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Fall Prevention And Social Determinants Of Health, Implications For Practice Podcast

Fall Prevention And Social Determinants Of Health, Implications For Practice Podcast
Lisa Juckett, PhD, OTR/L, CHT, Dennis Cleary, MS, OTD, OTR/L
May 25, 2022

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Editor's note: This text-based course is a transcript of the, Fall Prevention And Social Determinants Of Health, Implications For Practice Podcast, presented by Lisa Juckett, PhD, OTR/L, CHT,​ and Dennis Cleary, MS, OTD, OTR/L.

Learning Outcomes

  • After this course, participants will be able to:
    • Identify fall risk factors as well as social determinants of health as defined by Healthy People 2030.
    • Evaluate the extent to which social determinants of health influence fall risk among older adult populations most susceptible to health decline.
    • Apply occupational therapy approaches to addressing social determinants of health with older adults at high risk for falls.

Dennis: Hello, everyone. My name is Dennis Cleary. I'm a senior researcher and assistant professor at Cincinnati Children's Hospital Medical Center in beautiful Cincinnati, Ohio. We are fortunate to be joined today by Dr. Lisa Juckett from Ohio State University in beautiful sunny Columbus, Ohio. Dr. Juckett will talk to us today about fall prevention, social determinants of health, and implications for practice. Welcome, Lisa. Thanks for being with us. Can you just tell us a little bit about yourself and how you became interested in this topic?

Lisa: Certainly. First, I want to thank you, Dennis, for the invitation to do this and thank OccupationalTherapy.com for allowing me to be here. It is sunny in Columbus, Ohio, even though you all can't see it. I'm Lisa Juckett, assistant professor at the Ohio State University in the occupational therapy division. I, however, started my OT career as a clinician working primarily in inpatient rehabilitation. I also spent some time doing per diem or contingent work at a skilled nursing facility in Columbus, Ohio. About five years after practicing, I leaped back into academia as I wanted to explore some research questions. I ended up getting a PhD in social work. Working in OT practice for five years, I tried to get a different perspective on the complex, more significant factors. The social work field calls those the macro-level factors that influence how adults and older adults can receive high-quality care. I am happy that I explored the social work field as it has led me down the research path of fall prevention and looking at the social determinants of health. These are some things that sometimes we think about in OT, but perhaps not as thoroughly as we should.

Dennis: Gotcha! Your PhD was in the translation of knowledge, correct?

Lisa: One of the added draws of social work was that I was mentored by an expert in the field of implementation science. Implementation science is the study of the systematic process of moving evidence-based findings into routine practice or routine care. I won't be talking too much about that today, but much of what I will be talking about certainly can relate to the field of implementation science. What we read in the literature, we don't want the information to only stay in journal articles or at professional conferences. We want the research to impact the lives of our patients, and I'll try to sprinkle in a couple of implications for implementation science as we talk here. The majority of what I've always been passionate about is improving the older adult population's health and quality of life.

Dennis: Wonderful. From my personal experience with my parents, who have now passed, falls can significantly impact a person's quality and longevity of life. Can you talk about how you got interested in falls in older adults and the implications on an individual and our society in general?

Lisa: Sure. First, I know that the senior population is not everybody's cup of tea. It's not the most exciting group or field. I've heard different reasons anecdotally why there's a lack of interest in aging research. I've heard that older adults do not recover quite as quickly as younger clients. The instant gratification of seeing somebody progress in rehab occurs at a much slower rate. I get that there might not be the excitement of working in neuro-rehab or pediatrics.

Geriatrics is an understudied, in some cases, an undervalued population in our culture. However, it is a population that I've always cared about since I was a high schooler volunteering in assisted living facilities. As nerdy as that sounds, I am drawn to these individuals who deserve to live their later years with dignity and independence.

As you said, Dennis, almost everybody has a falls story. If it hasn't happened to them, they have a family member, a loved one, or someone on the periphery who has experienced a fall or a fall-related injury. This is an observation that is supported by a lot of research.

It is estimated that there are about 52 million older adults in the United States currently. Of those 52 million, we're looking at about 36 million annual falls. Indeed, that could be one individual falling multiple times, but those falls lead to almost eight million fall-related injuries per year. Falls cost the healthcare system upwards of about $50 billion. Depending on who you talk to, money makes the world go round.

When we think about healthcare expenditures and how we can improve the quality of care provided to all populations, we have to think about how to minimize costs on the healthcare system itself. Fall prevention could be one way to do that, but we've been singing this song for a long time without moving the needle on fall prevention for many reasons. I'll talk about those momentarily, but the other piece of information is the baby boomer population. By 2030, the number of older adults is going to grow exponentially. Whereas, right now, the numbers are about 52 million. By 2030, this number will grow to 73 million, and more individuals with a greater likelihood of falling. I want to say it won't if we implement the correct practices and approaches, but if we can learn from history, we've not done a great job of moving the needle on fall prevention. Ultimately I think that fall-related injuries will increase as the older adult population increases.

Dennis: You're saying we should do something to prevent the growth in falls now before this increase in our aging population? You mentioned age. Can you talk about some other common risk factors for falls?

Lisa: The older you are, falls and fall-related injuries increase exponentially. With age, there are changes physiologically in all of our different systems. We see changes in postural stability, sensory systems, muscle activation, and the visual system. Think about the connectedness of our muscular and sensory systems and how issues in these areas increase the likelihood of falling as we age. Older adults can be on particular medications, are often dehydrated, and experience orthostatic hypotension. Any sudden or even gradual changes in positions, for instance, moving from lying to a seated position or standing up too quickly, can cause blood pressure to drop and orthostatic hypotension to kick in. Additionally, we might see increases in dizziness and episodes of syncope that can then lead to falls.

Dennis: In terms of orthostatic hypotension, is there a different technique for adults getting out of bed to reduce the risk of a fall?

Lisa: There are a couple of evidence-informed strategies that address orthostatic hypertension. And indeed, with older adults, we've got an increased risk of comorbidities. Many chronic conditions often require prescribed medications. As OTs, we can consult with prescribing physicians and pharmacists to look at the medicines our older clients are taking to ensure they're needed and not affecting blood pressure leading to dizziness and syncope. Prescribing medications does fall outside the scope of occupational therapy. Still, we can collaborate with our pharmacy and physician partners to understand how these medications meet our older patients' needs. We can see if medications can be adjusted to decrease cases of orthostatic hypertension. If drugs seem to be appropriately prescribed, we can teach modified ways to transfer from lying in bed to getting up in the morning or the middle of the night. We know that individuals with incontinence are at risk for falls, especially at night or in not well-lit areas. Helping our older clients transition from lying, to sidelying, to sitting on the edge of the bed safely would be a great activity. However, this sequence is sometimes a little counterintuitive for older adult patients.

Dennis: You talked about physiology and medications. What other types of risk factors that older adults might have that lead to an increased risk of falls?

Lisa: Sure. I know we talked a little bit about physiological changes in the sensory systems and specifically about visual impairments. Individuals with poor visual acuity, poor depth perception, and light sensitivity have two times increased risk of falling. If we do a complete OT evaluation or administer specific visual perceptual assessments, those can be valuable in quantifying the magnitude of someone's visual impairment. We can do this in collaboration with optometrists or ophthalmologists who might be working with the same older adult patients.

Then, of course, we've got conditions that affect the vestibular and balance systems. Examples are patients that have Parkinson's with tremors and ataxia, multiple sclerosis, and other neurodegenerative disorders. These clients have an increased likelihood of falls as well.

Other populations on the rise, such as people living with dementia and other mild cognitive impairments, are also two times more likely to experience a dangerous fall than older adults without mild cognitive impairment.

Another topic that I am passionate about and will talk about more in our case example are older adults who experience malnutrition. They are eight times more likely to experience a fall. I bring that up because that proportion or ratio is very concerning. Thus, the adage that food is medicine is accurate. We also need to make sure that our patients are well hydrated. We can collaborate with physicians, speech-language pathologists, and registered dieticians to ensure that those nutritional needs are met.

Dennis: And even their social workers potentially, I suppose. If they don't have access to good food, that is a problem. Perhaps, we can get them Meals on Wheels or something like that. Does gender play a role in risk for falls or severity of falls?

Lisa: That's a great question. The last statistic I saw was that women are about 40% more likely than men to fall. We think it might be about bone density and how that decreases over time. Depending on the literature, women are more likely to experience a fracture related to a fall. The older white female population has an increased risk of experiencing a fall and an injury related to a fall.

Dennis: Gotcha. It makes sense in terms of the density of a bone for a man as opposed to a woman. Occupational therapists have a vital role in helping prevent falls or minimizing the risk of falls. What things might be helpful for an occupational therapist to have in their tool belt for clients at risk for falls?

Lisa: My go-to response is to use different fall risk assessment tools to objectively measure or quantify the degree to which somebody's at risk for falling. The Berg Balance Test is one option. The Timed Up and Go (TUG) and the Functional Reach Test are also used. These are helpful tools to predict somebody's risk of falling.

Dennis: Which one is your favorite?

Lisa: I prefer the Timed Up and Go because it is reasonably quick and easy with some training. There is also very minimal equipment required, and it can be completed in less than 20 seconds.

Dennis: Can you describe how to administer the TUG?

Lisa: The client is seated in a chair. You ask them to stand and instruct them to walk the three meters (10 feet) around an object and then walk back into the chair and sit down. You time them during this process and instruct them to walk at their average pace. I believe the cutoff criteria for an older adult population is 12 seconds. If it takes them more than 12 seconds to complete that walk from standing up from the chair, walking around the cone, and back, then that client would be considered at risk of falling. 

Dennis: We'll have links to the Berg and the Timed Up and Go. They're readily available free assessments that are, as you said, pretty quick and give you some good information.

Lisa: These can be done anywhere, especially the TUG, with minimal equipment, so its feasibility is appealing.

Dennis: What else can an occupational therapist do to prevent falls?

Lisa: A great CDC report by Stevens and Lee in 2018 indicated that home modifications saved several billions of dollars in fall-related healthcare expenditures when implemented by an occupational therapist. The report focused on home modifications coupled with certain exercise-based or balance retraining programs. You can probably do a quick Google search in your local community to find maybe some of these classes, like tai chi and balance retraining, like Matter of Balance. Stepping On is another evidence-based program.

These programs are supported by high-quality, rigorous randomized control trials, indicating that they lead to consistent improvements in fall-related outcomes in older adult populations. Often, these programs are sponsored at the state level, like the Ohio Department on Aging. At the local level, they're organized by Area Agencies on Aging.

Several of these programs are led by a peer, which is more beneficial. An older adult peer gets trained in these programs and helps to facilitate these exercise programs with other older adults. From a sociological perspective, peer-to-peer interaction evens the playing field. Think about what it would be like to go through a balance retraining program with somebody who has more in common with you than a healthcare professional who might not experience the same balance-related challenges. That could be pretty appealing to an older adult.

Dennis: That might be a wonderful thing for a retired occupational therapist, or maybe I'll do that in a few years when I retire.

Lisa: I think that'd be great for you, Dr. Cleary. It would expand your skillset and add to your toolkit. I'll add one more thing: the CDC's STEADI (Stopping Elderly Falls, Accidents, Deaths & Injuries) Toolkit. I promise I do not work for the CDC, and I'm not paid to endorse this tool.

Dennis: We'll also put this in the handout.

Lisa: STEADI provides you with a decision tree to lead you to interventions that could be appropriate depending on an older adult's fall risk factors.

Dennis: I've heard good things about the CAPABLE program as well.

Lisa: The CAPABLE program came out of John's Hopkins, and it's a very client-centered program developed by Sarah Szanton, a nurse by training. She created this community-based program for older adults who have a hard time leaving their homes on a routine basis. I like to avoid using the term home-bound. These are older adults who are lower-income, require home modifications and need behavioral interventions to help them employ more fall prevention practices.

CAPABLE consists of six in-home visits from an occupational therapist and about four visits from a registered nurse. There are also visits as needed from a home repair expert who can make any basic home modifications to minimize the risk of falling. The fall-related goals are client-centered. It is a collaborative effort across the home repair expert, the nurse, and the occupational therapist to identify meaningful goals for the client. It is very occupation-based and can ultimately lead to improvements in self-efficacy around falls, or falls efficacy as we might refer to it, and general well-being. Lastly, it increases independence in ADLs and IADLs.

Dennis: We supported my parents as they got older as my dad had dementia, and my mom was his caretaker. Then, she had a fall. And my father was the one at risk because he used a walker. My mom ended up having to use a walker as well. We made many adaptations to their house. I don't know if I've told you this story or not, Lisa, but we lived a block away from the fire department. My mom stopped by when dad was at a VA day program and got their kitchen phone number at the fire department. She asked if they would get my dad up if he fell as her son, the occupational therapist, demanded that she not try to get him up independently. They said, "If you call, and we're not on a run, we can help you." I thought this was a brilliant strategy for using your resources and thinking that through. This might be a good story to share with community-living folks.

Lisa: That's a great point because some work is done locally in Columbus. I have a physical therapy colleague Catie Quatman-Yates from Ohio State, who's done some innovative work with the fire departments in Upper Arlington, a part of Columbus. Ohio State has partnered with this fire department to assess and address the fall risk needs of older residents in this one community. Based on this partnership, they have seen a nice decline in fall-related calls to the fire department. Much of this has to do with the community paramedicine program deployed there. 

Dennis: Other countries are different in providing medicine to their population. They send an occupational therapist to the house as part of an emergency department run. They assess if the client needs to go to the hospital or not. They are finding that sending an OT decreases future calls and saves money. Some folks from outside of the United States could listen to us on this podcast and think, "Of course, that's what we do. Why don't you do that?"

Lisa: We should do that.

Dennis: Why aren't we moving the needle on fall prevention, and why does it seem like it stays the same or worsens? And as you said, with our boomers retiring, getting older, and more susceptible to falls, what are the things getting in the way of improving falls?

Lisa: That's the million-dollar, or I guess in this case, the billion-dollar question. We have upwards of three decades worth of evidence to support things like exercise and balance retraining programs, home modifications, or both, so why don't we see significant improvements in the rates of falls? That percentage of falls always in older adults hovers somewhere between 25% and 30%. The translational scientist in me thinks we're not moving evidence into practice, and we need more implementation research to help us do that. I would also like to believe, and it's not just me saying this, that these interventions are deemed effective but are targeted only at the individual level. We measure balance and fall efficacy without paying too much attention to external forces or factors influencing somebody's physiological state, nutrition, cognition, health status, and general well-being. Those larger-level factors or social determinants of health (SDOHs) are what this podcast is about today. These are external forces or factors that impact our health, at least in the United States, if not across the world. The Healthy People 2030 refers to five specific social determinants of health.

Dennis: What are those five social determinants?

Lisa: You may have heard the term social determinants of health without a clear definition. These conditions and environments where people are born, live, work, play, worship, and age significantly impact health, well-being, and quality of life. OTs help promote meaningful participation in activities we live, work, and play. Social determinants of health should always be on our radar. I know for many of us they are, but these SDOHs are typically found more in the public health literature, but I'm excited to see them infuse their way into occupational therapy. First, you've got education access and quality. Next is healthcare access and quality. The social community context is the third. The neighborhood/built environment is fourth and economic stability is the last determinant. 

Dennis: How would you define the built environment?

Lisa: A built environment is the structures around us like our home and other vital buildings. A built environment also affects our ability to get inside certain buildings. As I mentioned before, malnutrition is a significant risk factor for falls. A client may not live in an area with reliable access to a food store. The store may not open during the hours that the client is available or geographically inaccessible as the client cannot drive or access community transportation. These issues all add to fall risk.

And as Dr. Cleary and I have talked about, I come from a position of privilege. If I did not have my vehicle, I would feel safe walking to my local grocery store. However, safety is not guaranteed for all populations. The neighborhood and built environment are not just the structures around us, roofs over our heads, or stairs or ramps to get in and out of a building. We also need to look at the safety of the environment.

Dennis: I live in a place of privilege with a Homeowners Association (HOA). The president of the Homeowners Association lives next to me. She's not an occupational therapist, so I can talk about her because she's probably not going to be listening to this. There are trees bumping up the sidewalks left and right on the tree lawn. Several of my neighbors have cut the trees down and had had to shave off the sidewalk to make it flat and safe. She immediately sent out an email saying that it's required that you have a tree on your tree lawn or you're going to be taken to the HOA jail. This is an example of looking at universal design and access for everyone physically. How do we set up society so that people can access the types of services and products they need to live their lives?

Lisa: Along the lines of your earlier point about sidewalks, many older adults live in areas where repairs, to say a sidewalk, are not available or affordable. If sidewalks are not stable or on level terrain, individuals in these neighborhoods have an increased risk of falls. And people who have a lower perceived sense of safety in their communities, whether that has to do with just the activity around them or the sidewalks, are one and a half times more likely to fall.

Dennis: In one of the community courses I used to teach, I would have students take the public transportation down to the paratransit location. This beautifully designed center assesses people's ability to do regular fixed-route transportation versus paratransit. It was eye-opening for our students who routinely used the bus system around the Ohio State campus. They found it challenging to go from their house and complete a couple of transfers on public transportation. They experienced the busy streets and how unkept many of the sidewalks were. I'm sorry if I took a shot at anyone that might be affiliated with a Homeowners Association. My particular one may not have her eyes on the prize quite as much as they should.

Lisa: In Columbus, we have a fantastic initiative, and I know that other communities around the country use the Age-Friendly Initiative as well. There has been some excellent progress in community mobility and transportation, particularly the bus transit system.

There should be a needs assessment when looking at accessibility. This is not just getting on and off the bus but also being able to locate the bus stop. Is the environment around the bus stops considered safe and accessible for older adults? The Age-Friendly Initiative is a client-centered process of going straight to stakeholders (older adult clients) and asking them, "How can we make community transportation more accessible to you? Again, it is a very client-centered OT approach to maximizing mobility for these older adults.

Dennis: We talked a lot about the built environment because we're occupational therapists, and that's where we're most comfortable. Can you talk about other social determinants of health and risk factors related to increased fall risk?

Lisa: Sure, let's look at healthcare access and quality. In some circles, this might be a no-brainer. However, primary care providers do annual wellness visits reimbursed through Medicare, where they can do fall risk screens. But, as many as 72% of older adults are not reporting falls to their primary care physician. There are many reasons for that. They can forget that they fell or don't perceive their fall as a "fall" because it did not result in injury. There could also be a stigma associated with falling or something a little more severe like the fear of a physician suggesting institutionalization like a skilled nursing facility.

There are many valid reasons why older adults don't report falls to their primary care physician, but 72% is pretty concerning. As occupational therapists, we can build rapport with our older adult clients and review what falls are, why they happen, how they can be prevented, and the importance of avoiding them. We have more frequent contact with our patients than primary care physicians in many cases. In some circles, we might be a better link to fall prevention resources than primary care physicians because that's more of our scope of practice. Primary care physicians have a lot on their plates, and those specializing in geriatrics are becoming fewer. If we can take the burden off of our PCP friends, I think that is critical as the aging population grows at an exponential rate.

Dennis: I think it's an excellent access point for us, specifically in primary care, as some of the outreach that I did in a previous life with a Medicaid primary care practice. The physician and the nurse manager of the practice were most interested in OT helping clients with issues like falls.

Lisa: I think stories and case examples always help bring things to life. One of the home visits that I did when I was in full-time clinical practice was with somebody who had fallen and needed rehab services. Upon discharge, I did the home assessment, and they commented, "I've never needed any help getting around my house before."  The client then demonstrated walking without a walker around their home and up and downstairs. They also did a lot of furniture walking, relying on the back of a chair, couch, countertops, and door handles. You could tell that the door handles were used as grab bars as they were hanging on by a thread. It's not the fault of this older adult client as they didn't realize that they were at risk of falling or that they had a mobility impairment. It's our job as therapists to bring that to their attention in a compassionate and empathetic way. We can use our observational skills and relay that information non-condescendingly to our older adults.

Dennis: Can you give some examples of specific populations who may be more susceptible to poor fall-related outcomes because of these different factors?

Lisa: This is why I think these social determinants of health are so important. We want to not only look at falls but also the devastating impact of falls and how they can derail someone's independence and quality of life. Specific populations are at greater risk of health disparities. I don't use this term lightly, as the catastrophic consequences of falls can lead to injuries and disability with decreased independence. Falls can also lead to hospitalizations as well as nursing home placements.

One at-risk population that I've grown very aware of is low-income older adults who still reside at home and are close to needing more skilled services. Most of my fall prevention work has been in collaboration with the LifeCare Alliance, a local home and community-based service provider in Columbus, Ohio. They are one of the largest Meals on Wheels providers in the country. This older adult group has a lot of unmet needs. I have plenty of stories of how these social determinants of health increase the likelihood that this population will experience some health disparities that pertain to falls.

As promised, I am bringing this talk back to that statistic about malnourished people. They are eight times more likely to experience a fall. This "Meals on Wheels" population is a group that historically has a hard time reliably accessing healthy food. Typically, this is a lower-income group. The racial and ethnic breakdown is over 40% minority population, at least in my partner agency's community in the Greater Central Ohio region. They have many unmet needs, and I'm trying to look at them with a fall prevention lens.

Dennis: Gotcha. What kind of interventions are you looking to provide for this group, or what might they need?

Lisa: Is it alright if I give a little more background about the Meals on Wheels population?

Dennis: That would be awesome. Thanks.

Lisa: I think I need to do a better job explaining the importance of this program to people who want to learn about it. So with this captive audience, I will try to practice here. Meals on wheels are delivered to about 2.4 million older adults every year. The primary federal funding source for Meals on Wheels or home-delivered meals, as you might hear them referred to, is the Older Americans Act. Federal dollars get appropriated to pay for these meals that are supposed to meet 1/3 of older adults' daily nutritional requirements. This population's average age is about 74 to 75 years old. There are slightly more females. Almost half live in urban environments, with the others scattered across more rural and suburban settings. About 58% of these meals on wheels recipients live alone and have about six to seven, on average, health conditions.

As the number of comorbidities increases, the likelihood of falling increases. We see annual falls at about 25 to 30% in the general older adult population. A paper came out in 2019 that estimated that the proportion of falls was closer to 41 to 42% in the Meals on Wheels population. A more significant proportion of these individuals use assistive devices like canes, walkers, and wheelchairs. They also have a higher proportion of visual impairments, arthritis, stroke, and several other conditions that place folks at a higher risk for falling.

Dennis: Do some of these programs provide follow-along medical services?

Lisa: Well, this is where the disconnect is. I'd love if listeners have strategies to help with this disconnect or this fragmentation. These home-delivered meals are a social service provided and funded by government dollars. In contrast, occupational therapists work in more of a traditional, more formalized healthcare system. Social service systems and healthcare systems don't always do the greatest job of talking to one another.

Dennis: In the United States, notably?

Lisa: Yes, in the United States. We could learn a lot from our international colleagues as they're doing it better than we are. If there is a way to streamline communication and get into the weeds of data sharing and understanding, this might help. For example, when somebody is discharged from the hospital, they should have a referral to agencies to meet the non-essential health needs of the older adult, such as Meals on Wheels or DME. General health and wellness checks can be provided by Meals on Wheels providers and deliverers. 

Dennis: They could be assessed for the need for home modifications.

Lisa: Yes.

Dennis: It sounds like a phenomenal grant opportunity or an excellent place for occupational therapy students as part of fieldwork or capstones. It seems like a natural fit for us.

Lisa: Dr. Cleary, you were the first one that introduced me to this emerging practice area of having OTs embedded within the primary care clinics. This is an excellent opportunity to have OTs embedded within community-based organizations, such as agencies that provide personal care assistance, home-delivered meals, or home repairs not funded through other sources. It's just a matter of how we get it funded.

Dennis: As you said, some of our international partners have good evidence that we need to get outside our American box.

Lisa: Yes, the egocentric folks that we are. I mean ethnocentric, not egocentric. Well, perhaps I mean both egocentric and ethnocentric.

Dennis: I think you're right. What types of things can we do as occupational therapists to help improve outcomes and quality of life for vulnerable older adults?

Lisa: Sure, I think this is the big take-home point. I can rattle off statistics and proportions until I'm blue in the face and put everyone to sleep listening to this podcast. We can identify someone who is a fall risk by using an outcome measure such as the TUG and documenting that. However, as occupational therapists, I'd like to think that we have unique skills for evaluating more than the individual-level factors that influence the occupational performance of our clients. We need to take a step back and look at the built environment that includes the neighborhood and the structures that people live in or where they get discharged. We also need to collaborate with other care team members as they could be critical in ensuring that these other risk factors like nutrition and medication management are addressed. OTs can't do it all. I like to think that we can, but we shouldn't do it all.

Dennis: We can do most.

Lisa: We can do most. We can do much.

Dennis: But not all. That's right.

Lisa: Right. Collaborating with our interdisciplinary partners and identifying available resources are great, but we need to connect the older adult to the resource. That's a whole other bag of worms that or can of worms. Now that I said that out loud, I don't know who's ever held a bag of worms or a can of worms.

Resource use is more important than resource identification. We can do quick and easy food insecurity screens in these lower-income groups of older adults at risk of food insecurity and malnutrition. Perhaps your case management partner or a social worker has already done this in preparation for discharge back into the community. OTs may be able to advocate in these cases. You can even implement a simple two-question food insecurity screen that you can quickly on Google. There's a validated two-question item that I can add to the resource guide for listeners. This is a great way to think outside the box about those risk factors with an increased likelihood of falling.

Dennis: I would imagine this population has a high percentage of folks with a disability like those that have survived strokes or an intellectual or developmental disability. Is there any evidence about this?

Lisa: Sure, you are correct. I can't rattle off the numbers, but receiving these meals helps clients stay in their homes and delay the need for more costly care. These folks may have been recently discharged from the hospital and only need a couple of months of meals before they're back on their feet. Those that receive meals on a more ongoing basis have chronic conditions and food insecurity. To that point, you're correct.

In terms of the evidence, we know that those individuals with more chronic conditions and a history of disability are more susceptible to health decline. Services from home and community-based organizations can help keep older adults in their homes, where upwards of 85-90% of older adults prefer to age. I feel passionate that older adults deserve to age with dignity in the homes and communities of their choosing. These non-medical services have a critical role in helping this population remain independent in the community. Still, they don't perhaps get the same glory that our more traditional, formalized healthcare system.

Dennis: Is it a paid person delivering the meals and has some training in identifying potential risk factors? Or, it is a five-minute, "Here's your meal. I hope everything's okay," sort of relationship?

Lisa: That's much of the work we're trying to do here. The focus of one of our grant-funded initiatives with LifeCare Alliance is not precisely training but an "upskilling." Staff is responsible for conducting initial assessments on older adults interested in enrolling in Meals on Wheels. As part of this assessment, these staff, who are paid, evaluate areas such as fall risk history, health history, social history, nutrition risk, ADL function, and IADL function. Identification is one part of the game. When someone is identified as a fall risk, then what do you do? What is the follow-up decision tree? How do you determine that somebody is connected to the right home and/or community-based fall prevention service? This is where things get tricky. I don't have a good answer for that, but this is where I think that having an embedded OT clinician within the organization would be helpful. Many agencies can provide canes, walkers, and other durable medical equipment. But unless that equipment is fit to somebody's house and body proportions and accompanied by proper training, then the equipment itself can pose an additional fall risk. There is a need for an OT to be part of these community-based organizations. Some are, but it would be great to see more of those OTs more purposefully integrated.

Dennis: Have you had capstone students that have expressed interest in that? Typically, student populations tend to be passionate about the social justice aspect of what some of our practitioners are doing.

Lisa: We are starting that. I have three new capstone students beginning this summer that are specifically interested in falls in the community-based setting. We'll be excited to see what they learn and what they can implement in their respective capstone sites. These are great opportunities to identify the need for an OT in these different settings and to identify what OT's distinct value is to these organizations that have not historically had an OT on staff?

Dennis: If someone is working in a nursing home, acute care setting, inpatient rehab, or even an outpatient setting, what are the things you might see that would make you believe that a person is a good candidate for Meals on Wheels or other referrals?

Lisa: This is where I would collaborate with case management and social work colleagues to see what questions they ask. Although we did a great job collaborating across disciplines at Ohio State, I could have learned more about what each discipline asked of patients, especially when it came time to discharge. So I think that's a nice place to start. We don't know what we don't know, and we don't want to duplicate efforts. 

Dennis: This might be an excellent topic for a team meeting to address these different topics like food insecurity.

Lisa: Yes, 100%. Dieticians and speech-language pathologists come into play with this topic as well. 

Dennis: It's all about the team. Remember, there's no "I" in a team. Any last-minute takeaways related to falls and the social determinants of health?

Lisa: Think outside the box about the individual, risk factors, the built environment, and available resources in the community. We also need to broaden our assessment procedures to touch upon these social determinants of health as it is excellent for the profession and for fall prevention in older adults. The most effective fall prevention programs consider client-centered goals. 

Dennis: Absolutely. My mother-in-law is 78 years old and has some issues with her feet and balance. A phrase that I use with her is "risk reduction." This helps her make decisions, and she's shared it with a lot of her friends. 

Lisa: I like that. Sometimes, the word fall is not well received, and they may shut down immediately. 

Dennis: They are their choices, and it is hard sometimes for young therapists to realize. Dr. Lisa Juckett, from The Ohio State University, thank you so much for your expertise in fall prevention and for helping our folks understand social determinants of health in a better way.

Lisa: My pleasure. Thanks for having me.


Please refer to the outline and handout.


Juckett, L., and Cleary, D. (2022). Fall prevention and social determinants of health podcast. OccupationalTherapy.com, Article 5511. Available at www.occupationaltherapy.com

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lisa juckett

Lisa Juckett, PhD, OTR/L, CHT

Dr. Juckett’s research centers on bridging the gap between empirical discoveries and the use of these discoveries in real-world practice settings. Heavily informed by the field of implementation science, Dr. Juckett’s research examines the factors and strategies that influence evidence-based practice adoption, primarily in organizations that serve the older adult population. Specifically, Dr. Juckett’s work aims to develop and test “implementation strategies” that support the use of evidence-based practices in the areas of a) fall prevention and b) stroke rehabilitation. Active involvement of community and clinical stakeholders is a hallmark characteristic of Dr. Juckett’s research given their immensely valuable role in providing client-centered care to the older adults community.

dennis cleary

Dennis Cleary, MS, OTD, OTR/L

Dr. Dennis Cleary has over 25 years of experience as an occupational therapist.  Dennis’ clinical practice has been primarily with children and adults with intellectual disabilities to encourage their full participation in all aspects of life at home, work, and in the community. He has had faculty positions at The Ohio State University and Indiana University. As a researcher, he has been on teams that have received over seven million dollars in grants from state and federal agencies, including a National Institutes of Health multisite trial of the Vocational Fit Assessment, an age-appropriate transition assessment, which he co-created. He has numerous publications and national and international presentations. Dennis is passionate about increasing the role of Occupational Therapy in transition-age service with the goal of improving outcomes and quality of life for all. 


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