MMHA 6540 Week 6 Falls Intervention Blueprint Example

From Identification to a Safer Home in Thirty Days: A Falls Intervention Blueprint for Prairie Gate

Student Name

Walden University

MMHA 6540: Population Health Management Applications

Instructor Name

Month Day, Year

From Identification to a Safer Home in Thirty Days: A Falls Intervention Blueprint for Prairie Gate

The Segment

The intervention serves Prairie Gate Health Plan members aged 65 and older who, in the past twelve months, had a fall-related emergency visit or hospital admission in plan claims, or two or more lift-assist calls in county emergency medical services records. Members living long term in nursing homes are excluded, since their facilities manage fall prevention. About 1,100 members meet the definition, about 850 identified through claims and 250 more through lift-assist calls alone. The segment is refreshed monthly as new claims and EMS files arrive. The definition is deliberately narrow: it targets members who have already fallen, since a previous fall is among the strongest predictors of the next one.

Delivery Steps

Table 1 sets out the four steps, in place of the delivery diagram used in planning, with the owner, time standard and record for each.

Table 1

Delivery Steps

Why These Four Steps

The steps combine components with evidence of reducing falls in older adults living at home. Group and home-based exercise that challenges balance reduces the rate of falls (Sherrington et al., 2019). Home safety assessment and modification, particularly when delivered by occupational therapists, reduces falls among people at higher risk (Gillespie et al., 2012). Medication review targets drugs that increase fall risk, following the clinical approach in the CDC's STEADI resources (Stevens & Phelan, 2013). Combining an occupational therapist, a handyman and a nurse in older adults' homes has also reduced disability in a randomized trial (Szanton et al., 2019). No single component addresses all causes of falls, which is why the blueprint uses several.

Expected Flow

Of about 1,100 identified members each year, the plan expects roughly 55% to enroll after outreach, about 600 participants. Nearly all participants would receive a home safety visit. About 80% would need at least one modification, roughly 480 homes. About half would attend balance classes regularly, given transportation limits in the rural counties, and all would have a medication review request sent. The rates are placeholders; the pilot's actual acceptance and completion rates will replace them.

Handling Barriers

Four barriers are predictable. Members who decline at outreach often worry about cost or strangers in the home; coordinators will explain that the program is free and that therapists and repair staff are vetted and carry identification. Members in Ash and Corley may not reach class sites; the program will offer the area agency's home-based exercise booklet with a follow-up call, a weaker substitute but better than nothing. Renters may need landlord permission for modifications; the repair nonprofit will contact landlords with a standard letter. And the repair bottleneck identified in the readiness map means some members will wait; coordinators will put the most fragile members, such as those whose last fall broke a bone or who keep calling paramedics for help getting up, at the head of the repair queue until a second crew is funded.

What the Blueprint Leaves Out

The blueprint does not include vision testing, footwear assessment or home-delivered meals, though each can contribute to falls. Vision and footwear can be addressed by the occupational therapist's referrals within existing benefits. It also does not include members who have not yet fallen; a primary prevention program for all older members would be larger and less targeted. Those additions can be considered after the first year, once the plan knows whether this narrower program works.

Roles of the Care Coordinator

Two plan care coordinators hold the program together. They make the outreach call, enroll the member, schedule the home safety visit and track every later step until the member's case is complete. They also answer members' questions, which in practice means explaining the same program several times to adult children who manage a parent's affairs. When a step stalls, for example when the repair nonprofit has not scheduled an installation after two weeks, the coordinator follows up and, if needed, escalates to the program manager. Coordinators keep a running list of each member's status so that no one is lost between partners, and they close each case with a call about three months after the last step to ask whether the member has fallen again and whether the changes are still in use. That call also captures falls that never reach a claim or an EMS file, which gives the plan a fuller picture of the program's effect.

Each coordinator will carry about 300 participants a year, or roughly 75 active at a time, which is manageable for a program whose steps are mostly carried out by partners. If enrollment exceeds the expected 600, or if a large share of members need help arranging transportation, a third coordinator will be needed, and the budget for that position should be ready before it is.

Monitoring the Steps

Each time standard becomes a process measure: the share of identified members reached within seven days, the share receiving a home visit within fourteen days of enrollment, the share of modifications completed within thirty days and the share attending at least half of class sessions. The care coordinators will review these weekly, and the population health director monthly. Slippage in any step will show where to act, whether that means more coordinator time, another repair crew or transportation help for rural classes.

References

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2012(9), Article CD007146. https://doi.org/10.1002/14651858.CD007146.pub3

Sherrington, C., Fairhall, N. J., Wallbank, G. K., Tiedemann, A., Michaleff, Z. A., Howard, K., Clemson, L., Hopewell, S., & Lamb, S. E. (2019). Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2019(1), Article CD012424. https://doi.org/10.1002/14651858.CD012424.pub2

Stevens, J. A., & Phelan, E. A. (2013). Development of STEADI: A fall prevention resource for health care providers. Health Promotion Practice, 14(5), 706-714. https://doi.org/10.1177/1524839912463576

Szanton, S. L., Xue, Q.-L., Leff, B., Guralnik, J., Wolff, J. L., Tanner, E. K., Boyd, C., Thorpe, R. J., Jr., Bishai, D., & Gitlin, L. N. (2019). Effect of a biobehavioral environmental approach on disability among low-income older adults: A randomized clinical trial. JAMA Internal Medicine, 179(2), 204-211. https://doi.org/10.1001/jamainternmed.2018.6026