For the past several years, Union County, Ohio has experienced an increase in the number of falls, fall-related injuries, and deaths among the senior population, ages 60+ years. These alarming statistics align with trends seen in other communities across the country. According to the Centers for Disease Control and Prevention, every year one in three older Americans will fall. In response to this alarming trend, the Union County Health Department has formed the Union County Older Adult Falls Coalition. The Coalition is diligently working to create a comprehensive, community-based fall prevention program for Union County seniors. One component designed by the Coalition is the SLIPS home assessment and modification program. SLIPS, which stands for Seniors Living IndePendently and Safely, aims to prevent falls through home modifications and assist seniors in maintaining their independence. This evidence-based Union County program takes an innovative, multi-pronged community approach. The Coalition recruited a broad group of unique community partners to conduct assessments, many of whom incorporated the SLIPS procedures into the existing services they already provide to Union County seniors. These partners included the local health department, hospital, home health companies, parish nurses, long-term care and rehabilitation facilities, senior services organization and the local United Way organization. Through organizational policy and procedure change within these organizations, the SLIPS program has been designed to result in sustainable, lasting change.
Union County Health District
Prevention of older adult falls through home assessment and modification
The Union County Health Department is a government agency that serves the 52,300 county residents through its six divisions: Health Education & Community Partnerships, Environmental Health, Help Me Grow, Nursing, Disaster Preparedness, and Vital Statistics. The health department employs 33 staff members and is the only health department in the county. Union County is a primarily rural area just northwest of Columbus, Ohio. Union County’s largest city, Marysville, has been significantly growing over the past decade. The county population is predominantly white (93.1%) and the median age is 36.8 years. 91.6% of the population received their high school diploma or further education, and the median household income is $65,866. The county is home to many nationwide companies and employs a significant number of workers from across central Ohio. While Union County is a steadily growing community, it remains committed to its small town roots.
For the past several years, there has been a steady increase in the number of falls, injuries, and deaths occurring among Union County seniors ages 60+ years. This increase is consistent with trends seen in other cities across the country. According to the Centers for Disease Control and Prevention, one out of every three older Americans will fall each year. This startling statistic has been confirmed by local data. Union County ranks in the top 25% of Ohio counties for senior fall-related deaths. In addition, national statistics indicate that approximately 60% of older adult falls occur within the home. In Union County, 72% of all fall-related EMS runs were made to a senior’s residence.
In response to this, the Union County Health Department received funding in 2014 to form a local coalition and build a comprehensive fall prevention program for Union County seniors. This project includes multiple evidence-based strategies and draws upon community partners to ensure project reach and success.
As part of this project, one of the primary goals was to develop and implement a fall prevention home assessment and modification program for older adults. Annually 300 home assessments will be conducted through the SLIPS program. By December 2018, at least 20% of Union County older adults (roughly 1,465 seniors) will have had their homes assessed.
In the spring of 2014, the health department led Union County Older Adult Falls Coalition developed the Union County SLIPS program. SLIPS, Seniors Living IndePendently and Safety, is a fall prevention home assessment and modification program. The mission of SLIPS is to prevent falls among seniors in the home and assist seniors in maintaining their independence. The program was developed through multiple community partnerships and is innovative in the way in which assessments are conducted and seniors are reached. The program was launched in May 2014 with seven organizations conducting fall prevention home assessments. Trainings were held for each participating organization and regular follow up occurs between the staff and the Coalition. To date, 112 home assessments have been completed and over $3,600 in modifications have been made.
The SLIPS program has been successful because of the partnerships established with multiple community organizations and businesses prior to its’ development. Their commitment to the prevention of falls and their assistance with program development has allowed SLIPS to use a multi-pronged approach and effectively reach seniors across the county many of whom were unaware of their fall risk. SLIPS truly is a community-based program that is driven by community need.
The public health impact of the SLIPS program is very powerful. As cited above, the majority of falls occur within the home. By improving the safety of the home through very simple modifications such as the installation of a grab bar or the addition of a hand railing, the SLIPS program is able to reduce the senior’s fall risk and the future occurrence of a fall. The effects of this prevention strategy can be seen in reduced emergency room visits, hospitalizations, treatment, deaths, and all their associated costs.
Not only does SLIPS prevent falls within the home, it also provides an opportunity to empower seniors to further reduce their risk. According to statistics collected by the Coalition, 48% of Union County older adults worry or have anxiety that they will fall. This fear causes many of them to stay within their home and become disengaged from community activities. By doing so, they unknowingly increase their fall risk. Through the SLIPS program, seniors are encouraged to take advantage of other fall prevention programs being offered in Union County.
More information can be found at the Union County Health Department’s website: www.uchd.net
Every year one third of US older adults suffer a fall. In Ohio, this equates to a fall occurring every two minutes. Hundreds of thousands of these falls result in injuries severe enough to require emergency department treatment, hospitalization, and rehabilitative care. Thousands of these falls are so devastating that they are fatal. The annual economic costs associated with these injuries and deaths in Ohio total $4.2 billion. These staggering statistics are compounded by the fact that the older adult population is projected to significantly increase over the next thirty years.
This national and state injury epidemic for the aging population is also very present in Union County. Union County ranks in the highest quartile of the state for self-reported falls among adults (45+ years) according to the Ohio Behavioral Risk Factor Surveillance System. From 2009 through September 2013, the emergency department at Memorial Hospital treated a total of 2,077 falls among older adults ages 60+ years. Of these fall-related visits, 145 resulted in hospitalizations.
In addition to the increase in occurrence, the severity of fall-related injuries has also increased. From 2004 to 2006, there was one fall-related death. However, from 2011 through September 2013, an even shorter time period, there was a 700% increase in fall-related deaths among Union County older adults.
Not only are falls increasing in Union County, but so is the at-risk, target population. Older adults, ages 60+ years, currently make up 14% of Union County’s population. This equates to 7,329 seniors. By 2020, this segment of the counties’ population is projected to increase by 102%. By 2040, a quarter of the county population will be ages 60+ years. With this projected boom in the senior population, the number of falls, related injuries, and deaths will also dramatically increase.
While falls among older adults has been steadily increasing in Union County for several years, little was previously done to prevent their occurrence. Union County Senior Services provides many services through their licensed social workers; however, these did not include any fall risk assessments or home assessments. The long-term care and rehabilitation facilities provided treatment and follow-up care for older adults who had been severely injured from a fall; however, they were not involved in any prevention programming.
In 2014, after receiving funding from the Ohio Department of Health, the Union County Health Department formed the Union County Older Adult Falls Coalition. The Coalition’s mission is to prevent falls among Union County seniors ages 60+ years. One of the first projects of the Coalition was to create a fall prevention home assessment and modification program. The Union County SLIPS program, Seniors Living IndePendently and Safely, was developed and implemented in the spring of 2014.
Home assessments and modifications are an evidence-based strategy and identified by the Centers for Disease Control and Prevention as a building block to a successful community-based fall prevention program. They are listed in the CDC’s guide, “Preventing Falls: How to Develop Community-based Fall Prevention Programs for Older Adults.” http://www.cdc.gov/homeandrecreationalsafety/Falls/community_preventfalls.html.
While SLIPS is an evidence-based practice that is modeled after home modification programs described in the CDC guide listed above, it is very innovative in its design and approach. In many communities, fall prevention home modifications are offered through a single agency or entity such as a local fire department or health department. The assessments and modifications are completed at the request and expense of the senior. This requires the senior to identify and be willing to acknowledge their fall risk and take the necessary steps to participate in a home assessment. Due to the fear of loss of independence and other potential consequences, many seniors are hesitant or unwilling to even discuss their fall history or risk.
In comparison to these traditional home modification programs, Union County took an innovative, multi-pronged approach when developing SLIPS. The Coalition recruited a broad group of unique community partners to participate in the SLIPS program. These partners included the local health department, hospital, home health companies, parish nurses, long-term care and rehabilitation facilities, senior services organization and the local United Way organization. Once recruited, these partners all agreed to implement the SLIPS program procedures through the established services they already regularly provide to Union County seniors. Registered Sanitarians from the Union County Health Department are trained to offer SLIPS home assessments by request to the public. Memorial Hospital’s Health Center staff offer home assessments to the seniors who frequent their facility for exercise and nutrition services. Loving Care Home Health and Interim HealthCare incorporated the SLIPS home assessments into their initial visits with all seniors receiving home health services. The Parish Nursing Program offers the SLIPS program to seniors by request through the Union County churches they serve. Heartland of Marysville conducts SLIPS assessments with seniors receiving therapy services through their rehabilitation facility. Union County Senior Services incorporated the SLIPS program into the home visits conducted by their social workers across the county. Finally, United Way of Union County offers SLIPS home assessments as part of their annual Community Care Day event where volunteers visit seniors’ homes for home repair, gardening, and other light maintenance services.
As evidenced above, the SLIPS program has many unique community partners. Through these partnerships, the program is able to reach far more seniors, including those who live in the more rural areas of the county and those who are not as in engaged in social and community opportunities for older adults. In addition, while seniors are able to call and request a SLIPS assessment, the successful of the program does not depend on their interest and willingness to participate. As previously described, assessments are automatically built in to many services being conducted on a daily basis for Union County seniors by multiple community organizations and businesses.
In addition, the SLIPS program is also unique in that funding has been allocated to cover the expenses of the home modifications. When a SLIPS assessment is conducted by any of the partners listed above, the completed paperwork is sent to Union County Senior Services. Union County Senior Services then coordinates a qualified contractor to visit the home and make the modifications. If the senior is lacking the resources or ability to pay for the modifications, they are completed at no expense to the senior. The work is paid for by grant dollars from the Ohio Department of Health. In addition, Union County Senior Services has also allocated annual dollars in their budget to be used for these modifications.
The SLIPS program was launched in May 2014 in coordination with United Way of Union County’s Community Care Day. Since its launch, 112 home assessments have been completed. The Coalition has set a goal to conduct 300 SLIPS assessments every year. If this goal is met, 20% of the Union County senior population, age 60+ years, will have been reached by 2018.
The Union County Health Department has served as the lead agency for the Union County Older Adult Falls Coalition and the SLIPS program. The health department has been funded to provide injury prevention programming in the county since 2001. Because of this history, the health department is viewed as a leader in injury prevention initiatives in the community. In 2013, the health department identified falls among older adults as an increasingly concerning issue based on local injury and death rates and the projected increases in the Union County senior population.
Since receiving the 2014 funding, the health department has made much progress in establishing a comprehensive falls prevention county program. The Union County Older Adult Falls Coalition was formed in March 2014. It includes representation from the health department, local hospital, YMCA, Union County Senior Services, three local senior centers, home health companies, skilled nursing facilities, long-term care facilities, Alzheimer’s Association, and the senior population. While the Coalition is led by the health department, it is the Coalition’s responsibility for overseeing the planning, development, and implementation of all fall prevention programs and strategies. This structure was purposely created to ensure that members felt empowered and able to make decisions and influence change. Coalition members were relatively easy to recruit due to the increasing occurrence and severity of the injury issue and because of this, the Coalition was quickly engaged and ready to take action.
As previously described, one of the first tasks of the Coalition was to develop and implement a home assessment and modification program. This charge resulted in the creation of the Union County SLIPS program. The goal of the program is to prevent falls among Union County seniors ages 60+ years through home modifications and assist them in maintaining their independence. By 2018, the program aims to have reached 20% of the Union County older adult population. To accomplish this goal, multiple objectives were outlined by the Coalition. These included the following:
1. Create an assessment tool to be used during SLIPS assessments.2. Create and/or identify educational resources to be distributed during SLIPS assessments.3. Recruit a community partner to coordinate all home modifications.4. Secure additional funding for home modifications.5. Recruit community partners to conduct SLIPS home assessments at the request of the public.6. Recruit community partners to incorporate SLIPS home assessments into existing services offered to seniors.7. Provide training on SLIPS procedures for all community partners.8. Launch the SLIPS program.9. Track data regarding completed assessments and modifications.
During the spring of 2014, the Coalition diligently worked to accomplish all of the objectives listed above. The assessment tool, the Home Safety Checklist, was developed by the Coalition using a variety of other tools and checklists created by fall prevention coalitions across the country. Packets of educational materials were compiled including several handouts created by the Coalition. These packets are used during the SLIPS assessments to provide information about additional steps a senior can take to reduce their fall risk. Union County Senior Services was recruited to serve as the coordinator for all home modifications. All completed Home Safety Checklists are electronically sent to Union County Senior Services for review, further coordination, and tracking purposes. Union County Senior Services has secured the services of two qualified contractors to complete the home modifications as they are needed. In addition, the Coalition also successfully recruited Union County Senior Services to allocate funds within their annual budget to be used for home modifications. These funds are added to the grant dollars provided annually by the health department.
Three community partners were recruited to conduct home assessments at the request of the public. The health department’s Registered Sanitarians conduct SLIPS assessments and have dedicated Tuesday afternoons for the assessments as requested. Memorial Hospital’s Health Center offers SLIPS assessments by request to their senior clients. Finally Memorial Hospital’s Parish Nursing Program offers SLIPS assessments through the churches they serve by request. Four community partners were recruited to incorporate SLIPS assessments into the existing services they offer to seniors. Loving Care Home Health, Interim HealthCare, Heartland of Marysville, and Union County Senior Services have all incorporated the SLIPS procedures into their standard organizational practices. Home health aides, occupational therapists, and social workers from these organizations regularly conduct SLIPS assessments with their senior clients.
The Coalition was able to recruit such a broad base of partners because of the benefits the SLIPS program offers not only to seniors but to the participating organizations as well. Partner organizations are able to promote to their senior clients that they are offering services to reduce their fall risk, improve their safety, and better their quality of life. The SLIPS partner organizations are able to offer these services with very little expense on their end. All materials were created and provided by the Coalition. Staff training was free of charge and provided at the partner organization’s convenience. Finally and most importantly, all coordination of modifications and the related expenses are covered by the Coalition and Union County Senior Services. To participate, partner organizations simply had to identify qualified staff, allow them to attend training, and then incorporate the SLIPS assessments into their existing services. By making the process simple and very attractive, the Coalition was able to grab the attention and commitment of multiple community organizations and businesses.
Once all the partner organizations were recruited, training sessions for all involved staff members were conducted during April and May 2014. Each staff member designated to conduct SLIPS assessments was selected because of their skills and expertise related to home assessments. Registered Sanitarians were identified as a natural fit because of their skills in conducting school safety inspections and working with seniors on a variety of residential issues. Hospital staff including the health center employees and the parish nurses were selected because of their experience in providing health services to a primarily senior population. The home health aides, occupational therapists, and social workers all have specific skills and knowledge related to fall prevention strategies and working with older adults.
The SLIPS program was launched in May 2014 in coordination with another recruited community partner, the United Way of Union County. This organization conducts an annual Community Care Day event where volunteers visit seniors’ homes for home repair, gardening, and other light maintenance services. SLIPS assessments were conducted as part of this event for 36 seniors across Union County. Since the launch, SLIPS assessments have been and continue to be conducted by all trained partner organizations. To date, 112 home assessments have been completed and over $3,600 in modifications have been made.
Once SLIPS was launched, the Coalition set up a system for monitoring and tracking program progress. Union County Senior Services agreed to track the number the assessments completed, modifications made, and dollars spent. This information is provided to the health department and reported to the Coalition on a monthly basis.
The SLIPS program will continue to be implemented over the next four years. Benchmarks have been identified to annually check if the program is staying on schedule and meeting expectations. The Coalition plans to conduct at least 300 assessments each year. By 2018, the Coalition plans to have reached 20% of the Union County senior population through the home assessment program.
A breakdown of the direct costs associated with the SLIPS program is included below. The main cost for program development and implementation is staff time, however, this is considered as in-kind support from all the participating partner organizations.
Direct CostsSLIPS assessment tool (Home Safety Checklist) - $100.00 – 500 checklists at $0.20 eachSLIPS folders with other educational materials - $150.00 – 20 packets at $7.50 eachSLIPS promotional postcards - $250.00 – 1000 postcards at $0.25 eachFunds for home modifications - $5,000.00
Once the Coalition was formed, a second task was to gather data to create the Falls Among Older Adults in Union County Report. Injury and death data from a variety of local sources including Memorial Hospital, Ohio EMS, and Union County Health Department’s Vital Statistics was collected. In addition, the Coalition developed a survey to administer to seniors to collect information on their attitudes, behaviors, and beliefs. This data was compiled and reviewed by the Coalition and the report was finalized in October 2014. This report will be used as a baseline to measure long-term outcomes from the impact of the SLIPS program and other fall prevention strategies implemented by the Coalition in 2018 when the project is completed.
In 2014, process evaluation measures were used to evaluate the successfulness of the SLIPS program. This information was tracked and reviewed by the Coalition at the monthly meetings. No modifications were made as a result of the information obtained.
Process evaluation measures included:Number of materials developed/compiled to be used during SLIPS assessments.Number of partners recruited to offer SLIPS assessments by request.Number of partners recruited to incorporate SLIPS assessments into existing services.Number of SLIPS trainings held.Number of staff attending SLIPS trainings.
In 2014, outcome evaluation measures were also used to evaluate the SLIPS program. This information is tracked by Union County Senior Services and reported monthly to the Coalition. At the January Coalition meeting, a final report for 2014 with additional information will be available and presented by Union County Senior Services. This report will identify the number of assessments conducted, modifications made, funds expensed, and the average length of time between assessment completion and modification. In addition, it will also identify the number of assessments conducted by each partner organization. This information will be used by the Coalition to assess whether additional training, SLIPS promotion, additional contractors, or other changes are needed to improve program production and effectiveness in 2015.
Outcome evaluation measures included:Number of assessments conducted.Number of modifications made.Amount of funds expensed on modifications.Average time between assessment completion and modification.Number of assessments conducted by each partner organization.
The SLIPS program has been created by the Coalition through multiple, unique community partnerships. It was done so with the intention that the program will continue long after the funding from the state health department expires. As previously described, the Coalition designed the program so that minimal resources are needed from each partner organization. These organizations reap great benefits for their senior clients and their image by participating in SLIPS. The Coalition anticipates that these motivating factors will ensure that not only do the current partner organizations remain engaged, but that additional organizations will come to the table in the future and further the reach and impact of the SLIPS program.
Union County Senior Services, a primary partner for the Coalition and program, is highly committed to fall prevention strategies. As demonstrated by the Senior Survey data previously mentioned, Union County seniors are fearful of falling. This concern will only grow as the senior population increases. With this likely increasing demand, the Coalition is confident that Union County Senior Services will remain engaged and committed to the SLIPS program. In addition, the Coalition also benefits from the fact that Union County Senior Services receives sales tax levy dollars. Because of this funding source, Union County Senior Services has additional resources that many other counties’ senior service organizations lack. Union County Senior Services allocates these dollars to programming and services that improve the health, safety, and quality of life for Union County seniors. Fall prevention has a natural and necessary fit with that mission making it extremely likely that the SLIPS program will sustain long past 2018.
In 2015 and beyond, the Coalition intends to annually request that Union County Senior Services allocate funds in their budget to cover SLIPS modifications. In addition, the health department is committed to covering the minimal direct costs of printing SLIPS assessment tools, SLIPS educational materials, and promotional postcards. If the health department’s ability to cover these expenses should ever change, the Coalition partners are committed to cover these minimal program implementation costs.
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