Fall Risk, Supports and Services, and Falls Following a Nursing Home Discharge

Marwa Noureldin, PharmD, MS, PhD; Zachary Hass, MS, PhD; Kathleen Abrahamson, PhD, RN; Greg Arling, PhD


Gerontologist. 2018;58(6):1075-1084. 

In This Article


It is estimated that a quarter to a third of adults aged 65 years and older fall annually (American Geriatrics Society/British Geriatrics Society, 2011; Centers for Disease Control and Prevention [CDC], 2017; Marrero, Fortinsky, Kuchel, & Robison, 2017). Falls are the leading cause of injury-related mortality and a well-studied source of significant morbidity and diminished quality of life among older adults (American Geriatrics Society/British Geriatric Society, 2011; CDC, 2017; Lim, Hoffmann, & Brasel, 2007). Falls are also a major contributor of trauma-related hospitalizations for older adults, ranging from fractures to brain injury (Moncada, 2011), with costs of fall-related treatments totaling more than $31 billion annually (CDC, 2017). Risk factors associated with falls have been extensively studied and falls have been described as multifactorial events resulting from both patient-specific (intrinsic) as well as environmental (extrinsic) factors (Bueno-Cavanillas, Padilla-Ruiz, Jimenez-Moleon, Peinado-Alonso, & Galvez-Vargas, 2000; Ganz, Bao, Shekelle, & Rubenstein, 2007; Marrero et al., 2017; Moncada, 2011). In addition to being a major cause for hospitalization, falling among older adults is also a predictor for both nursing home (NH) admission and readmissions (American Geriatrics Society/British Geriatric Society, 2011; Howell, Silberberg, Quinn, & Lucas, 2007; Lim et al., 2007). Although incidence of falls among older adults and risk factors leading to these events have been examined in multiple settings (Bueno-Cavanillas et al., 2000; Ganz et al., 2007; Lim et al., 2007; Phelan, Mahoney, Voit, & Stevens, 2015), few studies have explored falls as an outcome during an older adult's transition from a NH to the community (Howell et al., 2007; Marrero et al., 2017).

NH Transitions

Transition from a NH to the community presents unique challenges. NHs provide care to a range of individuals based on their needs; short-stay residents (less than 100 days) are typically admitted following an acute-care hospitalization, whereas long-stay residents receive care for prolonged disease or disability. A recent analysis indicated that a large proportion (40%) of previously community dwelling individuals discharged to a NH following acute hospitalization did not return to the community, or they returned but were eventually readmitted to a NH (Hakkarainen, Arbabi, Willis, Davidson, & Flum, 2016). Studies examining transition-related outcomes have focused on NH readmission or hospitalizations (Howell et al., 2007; Robison, Porter, Shugrue, Kleppinger, & Lambert, 2015; Wysocki et al., 2014). Wysocki and colleagues (2014) reported that dually eligible older adults who transitioned from the NH into the community had an increased risk of hospitalizations compared to NH residents. On the other hand, Bogaisky and Dezieck (2015) reported that NH residents had 41% higher risk of 30-day rehospitalization compared to adults discharged to the community.

State-implemented Transition Programs and Falls

Over the last several decades, federal and state policymakers have advanced initiatives to assist individuals with long-term care needs to transition from long-term care settings to the community and to remain in the community after a transition (Bardo, Applebaum, Kunkel, & Carpio, 2014; Fries & James, 2012; Reinhard, 2010). These initiatives have mainly focused on Medicaid paying or dual Medicare/Medicaid paying residents through the Money Follows the Person (MFP) programs. Some studies have explored readmission outcomes associated with NH to community transition within the context of these state-implemented transition programs (Howell et al., 2007; Marrero et al., 2017; Robison et al., 2015). Howell and colleagues (2007) examined New Jersey's nursing home transition program participants and found that falls within 8 to 10 weeks of a NH to community transition were a significant predictor of long-stay NH readmissions. Another study evaluating the Connecticut Money Follows the Person (MFP) program examined fall incidence at two time points post NH discharge (6 and 12 months) and reported that 25% of participants fell in the first 6 months following a NH transition and 25% fell between 6 and 12 months (Marrero et al., 2017). Predictors of falling at 12 months included previous falls, depressive symptoms, unmet medical care needs, and older adult physical/verbal mistreatment.

Services and Supports

A major component of state-implemented transition programs is the provision of home and community-based services (HCBS), including both health-related and personal care services to ease transitions and assist individuals in maintaining independence in the community (Centers for Medicare and Medicaid Services [CMS], 2016; Reinhard, 2010). Although some studies have examined transition outcomes in the context of these state-implemented transition programs, these studies have not examined specifically the impact of home and community service accessibility on transition-related outcomes, including falls. In addition, these transition studies have not fully explored the impact of caregiver availability and support on fall occurrence among older adults. Hoffman and colleagues (2017) reported that receiving high levels of informal caregiving (≥14 hours a week) was associated with reduced fall risk among community dwelling older adults. Older adults who had physical limitations and cognitive impairments and who were receiving high levels of informal care experienced the greatest reduction in the risk of falling (Hoffman et al., 2017).

The purpose of our study was to examine whether the presence of supports and services impacts the relationship between factors typically associated with falls and the occurrence of falls within 30-days post-discharge from the NH. This time-frame is a critical period when older adults are re-adjusting to their community setting and can be at an increased risk for falls (Davenport et al., 2009). This study examines the relationship within the context of state-implemented transition program aimed at assisting private-pay NH residents. As previously mentioned, studies examining NH to community transitions have mainly focused on the Money Follows the Person initiatives that are targeted toward Medicaid populations and there is a lack of knowledge about programs tailored to other populations (Bardo et al., 2014; Howell et al., 2007; Marrero et al., 2017).

Study Context

The Minnesota Return to Community Initiative (RTCI) is a state-implemented transition program that assists private-pay NH residents to transition into the community. It provides a context for us to explore fall occurrence during a transition and to investigate the role of HCBS and various supports in fall prevention. Administered by the Minnesota Department of Human Services, RTCI targets transition-related assistance to NH residents who have a preference for discharge, fit a discharge "target" profile (Arling, Kane, Cooke, & Lewis, 2010), and have been in the NH for at least 60 days (Minnesota Board on Aging, 2017). RTCI has a staff of Community Living Specialists (CLS) that assists in care planning and offers information about community services and other resources to older adults and their families both during the NH stay and after discharge. However, they do not provide specific interventions or services related to falls.

Conceptual Framework

Previous literature on fall-related risk factors and fall prevention helped guide this study's conceptual framework. As formerly mentioned, falls can result from both patient-specific factors as well as environmental factors. Patient-specific factors include age, gender, having a history of falls, having certain musculoskeletal or neurologic conditions, depression, being cognitively impaired, and experiencing problems with balance (Bueno-Cavanillas et al., 2000; Moncada, 2011). Environmental factors include presence of home safety issues, use of certain high-risk medications or multiple medications, and having impaired abilities to perform activities of daily living (Bueno-Cavanillas et al., 2000; Ganz et al., 2007; Moncada, 2011). Interventions recommended in fall prevention guidelines are focused on screening for older adults at high risk for falls and modifying some of their risk factors (American Geriatrics Society/British Geriatric Society, 2011; Moncada, 2011; Phelan et al., 2015). Current guidelines recommend multifaceted interventions for fall prevention, including providing patient education, assessing and modifying medication regimens, ensuring a safe home environment, and enrolling older adults in physical therapy and exercise programs among other strategies (American Geriatrics Society/British Geriatric Society, 2011). However, there has been less focus on how other types of strategies, such as caregiver assistance, use of durable medical equipment, or use of HCBS-based services, can modify fall risk, especially following a transition from the NH to the community setting.

In our conceptual framework, we hypothesize that fall-related risk factors, including previous history of falls in the NH, concerns related to balance, falling, or the home environment, activities of daily living (ADL) deficits, and use of potentially inappropriate medications will contribute to falls among NH residents transitioning into the community. We also hypothesize that HCBS as well as various informal supportive strategies will have a moderating effect and ameliorate the impact of fall-related risk factors on fall occurrence. Modeling the effects of supports and services on falls is complex. We expect individuals with greater fall risk, e.g., ADL impairment, history of falls, or high-risk medication use will receive more supports and services. Consequently, a simple bivariate model might result in the counterintuitive finding that greater supports and services contribute to falls. We employed a structural equation model (SEM) to test our conceptual framework because this approach can be more effective at addressing direct, indirect, and moderating effects of both fall-related risk factors and supports and services. A figure of the conceptual framework is included in the Supplementary Figure 1.

Supplementary Figure 1.

Conceptual Framework