Senate Aging Comment Letter

To what extent are falls unreported among older Americans? What strategies can be employed to encourage patients to promptly notify their health care provider or caregivers of a fall? How can follow-up with appropriate healthcare providers be improved after a visit to an emergency department for a fall?

Research has shown that more than 1 in 4 older adults fall each year, but less than half tell their doctor. Recognizing this dramatic underreporting, BPC’s Senior Health and Housing Task Force recommended a number of ways to enhance falls risk assessment (mentioned below). Moreover, it called for the Centers for Disease Control and Prevention (CDC) to seek new ways to assist and encourage state health departments to optimize existing surveillance systems for falls by partnering with health care entities and health information technology companies. Such partnerships could help states collect improved epidemiological data to target CDC’s Stopping Elderly Accidents, Deaths and Injuries (STEADI), a falls risk assessment system, and provider training to regions with high fall rates and ensure that community-based falls-prevention programs are available in localities where there is the highest need.

Since most falls occur in the home setting, hospitals should also incorporate questions about housing as part of their discharge planning to prevent hospital readmissions, and nonprofit hospitals, specifically, should include housing in their triennial IRS-required community health needs assessment.

What learning tools, resources or techniques can be used to empower patients to change their home environment or modify risk factors to reduce the risk of falls?

Home modification is one of several strategies scientifically demonstrated to reduce older adult falls, and there are many tools, resources, and techniques available to connect older adults with the appropriate resources. Yet cost, ease of access, and a pervasive lack of understanding about fall risks present huge impediments.

What are the opportunities and limitations surrounding assistive technologies?

While assistive technologies can serve as tools to reduce falls, evidence shows that they make little impact on reducing the overall fall risk because they do not address all of an individual’s risk factors for falls.

However, Americans do increasingly use technologies to help them navigate their health and health care more broadly. With increasing comfort and acceptance, health technologies have great potential to remove impediments to independent, healthy aging—by helping to manage chronic disease, reduce social isolation, support physical activity, and offset functional and cognitive impairments. Such benefits are increasingly well-documented:

• Telehealth has been shown to improve access to care, reduce the cost of care (for example, through reductions in hospital readmissions and transportation costs), and increase the convenience of care. Telehealth also improves access to specialists and extends provider capacity—an important benefit given the projected shortages of nurses and physicians.
• Remote patient monitoring has been shown to reduce hospital readmissions.
• Secure messaging has been shown to improve quality of care and outcomes.
• Patients with online access to their health information are more likely to personally find and correct errors or incomplete information in their record, understand their health conditions better, and keep up with their medications.
• Mobile health technologies have been effectively used in managing weight; increasing physical activity; quitting smoking; and controlling high blood pressure, high cholesterol, and diabetes.
• Health IT-based fall risk assessments have helped clinicians identify individuals who are at elevated risk for falls and facilitate appropriate intervention strategies for those patients.

Yet there are key barriers that prevent greater adoption of such health-related technologies, including: high costs for consumers, lack of reimbursement, interstate licensing requirements, limited internet access (particularly in rural communities and among low-income Americans), and continued concerns about the privacy and security of sensitive health information. There are also other barriers that prevent effective use of technologies by older adults, including: paying for devices on a fixed income, forgetting or losing the technology, low ease of use, physical challenges, skepticism about benefits, and difficulty learning to use new technologies.

Are there are any federal policy barriers that make it difficult to offer tools and resources to patients to prevent falls?

The federal government can address policy barriers and do more generally to support falls prevention efforts. In particular, we recommend creating a cross-cutting, interagency initiative to coordinate, review, and promote the numerous federal home modification programs and resources that are currently available. Greater coordination across the departments, but at the very least between HHS and HUD, could result in development of an analysis of households served and approximate dollars invested for senior households by program. Coordinated and analysis could help identify and address gaps, or duplications, in populations supported. Further, the effort could inform private-sector entities offering modification services. Finally, the Aging Network, supported by HHS, could disseminate information on public and private resources available for home assessments and modifications to the 10 million low-income seniors currently served by senior centers. We applaud efforts to legislate these ideas in the Senior and Disability Home Modification Assistance Initiative Act of 2019 by Sens. King (I-ME) and Collins (R-ME) and Reps. Morelle (D-NY) and Fitzpatrick (R-PA) and others.

How can the “Welcome to Medicare” visit or the “Annual Wellness” visits be improved to better assess fall risk and fracture prevention and ensure appropriate referrals?

Medicare now covers an Annual Wellness Visit providing personalized prevention services to beneficiaries. CMS should clarify with providers that falls risk assessments are a mandatory element of the Annual Wellness Visit. While there is no single standard falls risk-assessment tool, CMS should share CDC’s STEADI program for falls risk assessment with providers. In addition, for those found at risk of falls, referrals to falls-prevention programs as well as personalized health advice are required elements of an Annual Wellness Visit prior to submitting a claim. Specifically, this advice should be consistent with current U.S. Preventative Services Task Force recommendations for exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling older adults who are at increased risk of falls.

More broadly, health risk assessments (HRA) are health-related evaluations used by providers, insurers, and employers to collect data for individual and population health improvement. CMS requires Medicare providers to administer HRAs as part of the annual wellness visit. HRAs are also commonly used by Medicare Advantage plans and are occasionally administered in the home. With respect to Medicare Advantage plans, CMS does not require utilization of a specific HRA but, in its 2016 Final Call Letter, strongly encouraged plans to adopt recommended best practices, including components of a model HRA developed by CDC. Though CDC’s sample HRA included important questions on health behaviors, activities of daily living, and self-reported biometric measures, it did not include questions related to housing and/or LTSS. CMS should encourage all providers, but specifically Medicare Advantage plans, through questionnaires or in-home visits, to include assessments of the following needs in HRAs: frailty and fall risk, living situation (e.g., lives alone), home safety/accessibility, and modifications. This will ensure more attention to the effects of housing on health and lead to opportunities to enhance healthy aging.

How can Medicare coverage and reimbursement for falls prevention and fall-related services be improved?

There are several efforts that could help improve Medicare coverage for falls prevention and related services:

• CMS should ensure that quality measures related to falls prevention are embedded in all of its quality-measurement programs. Specifically, these measures should be incorporated into the new Merit-Based Incentive Payment System created through the Medicare Access and Reauthorization Act of 2015 and into measure sets for alternative payment models. Quality measures should go beyond screening for falls, as is currently required of accountable care organizations, and also include quality measures that reduce the actual incidence of falls. These actions will further incentivize health care entities to focus on falls prevention.
• CMS’s Quality Improvement Organization program is one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries. CMS should ensure that falls prevention becomes a key part of the next “scope of work” of its Quality Improvement Organizations, groups of health-quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare. Taking this step will help create a national focus on falls-prevention screening and on building important clinical-community linkages on behalf of falls prevention.
• With passage of the Bipartisan Budget Act of 2018 and the release of a guidance letter from the Centers for Medicare and Medicaid Services (CMS), MA plans can offer new supplemental benefit options to their enrollees beginning in 2019. MA plans will have greater flexibility in targeting services to patients with multiple chronic conditions by offering coverage of nonmedical, health-related services and supports. This expanded coverage could include things like transportation assistance and minor home modifications, such as grab bars and ramps. Given the continued need to build the evidence base for the effectiveness of providing such benefits (particularly regarding their return on investment), in an upcoming report BPC will recommended that CMS collect data on this new benefit flexibility to build an evidence base to help better understand the types of interventions that can lead to reductions in hospitalizations and emergency department visits. As this evidence base is expanded, this information could be used to make coverage decisions in Medicare fee-for-service, including those enrolled in ACOs, Comprehensive Primary Care Plus and for those who are receiving chronic care management services.

How are existing Medicaid waivers being utilized for falls prevention and fall-related services?

While not specific to waivers, there are opportunities for Medicaid to support falls prevention and fall-related services. A final rule published by CMS on July 15, 2013, included a change to the Medicaid regulatory definition of preventive services. As a result, practitioners other than just physicians and other licensed practitioners can be reimbursed for furnishing preventive services that are recommended by a physician or other licensed practitioner. There are a number of evidence-based falls prevention programs in the community that could benefit older Americans. States, through state plan amendments to their Medicaid programs, could ensure that these services are provided and reimbursed. If the programs reduce falls-related health care expenditures on dual-eligible beneficiaries, consideration should be given to sharing any Medicare savings with the state Medicaid program. Such an arrangement could entice further interest by state Medicaid programs.

Are there demonstrations or pilot programs that the Center for Medicare and Medicaid Innovation should consider?

In 2016, BPC’s Senior Health and Housing Task Force recommended a broader demonstration to support the desire of low-income elderly Americans to age in place. The Task Force recommended that CMS launch an initiative that coordinates health care and LTSS for Medicare beneficiaries living in publicly assisted housing to test the potential of improving health outcomes of a vulnerable population and reducing health care costs.

Approximately 1.3 million older adult renters living in publicly assisted housing, the vast majority of whom are dually eligible for the Medicaid and Medicare programs. HUD-assisted dual-eligible beneficiaries have more chronic conditions and higher health care utilization compared with unassisted beneficiaries. HUD has a history of supporting service coordination at properties it finances and has even issued a funding opportunity for current grantees to provide enhanced service coordination coupled with wellness services. While this effort deserves praise, there should be a larger initiative funded through the health care system to demonstrate that this approach helps to prevent or delay health and functional declines in seniors and results in savings for taxpayer-funded health insurance programs. Such an effort would address the “wrong-pocket problem” by ensuring the health care system bears the cost of implementing a practice from which it can potentially benefit. If successful, the effort could serve as the foundation for a more robust set of activities.

More specifically, CMS—through its Center for Medicare and Medicaid Innovation and Medicare-Medicaid Coordination Office—should solicit proposals from health care entities (e.g., accountable care organizations, managed care plans, and provider groups) willing to be accountable for quality, health outcomes, and total costs of care for Medicare beneficiaries in publicly assisted housing (Section 202 projects, senior-restricted public-housing projects, LIHTC properties, USDA Section 515 projects, and other assisted units in congregate settings where seniors predominate). Applicants would have to partner with a large housing property or a network of housing organizations within a particular service, or “catchment,” area to achieve the volume of participants necessary to conduct and evaluate the demonstration. In addition, partnerships with state Medicaid programs and local community-service providers would be encouraged.

Eligible applicants would ensure the delivery and coordination of health care, LTSS, and preventive services and wellness programs within a congregate housing setting, using housing-based service coordinators and evidence-based models or programs that have a track record of helping beneficiaries remain in their homes and reduce health care utilization. Several-service demonstration models intended to support aging in place are currently showing significant promise. For example, the Support and Services at Home (SASH) program in Vermont relies on an onsite service coordinator and part-time wellness nurse team per 100 residents to coordinate and integrate services and supports in 130 low-income senior housing properties across the state. The program offers seniors comprehensive health and wellness assessments, creation of individualized care plans, on-site one-on-one nurse coaching, care coordination with primary care medical homes and hospitals, and health and wellness group programming. Initial data demonstrate positive impacts on resident health (which may include falls prevention), health care utilization, and a slowing of the growth in Medicare expenditures relative to two control groups.

Another example is the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) model. CAPABLE is a patient-directed, team-based intervention that includes an occupational therapist, a registered nurse, and a handyman to decrease hospitalization and nursing home usage of community-dwelling older adults with functional limitations who are dually eligible for Medicare and Medicaid. Activity of daily living limitations improved in 79 of the first 100 people who completed the intervention, and the disability level of the average participant was cut in half (factors which contribute to falls prevention). HHS’ Physician-Focused Payment Model Technical Advisory Committee (PTAC) recently recommended that CMMI should more broadly test the CAPABLE model among Medicare beneficiaries.

There are also a number of evidence-based programs addressing the specific health issues of senior populations that could be delivered to the senior residents of publicly assisted housing. These include falls-prevention programs, such as A Matter of Balance; programs to reduce depression symptoms, such as a Program to Encourage Active and Rewarding Lives for Seniors (PEARLS); and programs to help manage multiple chronic conditions, such as the Chronic Disease Self-Management Program. Several of these programs have been shown to reduce costs to the Medicare program and are currently available in the SASH model and other housing-plus services programs.

Eligible applicants would receive advanced payments (e.g., an amount per beneficiary on a monthly basis), which they could use to make important investments in their care-coordination infrastructure—including financially supporting housing-based service coordinators to enhance this function—and to provide the models and programs described above. The demonstration would look at health outcomes and costs over a five-year period and be matched with comparable control groups. Specifically, the demonstration would expect savings from reduced hospitalizations, hospital readmissions, and nursing home stays for beneficiaries. An important aspect of the payment model would be that any realized savings would be shared among participating entities and partners, including Medicare and Medicaid.

Are there evidence-based practices that reduce the rate of additional bone fractures among those older Americans who have fallen and broken or fractured bones? Are there regional differences in the utilization of these services, evaluations, or screenings? Are there models (such as the Million Hearts Campaign) for other health conditions that have applicability to reducing the overall rate and impact of falls among the elderly?

The CDC Compendium of Effective Interventions includes 41 evidence-based strategies for fall prevention. CDC’s STEADI initiative, previously mentioned, encourages healthcare providers to adopt
such strategies. In addition, the prevention of additional bone fractures could be improved by addressing comorbid conditions that increase fracture risk. For example, vitamin D supplementation may be warranted for older adults with osteoporosis or history of fragility fractures.

Information on the utilization of these evidence-based practices is not well tracked.

How can the transitional period from a hospital or skilled nursing facility to the home be improved in assessing the home for fall risks?

Medicare pays for more than 14 million hospital stays annually. Each hospital discharge offers an opportunity for health care personnel to inquire about aspects of housing that may impact a senior individual’s recovery at home. CMS has proposed a rule revising requirements for discharge planning for hospitals. The rule suggests that hospitals consider the availability of and access to non-health care services for patients, which may include help with home and physical environment modifications, assistive technologies, transportation services, meal services, household services, and housing for homeless patients. Regardless of rulemaking, hospitals should begin to more explicitly incorporate questions into their discharge process regarding both housing stability and falls risks.

With respect to the latter, hospitals should underscore several home safety recommendations from the National Patient Safety Foundation as patients are discharged. These include:

• Plan to enter your home without climbing steps. If you need to climb steps to enter your home, determine if a neighbor, friend, or family member will be routinely available to provide assistance to you.
• Plan to make your bedroom on a floor with a bathroom if possible.
• Use night-lights in strategic areas to prevent falls at night.
• Place the telephone and emergency telephone numbers near you.
• Keep hallways, stairways, and pathways clear of clutter.
• Wear snugly fitting, nonslip, low-heeled shoes or slippers.

These issues are all the more important given that Medicare reimbursements to hospitals are now impacted by 30-day readmission rates. Specifically, since 2013, the federal Hospital Readmissions Reduction Program imposes payment reductions on hospitals considered to have excessive readmission rates for Medicare patients. The program was created in response to the fact that nearly one in five Medicare patients discharged from hospitals were being readmitted within 30 days, at a cost of more than $17 billion annually. Many hospitals are now working in partnership with community-based organizations to facilitate care transitions from hospital to home. Although some hospitals are also beginning to conduct outreach to public and private housing associations and Villages, most hospitals are still at the earliest stages of determining how to work with housing stakeholders to reduce readmissions; much more effort needs to be undertaken in this area.

Finally, the nearly 3,000 nonprofit hospitals across the country could take a larger role in assessing the housing of seniors as part of their community benefit obligations. Specifically, community health needs assessments, mandated by the Affordable Care Act, are a requirement hospitals must meet to maintain their tax-exempt status with the IRS. Each assessment also requires a community implementation plan.

In this way, hospitals that uncover a lack of senior housing options in a community could consider working with partners such as city housing and planning commissions to address this issue as part of their community implementation plans. The IRS clarified that housing-improvement expenditures that meet a documented community need can be considered as a community benefit activity.

What more could be done by government agencies to support fall risk assessments and the implementation of protocols that could be used to prevent falls in the home care population?

BPC’s Senior Health and Housing Task Force previously recommended that Congress and the administration should work together to extend the Money Follows the Person program to support state efforts to rebalance their Medicaid long-term care systems. Some states are using the program to provide reimbursement for accessibility modifications and assistive technology that can prevent falls.

What can be done to create a care pathway for patients post-fracture to ensure proper follow up care and prevention of future fractures? Are there best practice models that can provide implementation opportunities? Are there any federal policy barriers to implementing best practices in post-fracture care?

To prevent falls and fall related injuries, CDC recommends healthcare providers screen their older patients for fall risk each year, assess modifiable fall risk factors, and intervene to reduce risk using effective clinical and community strategies.

As your fact-finding effort continues, we further hope to be a resource to you and the committee. As we detailed in a previous letter, cosigned by a handful of stakeholder organizations and aging experts, we also continue to see the value of a committee hearing on this topic. A hearing coordinated with your effort to solicit policy recommendations could help build a sense of urgency around this issue and ensure that falls prevention is a top public health priority.

Thank you for your important work and please let us know how we can be helpful.

Sincerely,

Michele Stockwell

Executive Director, BPC Action