Village or tribe? Expectations, roles, and responsibilities for effective fall prevention efforts.

Effective fall prevention efforts bridge the silos between clinical and community practice. A fall experienced by an older adult is rarely a straightforward event. Typically, falls are due to complex inter-related medical, behavioral, and environmental risk factors (1). For many older adults, medical risk factors such as medication reconciliation, treatment of atrial fibrillation, or physical therapy to address gait and balance impairments are primary in fall prevention (2). However, this is only the beginning of the fall prevention story. Once medical risk factors are managed, the focus of risk management should transition to behavioral and environmental factors (3). This will ensure that the older adult has the ability to safely interact with their environment to prevent a future fall. One of the most robust interventions is strength and balance training to minimize fall risk (4). Two hours of strength and balance training done each week is the minimum dose required to effectively prevent a fall or fall-related injury (5). To achieve this dose of exercise typically requires a behavior change (6). Established protocols to transition from a clinically supervised rehabilitation program to an evidence-based community program will support this behavior change. Once the initial clinical-community transition is complete, to further support behavior change, the older can be embedded into the continuum of the community. For example, the older adult could move from programs that target the more frail and deconditioned, like Stepping On (7), to those that target more robust individuals, like Tai Chi (8). This proposed model supposes that infrastructure is in place to build a continuum of care where none exists. To achieve this model, stakeholders have called for multi-level, multi-component interventions, with the goal of engaging policy makers, healthcare providers, community providers, and older adults themselves. Many have compared these efforts to building a “village” of providers (9). The concept of “village” is appealing, though may be inherently flawed. A village is a group of buildings that simply share the same physical location. These buildings are not necessarily inter-related, interdependent, or even connected by a common culture or value system. Besides being in the same physical location, there is no common commitment among members of a village. This scenario of assumed but not confirmed alignment of priorities and goals often plays out in fall prevention. Many public health providers mistakenly assume that healthcare providers integrate fall risk screening and management into their practices. For example, an evidence-based fall prevention exercise program is offered in the community. An older adult is interested in attending the program, and must be cleared by their physician before participating. The older adults request a falls screen from their physician. The physician, however, does not understand her expected role in fall prevention. She has not been trained in fall screening. She assumes that if the patient is asked to be screened then she is at risk of falling, and is not going to be safe in the community program. This is not an atypical behavior; studies have shown that less than 30% of healthcare providers who interact with older adults screen for falls on a routine basis (10). Physical therapists are also uncertain about their roles and responsibilities in the fall prevention continuum. For example, few physical therapists are aware of evidence-based programs that target populations at risk of falling (11). They also may not understand the role of State Fall Prevention Coalitions, or perceive them as partners in creating a continuum. In a survey of PTs interested in disseminating the Otago Exercise Program (OEP), the majority of PTs indicated that support of a program by State-Based Fall Prevention Coalitions was not a facilitator to program implementation (11). A similar story exists from the public health perspective. State-Based Fall Coalitions identified working with healthcare providers to disseminate evidence-based fall prevention programs as a top priority (12). However, it is clear that a disconnect exists between the expectations and actions of healthcare providers by the Coalitions may be resulting in gaps in the continuum. A final example is the complex and misunderstood role of older adults. Though almost all Fall Prevention Coalitions have the goal of education and public awareness, few, if any, actually have older adults as active members of their coalitions (12). Preliminary evidence from pilot studies supports a disturbing trend that even by educating healthcare providers and offering innovative programing, many older adults are likely to refuse when offered