This is one of few studies examining fall outcomes within 30 days of older adults transitioning from the NH to the community within the context of a state-implemented transition program. Previous studies have typically examined fall incidence during NH stays or during/after hospitalizations. Among this study's participants, 15% fell within 30 days of NH discharge, which is lower than reported fall rates for both NH and community dwelling older adults (American Geriatrics Society/British Geriatric Society, 2011; CMS, 2015). Marrero and colleagues (2017)reported that among older adults transitioning from the NH to the community, 25% experienced a fall within the first 6 months of discharge. This study's participants were specifically targeted for assistance through the RTCI based on health and functional characteristics (Arling et al., 2010), which may partially explain the lower fall rate. However, RTCI offered information about community resources and was not an intervention specifically aimed at fall prevention.
Factor analysis and structural equation modeling provided a unique and innovative approach to examining risk factors related to falling post NH discharge. Fall-related risk has been typically examined as a unidimensional construct with a fall score derived through conventional regression analysis, and fall screening and prevention guidelines typically list risk factors for assessment without discriminating among types of risk (American Geriatrics Society/British Geriatric Society, 2011; Moncada, 2011; Phelan et al., 2015). Our study moves the discussion forward by examining how various fall risk factors are related to each other as well as to the receipt of supports and services. We found three clinically meaningful fall-related risk constructs represented by the latent variables: fall concerns and fall history; ADL impairments; and use of high-risk medications. The fall concerns/fall history latent variable is comprised of older adults' concerns with balance, fear of falling, and concern with home safety along with previous NH fall history. The ADL impairments latent variable indicates that three ADL impairments are related, some difficulty with toileting, with walking, and with bed mobility. Likewise, the high-risk medication latent variable highlights three medication classes related to falling with psychotropic medications having a higher loading than the other two. The three latent variables were significantly correlated and had good model fit. Results of the SEM model indicated that fall concerns/fall history and use of high-risk medications had a significant positive direct effect on falls, whereas ADL impairments were not significantly related. These findings provide a unique view when examining fall risk from a clinical perspective and further strengthen empirical evidence for fall predictors in this older adult population undergoing a care transition. For example, older adults' concerns about issues related to falling, such as fear of falling or concerns with balance, can be vital considerations when assessing fall risk. Results also highlight the importance of high-risk medications, as a main contributor to falls in the community after NH discharge. This finding emphasizes the need for continued reviews of medications lists by health care professionals and adjustment of medication regimens to minimize use of unnecessary and potentially inappropriate medications in older adults.
Another key contribution of our findings is the role of supports and services in ameliorating the effects of fall-related risk factors. The latent variable for supports and services included several items that had not been extensively examined in the fall risk literature. Frequency of caregiver support, assistance with medication management, use of durable medical equipment, post-discharge living arrangement, and receipt of home health or skilled nursing services were all correlated within the latent variable. Durable medical equipment use has been previously considered as a risk factor for fall (Moncada, 2011) rather than a potential support, and variables such as assistance with managing medications had not been examined. This finding brings forward a new perspective on the interrelationship between different types of supports and services and provides insight into the potential benefit of both family and other informal supports in combination with HCBS in transitioning from the NH.
We found that receipt of supports and services had no significant direct effect on fall occurrence. This result highlights the complexity of relationships between the fall-related risk factors and support and services. In our study, older adults who had some ADL impairments were more likely to receive supports and services. Although this may have led to a lack of significant relationship between ADL impairments and falls, this finding is encouraging since it indicates those who need assistance seem to be receiving it among RTCI participants. More importantly, individuals who used high-risk medications and also received support tended to benefit from that support with a reduced likelihood of falling. It is not clear if one component of the supports and services latent variable is influencing this relationship or if it is a combination of the assistance provided, including assistance with medication management. Additional research is needed to further examine these supportive strategies and evaluate how they might vary across the older adult population and their potential impact on health outcomes.
There are several limitations to this study that should be noted. First, the study sample was primarily short-stay private-pay NH residents who had met specific targeting criteria for discharge. As such, these results may not be generalizable to Medicaid residents or private paying older adults transitioning into the community but who do not fit the RTCI targeting profile. Based on RTCI's design, some information was only collected prior to discharge, such as type and number of high-risk medications taken. Since medication lists tend to be dynamic in nature, participants' medication lists may have changed within the first 30 days. Additionally, not all fall-related risk factors were examined due to the nature and type of data collected. For example, gait and balance were not objectively assessed, and participants were only asked if they had concerns with balance or vertigo.
Methodologically, this study has unique strengths including the use of advance modeling (latent variables and structural equation modeling) that go beyond regression or hazards modeling commonly seen when studying fall risk. Given the complexity and multifactorial nature of fall occurrence and the dynamic relationships between various factors, higher levels of modeling provide a broader picture of the factors associated with falls, both positively and negatively. Moreover, other studies have focused on NH to community transition among Medicaid populations, and there is limited information on other populations, such as the private-pay population, which comprises approximately a third of NH users (CDC, 2016).
Within the context of a state-implemented transition program and using structural equation modeling, results indicate that fall risk factors can be viewed as latent constructs relating to older adults' fall concerns and fall history, ADL deficits, and use of high-risk medications. Supports and services are essential when assessing fall risk. Although they were not related directly to the occurrence of falls, they moderated the relationship between using high-risk medications and falls. Individuals with greater fall risk due to high-risk medications were less likely to fall if they had supports and services. This result points to the importance of both informal supports and receipt of HCBS in influencing older adult NH to community transition outcomes.
Results emphasize the importance of conducting fall assessment and medication reviews in older adults who are transitioning from an institutionalized to a community setting similar to current guidelines for fall prevention in the community (American Geriatrics Society/British Geriatric Society, 2011; Casey et al., 2016). Furthermore, it is also essential for health care providers to recognize the role older adults' concerns and attitudes, such as concerns with balance or with falling, can play in fall risk and address these concerns in a patient-centered manner. From a policy perspective, findings can help inform other state-implemented transition programs aimed at achieving successful NH to community transitions.
Gerontologist. 2018;58(6):1075-1084. © 2018 Oxford University Press