine, using our clinical staff to offer the program
    in the community. While it was very well received, the
    expensive of using clinical staff limited our dissemination.
        In 2003, the Administration on Aging used Older Americans
    Act funding for translational research to get the
    scientifically proven programs off the shelf and into the
    community. MaineHealth and our partners were awarded a grant to
    develop lay leader model for A Matter of Balance.
        We made adaptations, keeping the class structure and
    curriculum true to the original research. Now classes are
    taught by lay coaches. Curriculum materials include master
    trainer manuals and coach manuals, participant workbooks, and
    exercises that were adapted to focus on strength and balance,
    and we added visiting health care professionals.
        We developed a training structure. We teach master trainers
    who then teach and support coaches with an established
    curriculum.
        We provide support by updating materials and resources by
    quarterly conference calls through technical assistance and
    outcomes measurement.
        The results tested in Maine reflected the same
    statistically significant increases for up to 12 months in
    falls efficacy, falls management, and falls control, and for up
    to 6 months, improvement in physical activity and reduced
    isolation. Ninety-seven percent of participants are more
    comfortable talking about fear of falling and increasing
    activity levels, and 99 percent plan to continue to exercise.
        A Matter of Balance participation was associated with total
    medical cost savings of $938 a year in the 2013 CMS report to
    Congress.
        We work in partnership with our agencies on aging to
    provide State-wide access to classes. As Senator Collins
    mentioned, over 6,200 Mainers have benefited from the program.
        Nationally, 1,700 master trainers are spread across 46
    States, and since 2006, over 96,000 older adults have attended
    classes.
        I would like to also share a participant story. Sandy,
    following back surgery, was using a cane. One winter morning,
    taking her dog outside, she fell on the ice breaking her femur.
    After 3 months of physical therapy, she was still using a
    walker and was stuck at home. Sandy's daughter saw an ad for A
    Matter of Balance and encouraged her to attend.
        Skeptical, Sandy started the program. Within 4 weeks, she
    was no longer using her walker and had graduated to relying on
    a cane. Sandy said, ``The program teachers you to think and
    stay in tune with your body.'' Sandy then took Tai Chi, again,
    skeptically. She was not an earth muffin. Two months into
    taking Tai Chi, Sandy no longer needed her cane. She has gone
    on to be a coach for A Matter of Balance in Tai Chi, and she is
    now teaching other older adults to know they can get up and to
    reclaim their lives. In her words, ``Now I am free. I am here
    again, and I am back to being me.''
        Thank you for the opportunity to speak with you and for
    your leadership to reauthorize the Older Americans Act and your
    support for National Falls Prevention Awareness Day, and thank
    you for recommending the increased funding for fall prevention
    so more older adults can live independently.
        The Chairman. Thank you very much for your testimony.
        Ms. Demby?

               STATEMENT OF VIRGINIA DEMBY, ADVOCATE FOR
           COMMUNITY AND OLDER ADULTS, CHESTER, PENNSYLVANIA

        Ms. Demby. I am Virginia Demby. I was born in Chester,
    Pennsylvania. I also live in Chester, Pennsylvania. When I was
    younger, I would often work two and three jobs in order to meet
    my needs and the needs of my family members.
        Life has not been easy for me. I was also born with some
    birth defects. I had many things happen to me, and doctors did
    not know what was wrong with me. Many of the doctors were
    telling me, ``It is all in your mind,'' and I would fall a lot.
    Many times, I found that when I would get out of bed, when I
    tried to stand up, it was not going to happen and I would find
    myself on the floor.
        Before I got a wheelchair, I many times crawled across the
    floor to get to the bathroom because I did not want to make a
    mess. Even today, I still remain very independent, in spite of
    all the things that have happened to me.
        Nobody taught me what to do. I figured it out for myself
    because the time came that I also developed fibromyalgia, after
    having had a knee replacement. Due to some of the birth
    problems, defects that I had, I would constantly develop tissue
    growths and would always have to go back to the hospital to
    have those tissue growths removed, which also prevented me from
    walking, prevented me from standing up. I could not participate
    in many things.
        Doctors did not know what to do for me. I developed
    fibromyalgia before doctors even knew what it was. Most of them
    had never heard of it. I had arthritis, osteoporosis, rare
    genetic inherited blood factor, problems with the heart. I
    realized if something did not happen for me, I was not going to
    live. I could not possibly make it.
        Then there was also a matter of economics. When I reached
    the point where I could no longer keep my home, after having
    spent years of doing things to help other people even at that
    point, I no longer had enough money to even take care of
    myself. I have been very grateful to have assistance, where a
    portion of my rent is paid every month, and to have the SNAP
    program so that I can eat. Even with that, it is not enough
    money, getting Social Security and SSI, to really take good
    care of myself.
        I had to learn how to be a very thrifty shopper. I had to
    learn how to go to stores and find foods and things at a price
    I could pay for so that I could do healthy eating, so that I
    could look after my body, look after my mind, so many older
    adults have not had that experience. Nobody has taught them.
    They have not had the educational training, and they end up
    isolated, alone, not knowing what to do, not enough funds to
    support themselves.
        Many of them, like me, also end up in apartment buildings,
    nursing homes, and still not getting what they need.
        Healthy Steps. If you learn about it, if you participate in
    it, there is the opportunity to learn how to be active, how to
    regain what you have lost, what it is like to be rejuvenated,
    how to find a way to prepare your meals and shop so that you
    can have what is going to be healthy for you because, like I
    said, you cannot afford to do it on Social Security. SNAP helps
    a little bit, but it is not enough. Then you get criticized
    because that is what you get.
        Older adults lose their confidence, and no wonder. They
    become fearful, and no wonder. I am finding older adults are
    the ones who need the most help. Many of them are very set in
    their ways, very stuck in their thinking, afraid to share with
    other persons, and do not know who to turn to or where they can
    get help. Most older adults, as they have come along, their
    families along with them have all expired, and there they are
    left alone, no place to go, do not know what they are going to
    do and they just sit. They do not know that sitting is just
    going to make them even less active as time goes on. I go out
    and encourage them. I find them. I go to the apartment
    buildings. I go to the Department of Housing in the city where
    I live, and I encourage them to set up sessions. Have persons
    like COSA with Ellen coming in. Get in touch with the older
    people. Have them come, take the classes, participate, and
    where they do not have family and friends, buddy up and help
    each other. Get back to walking. Walk together.
        Me, as the Senator said, I do line dancing, Zumba,
    kickboxing, weightlifting, boxing, extreme exercise. I used to
    run. I do not do the running anymore because I am very visually
    impaired. Now I walk, but I do distance walking. I tell older
    adults, ``If you can walk a little bit, keep adding on to the
    distance that you can walk. Get those muscles working again.
    Health can be repaired, but you have to participate in it. Open
    up. Talk to your doctors. Ask questions, and if you do not
    understand what they are saying to you, ask them to break it
    down for you so that you can understand. Find someone to go to
    the doctors with you that may have more understanding of the
    body and the mind than you have, who may have a little more
    knowledge of medical terminology, and ask them to speak for
    you. Ask them to step in and help you understand what the
    doctors are talking about. Make sure you are getting the right
    kind of doctors. Make sure you are getting competent, caring
    doctors. Check out those doctors. Find out where did they go to
    school. Where did they do their internship? In the cases that
    they work on, how long have they been doing that kind of work?
    Do not be afraid to ask for a specialist. Search out the
    different organizations that can provide you with some help.''
        I am looking to live a long life. My grandmother was 105
    and was very functional. My grandfather was 98 and very
    functional. I just recently had a sister pass who was 94. Her
    only problem was arthritis, so because I have that long-life
    background, I expect it, and I am looking forward to it. I am
    determined to continue being functional. I am determined to
    continue doing things that will help older adults, and all that
    I do, I get no moneys for it. I do it for free, all because I
    care.
        The Chairman. Thank you very much for your very compelling
    testimony.
        Ms. Cameron?

                   STATEMENT OF KATHLEEN A. CAMERON,

                  SENIOR DIRECTOR, CENTER FOR HEALTHY

                   AGING, NATIONAL COUNCIL ON AGING,

                          ARLINGTON, VIRGINIA

        Ms. Cameron. Good morning. Chairwoman Collins, Ranking
    Member Casey, and members of the Committee, I appreciate the
    opportunity to speak with you on behalf of the National Council
    on Aging about the critical issue of older adult falls and the
    promise of falls prevention.
        I have dedicated a large part of my professional career to
    this issue. It is also very personal for me because my mother
    passed away due to consequences from a hip fracture she
    sustained after a fall.
        Almost every person knows an older adult who has fallen and
    whose quality of life, dignity, and independence were
    dramatically changed, as was the case for my mother. It is a
    health issue that crosses all genders, ethnicities, and income
    levels.
        NCOA's mission is to improve the lives of millions of older
    adults, especially those who are struggling. Falls prevention
    is a critical pillar of our work.
        NCOA directors the National Falls Prevention Resource
    Center that is funded by the Administration for Community
    Living, and we lead the National Falls Free Initiative, which
    includes coalitions in 43 States.
        Every year, on the first day of fall, we sponsor Falls
    Prevention Awareness Day to ring attention to the issue and
    proven solutions. Thank you, Senators Collins and Casey, for
    leading the effort to pass the annual Senate resolution to
    designate the day this year and for enlisting the vast majority
    of Committee members as cosponsors. Thank you.
        We know the predictors for falls. We have tools to identify
    those most at risk, and we have proven strategies to reduce
    risks and falls. Yet falls rates continue to escalate. Every
    hour, four older adults die from fall-related complications.
    This number is expected to reach seven by 2030 if we do not
    take significant steps now--by 203, fall-related costs are
    projected to double to $101 billion, and right now, as you
    mentioned, Senator Collins, Medicare and Medicaid pay the
    majority of these costs.
        Many factors contribute to falls, which is why NCOA
    advocates for multi-stakeholder solutions. First, we need a
    coordinated Federal effort. Today, there is no one
    comprehensive strategy under the purview of any one single
    agency. A coordinated effort could be modeled after the
    National Alzheimer's Project Act and include a National
    Awareness and Action Campaign. It could also include a cross-
    agency collaboration to develop the infrastructure to make it
    easier for older adults to access and afford falls reduction
    strategies.
        Second, we need early identification of falls risk factors
    and early intervention. Falls should be recognized as a medical
    condition to increase accurate reporting, compliance with
    medical recommendations, and payment for prevention and
    treatment.
        Falls risk screening and assessment tools must be used
    consistently. The CDC study is a gold standard, saving an
    estimated $3.5 billion over 5 years. We recommend incentivizing
    health care providers to use it.
        We also must promote electronic health records to
    coordinate communication and data exchange among those involved
    in falls prevention, also critical is widespread implementation
    of evidence-based community programs such as A Matter of
    Balance, Fit and Strong, Tai Chi, Healthy Steps that Ms. Demby
    mentioned.
        Older Americans Act health promotion funds have supported
    these programs, and the Prevention and Public Health Fund has
    made crucial new investments.
        Since 2014, the $5 million allocated annually from the
    Prevention and Public Health Fund has allowed us to reach
    100,000 older adults in 30 States through community-based
    organizations' efforts. Although impressive, much more is
    needed, especially in rural and underserved areas of the
    Country.
        We also need to focus on two of the most modifiable risk
    factors--medications and home safety. NCOA recommends all older
    adults receive at least an annual review of medications,
    especially during transitions of care, to identify fall-related
    side efforts. CMS should mandate that Part D plans expand
    medication therapy management services to include reviews for
    falls risk.
        We must incentivize people to modify their homes for aging
    in place. NCOA also urges wider implementation of evidence-
    based programs such as CAPABLE.
        We appreciate the efforts of Senators Collins and Casey to
    mobilize bipartisan support for OAA reauthorization to
    coordinate home modification and promote innovation.
        Finally, we must improve Medicare to prevent falls. We urge
    CMS to provide Medicare reimbursement for falls risk screening,
    referral management, and evidence-based community programs.
    Expand payment for the Welcome to Medicare and Annual Wellness
    Visit to physical and occupational therapists. Develop Medicare
    falls prevention billing codes, and use the CMMI to examine
    innovative payment models.
        We must face older adult falls head on. We understand the
    problem, and we know the solutions. Now we must create a
    coordinated strategy and devote resources to save lives.
        Thank you for this opportunity, and I welcome questions
    from Committee members.
        The Chairman. Thank you very much for your statement.
        Ms. Thompson?

          STATEMENT OF LIZ THOMPSON, CHIEF EXECUTIVE OFFICER,

                   NATIONAL OSTEOPOROSIS FOUNDATION,

                          ARLINGTON, VIRGINIA

        Ms. Thompson. Good morning, Chairman Collins and Ranking
    Member Casey. Thank you so much for calling this hearing today
    on a vitally important issue. I want to especially thank you,
    Madam Chairman, for your longstanding work on bone health
    issues. It is truly appreciated.
        The National Osteoporosis Foundation strongly agrees with
    the Committee that a thoughtful analysis in search for policy
    solutions to the problem of falls among older Americans must
    include an examination of bone health, osteoporosis, and bone
    fractures.
        In a minute, we will turn to some very big numbers, but
    before we do that, I want to make sure we are keeping patients
    and their families front and center.
        In December 2018, my friend and colleague, Claire, lost her
    mother, Rosaline Burke, to complications related to a fall. In
    June of this year, my father, Alvin, died of complications
    related to a fall. These millions of people that we are talking
    about are not abstract to Claire and me. We know their stories.
    They are our stories. As we discuss the issues today, remember
    Rosaline and Alvin and the millions of people they represent.
        Now, I promised you numbers, and here we go. I have a few
    slides that I will briefly review a few findings from a report
    that we commissioned recently from Milliman, the actuarial
    firm.
        Slide 1, please. Approximately 2.3 million fractures, bone
    breaks, were suffered by 2 million Americans on Medicare. That
    is right, more than one fracture per person. Those numbers are
    not acceptable.
        Slide 2, please. Secondary fractures are extremely costly.
    This is the second fracture people incur. The additional cost
    in Medicare for the 307,000 people who suffered a bone break in
    the 2 to 3 years after their first fraction was $6.3 billion.
        Slide 3, please. While we know from previous studies that
    about 50 percent of secondary fractures can be prevented by
    appropriate treatment, we also know from other studies that 80
    percent of those who have suffered a fracture do not receive
    the treatments that we know work. That is not acceptable.
        Slide 4, please. The total annual cost to Medicare and
    their families, including caregiver costs, is expected to
    balloon from $57 billion in 2018 to $95 billion in 2040 if we
    do nothing.
        Slide 5, please. Our new report from Milliman gives us
    hope. Our report finds that preventing even a modest 20 percent
    in the rate of secondary bone breaks could lead to a savings of
    $1.2 billion in Medicare fee-for-service.
        What do we need to do to stem this crisis? The National
    Osteoporosis Foundation has put forward an aggressive call to
    action to stem this crisis. First, we recommend that Congress
    should direct CMMI to conduct a Medicare demonstration or
    create a bundled payment model that incentivizes better
    coordination and management of care, such as the provision of
    fracture liaison services, to beneficiaries who have suffered
    one or more bone fractures and may be at risk of additional
    fractures.
        Today Medicare does not pay for the innovative care
    coordinated model known as FLS, or fraction liaison service,
    but we know from work by Kaiser and Geisinger, this model could
    have incredible impact on our seniors and our pay system.
    Number one, Congress should pass Chairman Collins' bipartisan
    Increasing Access to Osteoporosis Testing for Medicare
    Beneficiaries Act of 2019. This legislation would set more
    adequate payment rates for screening and should increase access
    to this critical preventive service. Based on a 35 percent
    prevention rate, we estimate 26,000 hip fractures could have
    been avoided if Medicare beneficiaries continued to receive DXA
    scans. Number three, appropriate quality measures for both
    optimal screening and treatment of osteoporosis and bone
    fractures should be established, adopted, and incentivized by
    Medicare and other payers, Number four, Congress should direct
    and fund HHS to implement a national education and action
    initiative aimed at reducing falls and bone fractures among
    older adults. One such model for this is already in place. The
    initiative is the Million Hearts 2022, an initiative co-led by
    the CDC and CMS, which aims to prevent 1 million heart attacks
    and strokes within 5 years.
        These steps along with others called for in the committee's
    excellent report being released today provide a roadmap for
    improving and saving lives and lowering health care costs.
        Thank you so much for the opportunities to share our views
    on this very important topic. We look forward to working
    closely with the Committee as its work progresses.
        I look forward to any questions you may have.
        The Chairman. Thank you very much, Ms. Thompson, and my
    sincere condolences on the loss of your father. As I have
    learned more about this issue, falls are the single greatest
    factor in the downward spiral that can lead to the passing of a
    loved one, and I am sorry that you had to experience that
    personally as well.
        I am struck, as I hear your testimony, that this is an
    issue where we know what to do in many cases. It is not
    something like Alzheimer's disease, where we still have not
    figure out. We know what to do, and yet we are slashing
    reimbursements. We are not focused on it. The public is not
    aware of how significant falls are, and that makes it all the
    more frustrating. I am sure it does to each of you.
        The costs are also so significant. Ms. Thompson, I want to
    start with you. I am just stunned by the fact that CMS slashed
    the reimbursement rates for the bone density scan by some 70
    percent, and we have seen the results in the last 13 years.
    Indeed, one of your charts, if I read it correctly, showed that
    even after a fracture, only 9 percent are being scanned. How
    important is it that we increase the reimbursement level?
        I had two medical experts in Maine, Cliff Rosen, who is the
    director of the Center for Clinical and Translational Research
    at the Maine Medical Center, and Ann Elderkin, whom I
    previously mentioned, who was the executive director of the
    American Society for Bone and Mineral Research, write that the
    DXA scans have declined dramatically, and as a result, we are
    seeing way more fractures.
        How important is it for us to fix this reimbursement
    problem?
        Ms. Thompson. First, I want to say thank you for
    recognizing the fantastic work of Anne Elderkin and the ASBMR.
    They are a terrific partner with us as well.
        Next, I want to say on behalf of all of us who are working
    in this, we do not believe there is any reasonable
    justification for the cuts that have been made to
    reimbursement. They were misguided, and they reduced access to
    screening. We believe this was penny wise and pound foolish.
        For those of you who do not know, I just want to make sure
    we understand how we got to this point. Congress first cutoff
    the DXA payments in 2007 along with Medicare payments for other
    imaging services as part of the Deficit Reduction Act in 2005,
    and then further cuts, phased in over time, were done to
    physicians in the course of interpreting those DXA results.
        It came up a little bit under the Affordable Care Act of
    restoring it to 70 percent of the 2006 level, but that increase
    only lasted for 2 years. In the end, a provision to increase
    Medicare payments for DXA was not included.
        We strongly support your legislation, Increasing Access to
    Osteoporosis Testing for Medicare Beneficiaries, to get back to
    the levels where patients will have access and physicians will
    have the ability to do this critically important test.
        Thank you so much for your leadership in this, Senator
    Collins.
        The Chairman. Thank you for giving us the history as well.
    That is very helpful.
        Ms. Haynes, you have done such an extraordinary job with A
    Matter of Balance program, which is such a commonsense,
    inexpensive way to reduce the risk of falls and the fear of
    falling that can cause seniors to become homebound.
        I am curious, however, how you reach individuals who are
    living in the more rural areas of the State of Maine. Are the
    local community health centers and rural hospitals and physical
    therapists participating in offering the program, or is it
    mainly available in Southern Maine?
        Ms. Haynes. Actually, it is available State-wide, and
    Aroostook Area Agency on Aging has been doing a wonderful job.
    We just had two folks come down to our master training last
    week because they have demand that they cannot meet for
    classes.
        I asked them what their secrets were. Town halls, churches,
    where do people go, the rural health centers, where there are
    meeting rooms, people team up. You said to buddy up, so they
    give each other rides. People who can still drive pick up those
    that cannot. In small communities, that is easier in some ways
    because you know each other, and you have known each other for
    years. It really is a matter of reaching out and finding those
    locations where people already go.
        Likewise, we just trained more folks from Franklin County
    because they have a waiting list, and they are going to very
    small communities. In both of those situations, they have
    serious winter issues to deal with too.
        Senior housing is another place, if there is senior
    housing. You mentioned early on, we need to touch all of those
    places. It is an issue for housing. It is an issue for health
    care. It is an issue for our community-based organizations. We
    need to work together, whether you are urban or rural, for
    those touch points.
        The Chairman. Thank you very much.
        Senator Casey?
        Senator Casey. Thank you, Chairman Collins. Thank you for
    indulging in my schedule with the Judiciary hearing, and I am
    back.
        I wanted to start with Ms. Demby. Virginia, it is obvious
    that you are an advocate in more ways than one, and that you
    are certainly a force to be reckoned with. This question could
    only go to someone with your background and your credentials as
    an advocate.
        You said that you are working with Ellen, who is with you
    today, to connect other seniors with falls prevention classes
    and getting scores of your friends and neighbors moving,
    literally, but you are just one person, and we know that
    today's report, among its other recommendations, suggest that
    the Federal Government engage in a national effort, really a
    national campaign to promote falls prevention strategies.
        Here is the question: Do you think this type of investment,
    a falls prevention campaign, would be helpful in getting more
    people across our Commonwealth and our Country moving
    literally?
        Ms. Demby. Yes. I live in an apartment building that is
    designated for seniors and persons with disabilities. I am now
    also seeing younger persons being admitted into those
    facilities to be residents there, and even with seeing that, I
    see the seniors still separated. I see seniors, the older
    adults, being mistreated by managers and property owners,
    intimidated, afraid to speak up. I go and speak for them, or I
    encourage them to speak for themselves, or I tell them, they
    must change their way.
        Many of them do not even leave the building unless somebody
    comes and takes them, and usually, it is for a medical ride.
    Where I live, if it is not a medical ride that you are getting,
    if someone you know does not take you, if a family member does
    not take you, you do not get to go. They go nowhere.
        I approached the housing authority in the city where I
    live, Chester, Pennsylvania, and they have promised me, because
    of what they know of me, that if a center is closed, all I have
    to do is get a schedule from COSA, from Ellen, COSA's
    instructors, get it set up and bring them in to teach those
    seniors, but then there is a problem with that too sometime
    because sometime that older adult has no way to get there, and
    it is not considered a medical ride, so they get left out.
        I further went to the extent of going to find a way to get
    it to them, going to find a way to get them to it. It is a
    must. Until the death of that older adult, they must find a
    way. They must have a way to participate. There must be support
    for them. There must be somebody who speaks up for them,
    especially when they do not speak for themselves. I am that
    community advocate and that advocate for older adults. I do not
    know anyone else in the area where I live or anywhere in
    Pennsylvania that somebody has taken that on and is doing it.
        Senator Casey. A national campaign is pretty important?
        Ms. Demby. Yes, very.
        Senator Casey. Thank you.
        I just have a little bit of time left. I wanted to turn to
    Kathy Cameron and ask a question just emanating from your
    testimony.
        You stated that the Falls Prevention Resource Center at
    NCOA is responsible for supporting ``implementation,
    dissemination, and sustainability of evidence-based falls
    prevention programs.'' We know that there is evidence, strong
    evidence that that works.
        Can you explain some of the challenges that you see and
    what is needed to grow the number of an availability of
    evidence-based programs for seniors?
        Ms. Cameron. Yes. Thank you, Senator Casey.
        We work with community-based organizations and State
    agencies across more than 30 States to implement these
    evidence-based programs, and they are using Prevention and
    Public Health Funds in order to do that. Most of these grantees
    have 3-year grants, and a big part of what we work on is to
    develop sustainability strategies with them. Part of that
    includes outreach to health care providers, informing
    partnerships with health care entities, whether it be a
    Medicare Advantage Plan or local health system or hospital
    system. A lot of time, these entities do not know anything
    about these programs, so that is definitely a challenge.
        We work with them to articulate the value that these
    programs bring to older adults, most importantly, in terms of
    improving their independence, reducing the fear of falling that
    can often lead to social isolation and depression, but, also,
    many of these programs have shown a return on investment that
    can be of benefit to some of these health care payers.
        Those are some of the challenges, but many of them are also
    strapped for money to pay for these programs, so that is why we
    really believe greater investments in evidence-based programs
    are needed, really as a Medicare preventive service is what is
    required, like other preventive services in Medicare. Evidence-
    based programs need to have payment in order for them to be
    more widespread across the U.S.
        Senator Casey. Thank you.
        The Chairman. Senator Braun, welcome.
        Senator Braun. Thank you, Madam Chair.
        As usual here, I think of any of the committees that I
    serve on and four others, you have some of the best topics that
    are pertinent to, I think, what affects us all in the real
    world.
        Prevention, an ounce of prevention worth a pound of cure, I
    took that on as a mantle for fixing health care in my own
    company as a CEO 11 years ago.
        When I talked about things like wellness and prevention,
    the insurance industry was more interested in remediation and
    claims processing, so we are on to something here.
        I guess my curiosity would be, since the portal for most,
    before they get to Medicare, is through private insurance, I
    know when we look at all the information we have got currently
    to try to prevent, we see clusters of diabetes. Of course, we
    have cancer. We have heart disease. Falls and the prevention of
    them would not be high on the radar screen.
        I guess I got a couple questions, and I will start with Ms.
    Cameron. When it comes to tools in the private sector, what is
    our responsibility of kind of putting this out there as
    something you need to be aware of before you get on Medicare?
        Other than a BMD, which I know the particularity of what
    that test says, is there anything through general biometric
    screenings that would give us, as employers, the information to
    say, ``Hey, you may have an issue down the road, even though
    you are not falling currently''?
        Ms. Cameron. Great. Wonderful question. Thank you.
        Yes, prevention is truly important, and I believe starting
    early and educating people in their forties and fifties about
    falls prevention and what they can do, particularly around
    improving balance and strength and continuing exercise
    programs, physical activity throughout their elder years, just
    like Ms. Demby has been doing throughout her life.
        Some of the things that employers could look for are
    chronic illnesses. We know that heart disease, diabetes,
    arthritis are risk factors for falls, so ensuring that those
    conditions are well managed from the very beginning is really
    important.
        Often the medications that are used to treat some of those
    conditions can also lead to increased risk for falls, and we
    are seeing much higher rates of medications being prescribed
    really across all age groups, but particularly among older
    adults. Educating people early on too about medication side
    effects like drowsiness, dizziness, visual impairment that can
    sometimes happen with certain medications is really important
    from that perspective.
        Senator Braun. A standard blood panel test, which is
    probably the baseline of any biometric screening, we started
    that when I put in a new dynamic based upon--also employees,
    patients be engaged in their own well-being. I found that so
    much of our society is ``fix it,'' regardless of the cost, and
    we changed that and it is unbelievable what can happen. My
    employees have not had a premium increase in 11 years. People
    did not believe me when I ran on that, so it can work.
        When things are simple, they work better. What is the first
    baseline, other than just observation that if you have heart
    disease or arthritis, common sense would tell you, you are
    going to be prone to falling? Is there any simple tool, and
    does a standard blood test reveal anything? - because that is
    simple, and you get the results.
        Ms. Cameron. Well, we have a tool called STEADI, the
    Stopping Elderly Accidents, Deaths, and Injuries, and that is
    an assessment for falls risk that looks at a number of
    different risk factors, so it is a very comprehensive approach.
    It is based on some guidelines that were developed by the
    American Geriatric Society, so that is a great place to start.
        There are also functional assessments that can be done to
    measure a person's strength and balance, for example, that
    could be started early on, so those are simple things that
    could be put in place.
        Senator Braun. Thank you.
        Ms. Haynes, a question for you. Are you aware of any of the
    major insurers that are going to be the interactors with us as
    business owners that have fall prevention as part of what they
    talk about?
        We do a lot of things with our underwriters looking at what
    we can do to prevent things, and I do not recall that I have
    heard much input. Are insurance companies actually talking
    about it?
        Ms. Haynes. Thank you for the question.
        I am not aware of any that in the commercial younger
    population talk about fall prevention.
        I think to your point about wellness programs and keeping
    people active and encouraging that kind of--whether it is a
    walking meeting or whatever, those are activities that we all
    need to do while we are still in that population.
        For Medicare, it is a different story, where we do include
    in, for example, the annual wellness visit, the question about
    ``Have you fallen?'' The bee in my bonnet, I guess, and my
    teams is you would not say, ``You have high blood pressure. See
    you.'' You would say, ``Come back, and let us do an assessment
    and find out what it is,'' and then you would make a referral,
    whether it is PT or an OT, to Senator Collins' point about the
    home health, homebound benefit being restrictive. We would take
    those kinds of actions and then refer out, whether it is a
    community program or a medical intervention.
        Senator Braun. Thank you.
        Ms. Haynes. CMS has a big role to play.
        Senator Braun. I would do this as a public challenge to
    insurance companies, which many Senators are wrestling with
    them and the health care industry in total, that there ought to
    be more awareness of this kind of thing. Just because you do
    not handle many claims associated with it because that domain
    is going to be in Medicare, that does not mean you should not
    be talking about it.
        Thank you.
        The Chairman. Thank you.
        Senator Jones, I think you came in before Senator Rosen,
    but I am not sure. You were here? I am sorry. Senator Rosen.
        Senator Jones. She fell recently.
        The Chairman. I know.
        Senator Rosen. I did fall and fracture my wrist. I was at a
    parade and high-fived someone, and I went in a little too far.
    I could have used some of the--I wore the wrong shoes. I should
    have had flats on, a whole nother story, but, anyway, I thank
    you for bringing this really thoughtful hearing here for all of
    your work in advocacy because, as a daughter and daughter-in-
    law, I took care of my parents and in-laws as they aged, and so
    went through OT, PT. My mother-in-law fell in the garage and
    had to have a knee replacement. I really understand how
    important it is, what I learned as a caregiver taking them to
    OT and PT, about how you get in and out of cars and grab for
    things, so it is not just the patient. It is also sometimes the
    family members that can benefit from some of this training.
        I wanted to say that in July, I launched a bipartisan
    Senate Comprehensive Care Caucus, which serves to raise
    awareness and work toward improvements in areas of palliative
    care, care coordination, and issues impacting caregivers,
    because for some seniors, as you said, lack of care
    coordination is a barrier for people as they need to receive
    services, such as your evidence-based falls prevention
    programs.
        Ms. Cameron and Ms. Haynes, as advocates for older adults,
    I want to ask you a couple of questions. Can you speak about
    some of the care coordination services you would like to see
    provided in our communities, and what can Congress do to help
    coordinate amongst these evidence-based programs discussed
    today? Housing, health care providers, and even using
    telehealth apps, people are on their iPad. People are doing a
    lot more things, perhaps, so we break down those barriers so
    that everybody gets the care they need.
        Ms. Demby, sure, you can answer.
        Ms. Demby. Some of this could probably be incorporated into
    the physical education program in schools. Money is being taken
    away from some of the physical education programs. Some of the
    children are not really getting what they need.
        If fall prevention is included in the school curriculum, by
    the time you get to be an older adult, you know something about
    it. You know how to fall. You have learned something about
    fear. What do I do when I know I am going to fall? At that very
    instant it happens, I need to know to relax.
        Senator Rosen. Of course, those teenagers are fearless.
        Ms. Demby. Let the fall take place. Relax.
        Senator Rosen. Yes.
        Ms. Demby. When you relax, there is less injury----
        Senator Rosen. Yes, ma'am.
        Ms. Demby [continuing]. and sometimes no injury at all. I
    had to learn that, and I had no one to teach me.
        Senator Rosen. Well, so, Ms. Haynes or Ms. Cameron, can you
    speak to how we can integrate this, even using apps or
    telemedicine or television, even, Skype? I do not know. Use
    technology to maybe help people, even in their homes?
        Ms. Cameron. Yes. Well, I think there are a number of
    opportunities to better coordinate around falls prevention, the
    first being utilizing the annual wellness visit. First of all,
    we need to increase the uptake of the annual wellness visit
    among Medicare beneficiaries, but we really feel that that
    visit has been a missed opportunity to fully assess for falls
    risk and intervention and referral to a number of different
    programs that are available in the community that we have been
    talking about today, so using that visit to really coordinate
    care is vitally important.
        The CDC has done research on the impact of primary care
    coordination in doctors' offices using the STEADI toolkit that
    I mentioned earlier, and they have been able to show a
    reduction in falls, reduction in health care utilization as a
    result of developing a falls plan of care that could be put in
    place for those who are at high risk for falls, and then we are
    also waiting for the results of a study funded by PCORI, or the
    Patient-Centered Outcomes Research Institute. A number of
    universities are involved in that initiative, using a falls
    care manager to coordinate the care around for those who are at
    high risk for falls. I am hopeful that that is going to have
    some positive results on outcomes for older adults as well as
    reduction in health care utilization.
        Senator Rosen. Fantastic. Thank you. I think I am just
    about out of time, if you go quick, yes.
        Ms. Haynes. I will go quickly.
        We have been doing a lot of work as a health system
    coordinating between our care managers and our community-based
    organizations with direct referrals for the evidence-based
    programs.
        The other piece is just the opportunity that might be
    presented by CMMI for an innovative grant to bring together t
    hose organizations that you suggested. A model might be the
    community-based care transition program, which was quite
    successful.
        Senator Rosen. Thank you so much.
        The Chairman. Thank you, Senator.
        Senator Hawley?
        Senator Hawley. Thank you.
        Thank you all for being here today and for your
    testimonies, and a special thanks to Chairwoman Collins for
    holding this hearing and for your leadership on the Committee's
    annual report on falls prevention.
        I was proud to joint Chairwoman Collins, Ranking Member
    Casey, and many of my colleagues on the Committee in
    cosponsoring the Senate's resolution on National Falls
    Prevention Awareness Day, and I hope that that resolution and
    your testimony here today will help elevate this issue and
    educate more people about it, so thank you so much for being
    here.
        I also want to mention that I am personally very proud that
    my home State of Missouri was featured in this year's report.
    The Show Me Falls Free Missouri Coalition is an organization
    that includes over 50 partners from both the public and private
    sectors. To help reduce the risk of falls and falls-related
    injuries, the coalition offers education and outreach, both
    online and in person, to help connect Missourians to resources
    and evidence-based programs, and this program is just one of
    many, where we are seeing effective coordination between States
    and partners in the community to help prevent falls.
        I am hopeful that the report will help encourage more of
    these kinds of partnerships by highlighting some of the good
    work that is currently being done.
        One area I would like to explore today is the link between
    falls and traumatic brain injury. According to the Center for
    Disease Control, falls are the leading cause of traumatic brain
    injury for individuals who are 65 and older. Specifically, four
    in five TBI-related emergency department visits in adults age
    65 and older were caused by falls, and I understand that those
    rates are significantly higher for individuals who are 75 and
    older.
        Ms. Cameron, maybe let me ask you. To your knowledge, what
    is currently being done to ensure that older adults who have
    sustained a fall are being screened for brain injury and
    referred to appropriate resources, and what more do we need to
    do?
        Ms. Cameron. That is a great question. I think oftentimes,
    we are missing opportunities to do that screening for those who
    have had a brain injury as a result of a fall, but we need to
    educate more of those who have had a brain injury about
    interventions available in the community.
        One thing that we do not have a lot of are interventions
    specifically designed to prevent TBI, and we need to look at
    that more closely and see what is really effective in
    preventing traumatic brain injury, what types of physical
    activity, those sorts of things, and how we can prevent the
    sequelae from those who do suffer a traumatic brain injury,
    but, again, it is all about awareness and education to ensure
    that those with a TBI as a result of a fall get into programs,
    so they can prevent future falls from happening.
        Senator Hawley. Thank you very much. That is very helpful.
        Switching gears slightly, my home State of Missouri has a
    large rural population, and the Chairwoman asked a question in
    this vein that I thought was important. I can say from growing
    up in rural Missouri, I know that access to care in rural areas
    can be a big challenge, and it is one that is becoming
    particularly acute in my home State and I suspect in many other
    places.
        Ms. Cameron, let me ask you again. In your view, are
    current falls prevention programs adequately accessible in
    rural areas, and what do we need to do to improve access for
    our seniors, many seniors who live in rural places like where I
    am from?
        Ms. Cameron. I think there is always more we can do to
    increase access, and that is one of the areas that we are
    focused on in terms of the technical assistance that we provide
    to State grantees that have received Prevention and Public
    Health Fund grants.
        To me, it is all about partnerships, as Peggy Haynes was
    talking about, ensuring that rural organizations are partnering
    with others so that older adults in rural communities can
    access those programs, partnering up. Perhaps it is on training
    coaches and leaders for these programs is one avenue, maybe
    looking at alternative models in which programs can be
    developed, using telehealth approaches.
        We are just starting to look at ways in which programs like
    A Matter of Balance, I think, CDSME, the Chronic Disease Self-
    Management Education, can be provided in person and then having
    folks remotely join these programs. I think there is a number
    of models that we need to explore more in depth to ensure that
    those in rural communities can engage in programs.
        Senator Hawley. Would you like to add something to this,
    Ms. Haynes?
        Ms. Haynes. I would. Thank you for asking.
        One partner we have not talked about that we have partnered
    with in Maine--and I am a native Michigander, and the Upper
    Peninsula in Michigan is using A Matter for Balance and that is
    our cooperative extension programs. We have those all over the
    country. They are great partners. They are already getting out
    into the community, so just to think more broadly about who we
    can tap into.
        Senator Hawley. That is super. Thank you.
        Well, my time has expired, but thank you all so much again
    for being here today. Thank you for the important work that you
    do. Thank you, Madam Chair.
        The Chairman. Thank you.
        Senator Jones?
        Senator Jones. Thank you, Chairman Collins.
        The Chairman. The very patient Senator Jones.
        Senator Jones. Thank you, and thanks for all of our
    witnesses for being here today.
        I am patient in part because, as we speak, my mom is also
    recovering from one of her latest falls. I worry that my mother
    has skewed the average in Alabama somewhat, and it has been a
    real challenge for her. She is in assisted living now, and as
    hard as she tries to stay conscious about it, it is a
    continuing problem.
        Fortunately, we have been very lucky. She has not broken
    any bones. She is on blood thinners and has not hit her head,
    which is a fear.
        Many of the falls do not result in very serious injuries,
    but they are falls nonetheless. What I have seen, I think, with
    my mom, sometimes falls beget falls. I am not sure that folks
    are adequately getting followup. When they go and they are
    treated for a fall, they are seen in the emergency room or a
    nurse in an assisted living comes, and the patient is saying,
    like my mom, ``Oh, I am fine. I am fine. I am fine. Do not
    worry about it. Do not call an ambulance. I am not going in,
    anyway.'' It is a problem because everybody just goes about
    their business.
        My question is a little bit compound. Number one, how
    important is it--and I guess this is mainly to Ms. Cameron and
    Ms. Thompson. How important is it for any fall of an elderly
    person to receive some form of whether it is physical therapy,
    occupational therapy to have some followup to see how they are
    doing? How important is that? Number two--and I have
    experienced this with my mom, who says, ``I do not want that.''
    After a fall, you get kind of sore, and it hurts to go through
    physical therapy sometimes, so they are just like, ``I do not
    want that.'' Education the patient as much is kind of a
    compound problem, and I would like for you all to address that
    because I believe--and I have tried to preach to her that I
    thought some form of physical therapy was incredibly important,
    regardless of what happened during the fall itself. I will let
    either of you address it.
        Ms. Cameron. Sure. We see a lot of stigma associated with
    falls, and many older adults feel that if we address falls that
    their independence may be reduced in some manner, but we want
    to educate them that falls prevention is all about ensuring
    long-term independence, helping to reduce the fear of falling
    that they may experience that could lead to such things as
    social isolation and depression.
        One thing that we feel at a minimum physicians should ask
    an appointment, ``Have you had a fall?''
        Senator Jones. Right.
        Ms. Cameron. ``Do you have a fear of falling, or do you
    worry about falling?'' If they say yes to any of those
    questions, action should be taken to educate them about the
    importance of falls prevention, and it is not something to
    reduce their independence but really to empower them that they
    can have control over their falls risk.
        Senator Jones. One thing I just want to throw out, my mom
    uses a walker, but when she first started using that walker,
    nobody really told her how to use the walker.
        Ms. Cameron. Yes.
        Senator Jones. They just said, ``Here, you need to go get
    this walker,'' and I am telling her all the time. She is
    pushing that walker and leaning forward, and I said, ``Please
    walk up into this walker.'' I think part of that education
    process goes back to the early times.
        Ms. Cameron. It is referral to occupational and physical
    therapist to ensure that those assistive devices are being used
    properly because we do not want them to cause other falls.
        Senator Jones. Is it important for after any fall to get
    somebody to come talk to them, look at it, try to help them
    work through the soreness, work through the physical therapy a
    little bit? Is that important?
        Ms. Thompson. It is critically important. It is not just
    the physical therapy, but again, I would underscore only 9
    percent of people who have had a fracture are screened and what
    we know is not just that falls beget falls, but fractures beget
    fractures. That is really what we are trying to prevent.
        As I said earlier, 80 percent of patients who have had a
    fall or a break are not getting the treatment that they need.
    We need to kind of back that up in the system so that we make
    sure that not only are they protected by wonderful devices that
    we have, but they have the medication, and they have the other
    support that they need.
        Senator Jones. Okay. Thank you. I am going to give you
    mom's cell number, and you can call her and reiterate that.
        Ms. Thompson. I would be delighted.
        Senator Jones. Real quick, Ms. Cameron, you mentioned the
    problems associated with medication with elderly patients. How
    can pharmacists play a role in this? I think pharmacists, to
    some extent, are underutilized in so much of our health care
    issues today. Can pharmacists play a role in helping this, fall
    preventions with elderly patients?
        Ms. Cameron. Absolutely. Thank you for that question. I am
    a pharmacist myself, so, yes, pharmacists are playing, are
    starting to play a greater role in falls prevention activities.
    I think certainly the annual wellness visit is a key area again
    where pharmacists can do medication reviews, medication
    reconciliation.
        Right now, in the annual wellness visit, all that is
    required related to medications is an inventory, actually
    creating a list of all the medications that an older adult is
    on, but we need to go much more in depth about those
    medications and look for a duplicative therapy, maybe
    inappropriate doses. Maybe the older the adult does not
    understand how to take those medications, and there are a
    number of side effects. Many medications, particularly
    psychoactive medications that we are seeing huge increases of
    being prescribed to older adults, those can cause those side
    effects that lead to falls.
        Pharmacists are in the best position. They have the
    training to identify where there are problems, and they can
    work collaboratively with physicians to ensure that the
    medication therapy is appropriate, effective, safe, and used
    correctly by older adults.
        Senator Jones. Great. Thank you. Thank you all for being
    here today. Appreciate it.
        The Chairman. Thank you.
        Senator Sinema?
        Senator Sinema. Thank you, Chairman Collins and Ranking
    Member for holding today's hearing.
        Nearly one in three Arizonans over the age of 65 report
    falling each year, and in 2016, falls amongst older Arizonans
    were responsible for more than 42,000 emergency room visits,
    14,000 long-term hospitalizations, and nearly a thousand
    deaths, so hospital bills related to unintentional falls in
    Arizona annually total almost $1 billion. For many older
    Arizonans, falls can result in injuries that cause pain or
    limit mobility for the rest of their lives, but falling does
    not need to become a part of growing older.
        As today's witnesses have made clear, there are a range of
    early interventions and technologies that can reduce the risk
    of falling and mitigate the consequences. With that
    information, I would like to ask our panel a couple of
    questions. My first question is for Ms. Cameron and Ms. Haynes.
        Earlier this year, Banner University Medical Center in
    Phoenix became the first hospital in Arizona to open an
    accredited geriatric emergency department. In the specialized
    department, older patients are cared for by nurses and doctors
    who are specially trained to detect and prevent falls. A
    dedicated pharmacist monitors all medications taken by a
    patient to prevent adverse drug reactions which may cause
    dizziness. Patients are given non-slip socks, and their
    belongings, food and water, are kept close to their bed so they
    do not need to get up.
        Practical and commonsense approaches like this are
    extremely affordable and can prevent thousands of injuries a
    year, yet relatively few health care facilities have chosen to
    make investments in these initiatives. What more should health
    care facilities, whether hospitals, doctors' offices, or long-
    term care facilities do to mitigate the risk of falls, and what
    more can be done to better incentivize health care providers to
    prevent falls?
        Ms. Haynes. Thank you for the question.
        One really wonderful opportunity that Maine Health is
    involved with is the John A. Hartford Foundation and IHI
    initiative around age-friendly health systems, which focuses on
    the four M's: what matters to the patient; mentation which
    would be depression, delirium, and dementia; mobility; and
    medications. That would be, I think, my soapbox.
        I have worked with older adults in various settings for 40
    years. It is medication, not just review, reconciliation, and
    really de-prescribing and some focus on that.
        There are 120 health systems now focusing on that
    initiative, and I think it is a wonderful opportunity for us to
    build on exactly what you are suggesting.
        Ms. Cameron. Yes. One recommendation that we have in our
    written statement relates to the Hospital Readmissions
    Reduction Program, where we really believe that second falls
    should be added as a falls Hospital Readmission Reduction
    Program measure to incentivize hospitals to engage in falls
    prevention efforts, either by offering programs themselves or
    partnering with community-based organizations deliver programs
    to their patients who are being discharged for falls. It really
    incentivizes them to do some discharge planning around those
    patients who are being discharged who are at high risk for
    falls and really engaging health care providers in those
    efforts but also referring to evidence-based community
    programs.
        Senator Sinema. Thank you.
        My next question is for any of our panelists, especially
    those who have experienced working with rural communities.
        This year's Aging Committee report highlights an innovative
    solution to the challenges posted by unintentional falls from
    Northern Arizona. The Northern Arizona Agency on Aging has an
    extremely successful program called Carenect that connects low-
    cost wearable devices for seniors. These devices can connect
    seniors to multilingual care coordination centers, which can
    call emergency services if they fall.
        Carenect also addresses the serious problem of social
    isolation. The coordination center and their trained staff are
    available day or night to talk to and connect seniors with
    local programs in their area where they can socialize.
        While many Americans can purchase services like this
    commercially, for seniors in rural Northern Arizona, these
    devices were either unaffordable or unavailable due to limited
    broadband and cell phone coverage in many rural areas.
        The Carenect system was designed to reach seniors in rural
    communities, including our Tribal areas. Northern Arizona
    seniors benefit from the innovative leadership of the Area
    Agency on Aging, but many other older Americans living in rural
    communities are not so lucky.
        What are the unique challenges and risks faced by seniors
    living in rural areas with respect to falls prevention, and
    what efforts could this Committee support to reduce the risk of
    falls for all seniors, no matter where they live?
        Ms. Haynes. I would suggest that is a fantastic model that
    we should learn a lot more about.
        I think one of the things we see in our rural areas--and it
    may be because Maine has some of the oldest housing stock in
    the country--is around home modification. People want to remain
    in their own homes for the most part, and they may not be safe
    or adapted for whether it is a grab bar or--my younger sister
    had her knees replaced, and the walker did not fit through the
    bathroom door, so that would be an OT going in before some of
    those things happen.
        I think that model and some of what we discussed earlier
    about innovative grant funding to be able to replicate that as
    well as taking a look at the home modification piece in rural
    areas.
        Ms. Cameron. Yes. Certainly, transportation is a huge issue
    for older adults living in rural areas who are no longer able
    to drive themselves and may not have family members who can get
    them, whether it is so doctors' appointments or to some of the
    programs that we have been talking about, so looking at
    innovative approaches in rural areas to provide access to
    transportation is sorely needed.
        Senator Sinema. Thank you.
        Thank you, Chairman.
        The Chairman. Thank you very much.
        Unfortunately, we have votes beginning at 11 o'clock.
    Although there are numerous additional questions that we would
    love to ask each of you, I think we will wait and submit those
    to the record for you and give other members that opportunity
    as well. The record will stay open until Friday, October 18th,
    for additional records.
        In my closing comments, I want to put back up the map that
    shows the rate of falls in every State, and the reason that I
    do is actually the rate is remarkably similar from State to
    State.
        Alaska is an outlier being higher than average. Hawaii is
    an outlier being lower than average, but in general, what we
    found when we crunch the data is that about a third, nearly a
    third of older adults will suffer a fall.
        It is hard for me to think of another health care problem
    that affects nearly a third of older Americans where we do not
    have a strategy and we are not pursuing policies that would
    make a difference. Not only does this cause tremendous harm to
    the senior and often sets off a downward spiral, but it is
    extraordinarily expensive as we have learned today and yet many
    of the remedies are not expensive.
        Our report focuses on recommendations in four key areas,
    all of which we have touched on today. One is raising
    awareness. One is improving screening and referrals for those
    at risk of falling. A third is targeting risk factors,
    including increasing the availability of home safety
    evaluations and modifications. Fourth, which we have touched on
    only lightly, is reducing polypharmacy; in other words, the
    interaction of prescription drugs with one another and also
    with food and drink, which a lot of times are factors as well.
    We have a series of recommendations under each of those four
    key areas.
        I am going to ask unanimous consent--and I do not think
    that my colleague will object--that the huge number of
    responses that we had from nearly 200 stakeholders be entered
    into the record so that we have a complete hearing record.
        The Chairman. I want to thank all of our witnesses for
    sharing their personal experiences, their families'
    experiences, and their expertise today.
        I will share mine as well. A couple of years ago, I slipped
    on my front steps and badly broke my ankle at Christmastime and
    had to crawl back into the house and had broken both bones and
    have ended up with a plate and eight screws in just one ankle.
    That taught me what a fall was like, and I was forever grateful
    not only to the surgeon who repaired me, but to the
    occupational therapist and the physical therapist who helped me
    regain function.
        I am on the young side of the older population, but this
    was a real lesson to me and I will tell you that to this day, I
    have a fear of falling. I hold onto railings now, which is
    probably not a bad idea. I no longer wear high high-heels. I
    have changed a lot of lifestyle factors.
        The point was made that we need to teach people at an
    earlier age about what you can do to reduce the possibility of
    a fall, but it was the occupational therapist--and surgeon, of
    course, but the occupational therapist and the physical
    therapist who really got me back on my feet and walking again.
        Doug Jones was talking about the walker, which I had at the
    beginning, and I did not want to use it because I felt only
    very elderly people used walkers, ``I will not use the
    walker,'' which was not smart, of course, so someone--I think
    it was Ms. Cameron--mentioned the stigma that is associated
    with falls, and that is what I felt when I fell too.
        I think it is so important that we talk about these
    personal experiences, that we encourage people to come
    together. I would love to have taken A Matter of Balance, if
    only I had had the time to do so, because I think it would have
    helped me in so many ways, but you have helped us identify very
    specific steps that we can take to change the trajectory of
    falls among seniors and improve the health and well-being of
    our older Americans.
        We have to remember that our older population is growing
    very rapidly in this Country, and Maine is the first State next
    year to reach the milestone--and it is not a good one--where we
    will have more people over age 65 than we do people under age
    18, but our Nation as a whole is going to reach that
    demographic milestone, and that is why getting ahead on this
    issue is so important.
        With the release--and it is online already and soon will be
    available in printed form. It is being printed, even as we
    speak. With the release of our 2019 Committee report on ``Falls
    Prevention: Nation, State, and Local Solutions to Better
    Support Seniors,'' I hope that we can reach more people, and
    that is the purpose of this hearing as well.
        I do want to thank all of the individuals, organizations,
    and universities who contributed to our public comments, as
    well as Federal agencies and private organizations who engaged
    with us throughout the process.
        I also want to acknowledge the Committee staff on both
    sides of the aisle who worked closely together to prepare our
    report.
        I want to thank a fellow, a Health and Aging Policy fellow,
    who we have had for this year, Thuc Nhi Nguyen, who worked very
    hard on this report. She holds a PhD in Social Work from Boston
    College and brought her expertise in aging to this report, and
    I know that we also benefited from the Minority staff having an
    Health and Aging Policy fellow this year. I noticed that she
    went to the University School of Medicine in St. Louis, which
    just might be how Missouri sneaked into the report and it did
    not just focus on Maine and Pennsylvania.
        In all seriousness, this is a huge problem, and unlike so
    many others, it is one where we know what to do. Whether it is
    Ms. Demby getting her friends together to go exercise or Ms.
    Haynes' extraordinary work on A Matter of Balance or Ms.
    Cameron's work on so many issues, including the polypharmacy
    issue where she brings a special expertise being a pharmacist,
    or Ms. Thompson's work on osteoporosis, I am just determined to
    fix that reimbursement.
        Ms. Thompson. Thank you very much.
        The Chairman. That just makes no sense at all and the work,
    of course, of the Ranking Member.
        I want to thank everyone for your contributions and now
    turn to the Ranking Member for his closing statements.
        Senator Casey. Thank you, Chairman Collins, and thanks for
    bringing your passion and your personal perspective to this
    critically important issue.
        We know from today's testimony and from the report that we
    have got to redouble our efforts at the national level to
    invest in falls prevention efforts. We cannot do it without
    partners at the State and local level as well as those in the
    community.
        As I said in my opening, I look forward to engaging in
    active dialog with departments and agencies across the Federal
    Government to implement these important recommendations from
    this report, which we have to make sure we implement the
    recommendations, not just have them in writing.
        I also want to thank our witnesses here today for sharing
    valuable insights into the need for this work, and we are
    grateful for the time and expertise and your passion as well
    for these issues.
        I also want to reiterate our thanks to the staff. I will
    mention five staff members on the Committee who helped to draft
    the report over the last year in support of this hearing:
    Samantha Koehler, Beth Prusaczyk, Sarah Khasawinah, Amy
    Pellegrino, and as the Chairman mentioned, Thuch-Nhi Nguyen and
    any other staff member who worked to make this possible.
        Chairman Collins, thanks very much, and I think we are just
    about ready to vote.
        The Chairman. We are.
        Thank you, Senator.
        This hearing is now adjourned.
        [Whereupon, at 11:08 a.m., the Committee was adjourned.]

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                                    APPENDIX

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                          Prepared Witness Statements

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                           Statements for the Record

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