[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
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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
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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
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Sarah Khasawinah, Majority Acting Staff Director
Kathryn Mevis, Minority Staff Director
C O N T E N T S
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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
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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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