[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.]

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


                                APPENDIX
      
=======================================================================


                      Prepared Witness Statements

=======================================================================
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

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


                       Statements for the Record

=======================================================================
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                  [all]