Introduction

Background

Known fall-related factors in noninstitutionalized selfidentifying Hispanic elderly include modifiable and nonmodifiable risks such as age, gender, level of education, socioeconomic status, and chronic disease. Studies indicate that nationally and in Texas CDHEs are at increased risk for falls, and a knowledge deficit in nurses caring for elderly patients limits the potential fall prevention intervention opportunities that may help to decrease fall rates among this patient population. Despite the impact of elderly falls on society, there is no single interventional instrument for nurses to use to identify older adults at increased risk for falls in home health care [7] US Preventive Services Task Force [USPSTF], [8]. Nurses are healthcare professionals that have a valid and active nursing license to practice in Texas.

Evidence-based resources have been identified as lacking use/access in the field for nurses, which include: 1) prediction systems, 2) feedback techniques, and 3) available interfaces for nurses to identify key fall risk factors [9]. Stop Elderly Accidents, Death, and Injury (STEADI) is an evidence-based practice (EBP) toolkit identified to prevent falls in those above the age of 65 and is recommended for nurse use to prevent falls in the CDHE population [7,8,10]. The Centers for Medicare and Medicaid (CMS) (2020a) annually tracks and publishes national statistics on home health agency (HHA) fall rates in a Home Health Compare report. Home health is a professional healthcare service received in the home setting [11].

The CMS Home Health Compare is a HHA quality of patient care rating. It calculates and compares HHA’s yearly performance to itself and other HHAs. According to the project’s HHA’s CMS Home Health Compare results, the HHA presented an increased fall rate, needing to reach its fall prevention goals. Elderly falls are concerning, and measures for nurses to address falls in the home setting are required [12]. Addressing falls in this population is essential because its incidence is rising, debilitating, costly, and potentially fatal. If this trend continues, CDHEs will likely experience a higher fall rate that could affect their health and independence and result in a substantial financial burden, negatively impacting patients and families and stressing their community resources. This project was a quality initiative in a South Texas HHA that aimed to reduce CDHE fall incidence by improving nursing staff’s knowledge through education on fall prevention assessment skills and interventions using the STEADI toolkit over three months. This project implemented an evidencebased fall prevention program (STEADI) and its interventions within an HHA to improve patient outcomes and decrease the fall rate for patients aged 65 and older. The persons impacted by this study were the home care agency, its nurses, and its CDHE population.

Review of the Literature

The purpose of the literature review was to examine nursing EBP regarding falls. Studies indicate that those above age 65 are at increased risk for falls, and improving nurses’ knowledge about screening for fall risk may decrease patient fall rates [13,14]. A gap exists between nurses’ fall knowledge and the interventions required to screen, identify, and prevent falls. Hakvoort et al. [13], conducted a mixed method study that used the Behavioral Change Wheel framework on hospital nurses (n = 26) to target their behaviors related to fall prevention. The study discovered an exceptionally high need for nurses to continue education about elderly falls. The study identified that educating nurses about falls often receives scant regard and discovered an exceptionally high need for continual nurse fall education because there is a strong correlation between nurses’ education and their fall reduction practice.

The CDHE have an increase in fall risk, and a deficit in nurses’ fall knowledge limits the opportunity to decrease their fall rates. Cho & Jang [14] conducted a cross-sectional study, surveying hospital nurses (n= 162). The participants were nurses who worked at small- and medium-sized hospitals with fewer than 300 beds. The nurses were classified by educational level preparation as community college (n=81), university (n=77), and master prepared or higher (n=4) rather than by license. The study found a positive relationship between nurse fall attitudes and prevention activities (r = .25, p = .001). The study determined that the nurses’ knowledge about falls in smaller hospitals, with less than 300 beds, was lower than that of nurses in larger hospitals resulting in fewer fall prevention practices by nurses in smaller hospitals. Cho & Jang [14] explain that smaller hospitals have limited nurse educational programs and speculate that the cause of the nurse fall-related knowledge deficit in smaller hospitals results from fewer educational opportunities. Studies indicated that a decrease in nurses’ fall knowledge and education correlates with increased fall incidence.

Falls threaten Hispanic older adults’ quality of life and often cause a decline in self-care ability [15]. Hanlin et al. [16] conducted a quantitative study’s cross-sectional survey of 103 participants and determined fall prevention barriers and strengths in Latinos. A finding of the study was that the fall risk factors for the Hispanic elderly are five times or higher than the other groups [16]. Fall risk factors, especially in the community dwelling elderly, include co-morbidities, balance and gait, repeated falls, rehospitalizations, and dependence on caregiver assistance. A quantitative cohort study with 22,722 participants, found that 86% of hospitalized subjects had falls associated with a lack of caregiver availability and limited functional status [10]. Chase et al. (2020) examined hospital records and determined Hispanics in the home setting have more critical mean assistance with activities of daily living (3.53, SD 1.43) (p<.001). Elements of the home environment such as fear of falling and unmet healthcare needs in the home cause fall risk factors which are associated with greater healthcare utilization and elderly fall-related emergency room visits. Emergency rooms are frequented by the elderly as they receive two million fallrelated emergency rooms treatments annually [7].

A quantitative correlational study utilized patient evaluations and interviews to examine functional independence in communitydwelling older adults who receive home health services [17]. The study determined that functional limitations cause fear of falling and contribute to falling in the elderly (p = .001) [17]. Currie (2008) indicated that functional limitations cause repeated falls and repeated falls cause increased hospitalizations and chances of rehospitalizations by 15% [18]. Studies concluded that one- third of elderly who fall require home safety measures and assistance with activities of daily living (ADL) to minimize incidence [12,10,19]. Minimizing incidence is essential as ten percent of the elderly who fall suffer from severe injury or fatal outcomes [15]. However, minimizing incidence requires the use of elderly fall prevention methods as home safety measures and ADL assistance thereby increasing direct and indirect medical costs. Florence et al. [20], conducted a quantitative quasi experimental regression analysis using a tracking methodology to evaluate fall-associated medical expenditures and found that older adult falls costs billions (95% CI). A substantial amount of federal funds, fifty billion, are spent annually on fall-related direct medical costs with 75% of cost covered by Medicare and Medicaid creating a financial burden on society [1].

Cost may be substantial, but the elderly require home assessments, and the community-based programs that serve the elderly must offer fall prevention solutions for them in their setting. A literature review conducted to understand fall determinants and public health solutions concluded that efforts are needed to engage professionals and organizations such as HHA’s to address falls because older adults are not targeted for fall prevention interventions [21]. In outpatient settings, professionals and organizations such as HHA’s lack completing assessments in identifying fall hazards, putting the elderly at risk [12,10,16,17,22]. Professionals and organizations should reduce fall risk in the home as home safety is just as crucial as hospitalization, and interventions that do not include HHA’s nurses to prevent falls in the elderly are dangerous [23]. Adoption of a fall policy by community-based programs as HHAs meets their regulations and clinical practice guidelines. The current home care regulations and clinical practice guidelines require that HHA’s policies and procedures monitor, track, and analyze falls [24]. Guidelines also recommend that organizations implement EBP fall programs to engage nurses to utilize when identifying elderly risk factors, strategies, and assessment tools to minimize fall risk [25,26] (CDC, 2021). The USPSTF, recommends and evaluates evidence-based practices of preventing disease and prolonging life using an A to D grade category, with A being highly recommended. The USPSTF [26] categorizes falls as a grade B, meaning that fall interventions and clinician assessment in community-dwelling elderly is highly beneficial. In a cohort study, Lohman et al. [27] surveyed adults over the age of 65 (n=7392). The study found that implementing a toolkit such as STEADI that identifies fall risk and coordinates clinical and community-based fall prevention practice is essential. Categorizing elderly, utilizing STEADI, as having moderate and high fall risk are 4 to 13 times more likely to report multiple falls than low risk individuals [27]. Studies indicated that categorizing individuals with fall risk factor levels using the STEADI toolkit allows for proactive actions in preventing incidence and hospitalizations. Literature supported the need to conduct this quality improvement (QI) project. Practice and clinical guidelines support using the STEADI toolkit for nurse use in CDHE fall prevention [10,12,25,26,28,19].

Problem Description in the Setting

The practice location is a for-profit privately owned South Texas home health agency which employs Licensed Vocational (LVN) (n = 4) and Registered Nurses (RN) (n = 4) who service the HHA’s 98% CDHE population. The HHA’s location is in a city that has a 95.4% Hispanic population, and nearly 27% of this population lives below the Federal poverty level [29]. A query of the institution’s CMS Home Health Compare report indicated an increase in falls from 3.23% in 2020 to 7.14% in 2021. The national average is 8.13%. The HHA’s electronic healthcare record (EHR) software system indicated that of all the CDHE served by the agency, seven fell in 2020, averaging 1.75 falls per quarter, and 15 fell in 2021, averaging 3.75 falls per quarter. Even though the agency’s fall rate was below the national average, it did not meet its fall goals in 2021 to decrease quarterly fall occurrence by 25%. A retrospective query of the HHA’s QI measures and EHR discovered that no consistent fall educational or systematic identification and assessment process existed. Failure to address QI measures may result in poor patient outcomes, agency penalties, and sanctions [30].

Project Purpose

The HHA lacked a consistent fall program and a single instrument for nurses to identify older adults accurately and feasibly at increased risk for falls, did not exist. Despite the existence of EBP such as STEADI, nurses in home health care are not using risk assessments, protocols, and education to manage falls [8]. This project aimed to implement STEADI, improve nurses’ knowledge and practice and reduce falls in the CDHE population. The project answered the following question: In nurses aiming to prevent fall incidences in home health care, does implementation of use Stop Elderly Accidents, Death, and Injury (STEADI) protocol, as compared to the existing home health fall prevention program, improve nurse’s knowledge and practice and reduce falls in the Community-Dwelling Hispanic Elderly (CDHE) during a three- month project period? It utilized evidenced-based findings in determining improvement in nurses’ fall knowledge for care delivery approaches related to the fall prevention of the CDHE population. This project used EBP (STEADI) for organizational change in nurse education to foster competencies and develop goals for fall-related outcome-based performance and management. STEADI was used as an organization-wide quality health measure to ensure policy compliance and facilitate staff/ patient education, health promotion, and risk identification.

Project Aims

The primary goal of this DNP project was to improve nurses’ fall knowledge and practice and reduce CDHE falls by the end of the project period. This QI project had three specific improvement outcomes. The first was to improve the HHA nurses’ fall prevention knowledge post-STEADI education by 10% of the baseline score. The second was to improve nurses’ use of EBP (STEADI) fall assessments by 30% by the end of the three-month project period. The third was to decrease the CDHE quarterly fall rate by a 25% by the end of the three-month project period.

Guiding Frameworks

The project’s guiding frameworks were Quadruple Aim Model and the Pender’s Health Promotional Model (HPM). The conceptual framework, the Quadruple Aim Model, is a theory that supports the improvement of patient and provider experience and outcomes, advancement of population health, and cost reduction [31]. The authors Bodenheimer and Sinsky (2014) [31] explain the Quadruple Aim Model optimizes healthcare systems’ performance and aims to improve the work of clinicians and staff. The theoretical framework in defining the project’s phenomena was Pender’s HPM. Nola J. Pender first developed the HPM, a middle- range theory, in 1982 and revised its perspectives and empirical findings in 1996 [32,33] (Nursing- Theory.org, 2016). Pender used the expectancy-value theory and the social cognitive theory in developing the HPM (Pender, 2011) [33]. This conceptual model is a framework for nursing protocols and interventions and was applied to this project as it assesses biological, psychological, and sociocultural factors and prior related behavior. The model guided the fall project in the behavioral outcomes of the nurses because nurses make up a part of the interpersonal environment and influence people throughout their lifespan in reducing falls.

Methods

Project Design

The project design is Quasi-Experimental with a Quality Improvement Initiative. This DNP project used quantitative pre-/ post-tests, EHR chart review, and participant feedback surveys. This project plan was reviewed by the Texas A&M UniversityCorpus Christi Institutional Review Board (IRB) for project/study classification and this DNP project was determined to be exempt under the Exempt Category 1 status.

Intervention

A retrospective facility budget was conducted as well as a gap analysis, risk, and forcefield analysis. The facility’s gap analysis identified a need for a formal and consistent nurse EBP fall educational program. The facility’s risk assessment determined potential barriers that could have affected the success of this project. The project utilized three phases: (1) pre- project activities such as identifying nurses within the HHA that meet inclusion criteria (2) initiating the process of educating HHA nurses about fall prevention using the STEADI toolkit online training and evaluating knowledge pre and post training (3) monitoring project adherence, data collection and analysis, and assess the project’s impact on the nurses and CDHE population, as seen in Figure 1. 2023.

Figure 1: STEADI Study Phases and Timeline; Note: Figure depicts project phases and timeline between February 1, 2023, to April 30,

The budget provided the project projected cost. Potential barriers to this improvement project included cost, time, and limited participation, identified in the facility’s force field analysis. Testing schedule and adherence timeline are seen in Figure 1. The project team consisted of the project director. The project director approached every possible participant, provided contact information, and conducted and oversaw project activities. These activities included obtaining consent forms, maintaining confidentiality and security, documenting, analyzing, and reporting the project’s fall-related data. Details of the project relayed to participants by the project director included voluntary participation and withdrawal, reimbursement, and participation expectations. Lastly, the project director was available throughout the project.

A week before project initiation, the project director initiated the project recruitment. Posters and flyers were displayed and located in the agency lobby and contained the same information. The project director approached potential participants at the HHA’s lobby to determine participation interest. All nurses, RNs and LVNs (n=8), and the HHA’s CDHE were approached and informed about the project and its expectations and asked if they were interested in participating. Nurses and CDHE that agreed, were provided with a voluntary participation consent form for completion before project initiation. The participants received written and verbal instructions, and a randomly drawn personal identifier to use in place of their names. The project documents were retained and accessible only to the project director for the required duration.

To reduce elderly fall rates, experts recommend nurses STEADI train and use its EBP interventions in an effort to decrease fall rates, improve fall prevention awareness, and provide families the tools to keep their loved ones safe [10,12,24,25,26,27,28,19]. STEADI incorporates the American and British Geriatrics Societies’ Clinical Practice Guidelines for fall prevention. STEADI’s three elements are that nurses’ screen patients for fall risk, assess modifiable risk factors, and intervene to reduce risk using effective clinical and community strategies, as seen in Figure 2. STEADI toolkit includes an education component to improve the HHA nurse’s fall knowledge and practice (assessment, instruction, and documentation) and reduce CDHE fall incidence (see Figure 2). The home health nurses completed the pre-test, underwent STEADI training, then completed the post-test on day one. The pre-/post-test result data from day one was collected and analyzed by the project director. The participants learned, implemented, and performed the STEADI algorithm in their daily routines on CDHE documenting assessment, falls, treatments, and referrals in the EHR for the remainder of the project period. The project director collected data throughout the project completing data analysis on the last day of the project period.

Figure 2: STEADI Algorithm; Note: Algorithm form the Centers for Disease Control and Prevention National Center for Injury Prevention and Control. 2019. https://www.cdc.gov/steadi/pdf/steadi-algorithm-508.pdf.

Results

Data Collection

This project used pre/post-tests, participant feedback surveys, and a cumulative fall report. No personal identifying data was included in the study; thus, confidentiality was ensured. The project director collected data, secured confidential documents in sealed envelopes, and stored them in a locked file cabinet in a locked private office within the facility. The project director accessed the facility’s EHR system using password-encrypted limited access. Primary data collection consisted of STEADI: Older Adult Fall Prevention Online Course -Pre/Post-Test, the CDC’s post-STEADI training evaluation, and the HHA’s average of three months (November 1, 2022- January 31, 2023) fall rate. Secondary Data Collection consisted of pre-STEADI training Home Health Survey, the preceding year’s (2022) documented fall assessments, therapies, current documented STEADI assessments, fall incidence data, related treatments, and referrals.

Measurement Tools

This project’s measurement tools comprised surveys, tests, a training evaluation, EHR fall rates, and fall assessment data. Measurement tools included: the pre-STEADI training Home Health Survey retrieved from the Agency for Healthcare Research and Quality (AHRQ) [7, 34], the pre/post-test from the CDC’s STEADI toolkit STEADI: Older Adult Fall Prevention Online Course, and the post-STEADI training Participation Survey from the World Journal of Emergency Surgery [35], Permission was obtained for their use prior to beginning the QI project. STEADI tools and materials are publicly available and its validity is supported through statistical data. Lohman et al. [27] gathered cohort data from five annual rounds (2011-2015) on adults aged 65 and older from the National Health and Aging Trends Study to evaluate the predictive utility of STEADI. They found that STEADI has a 95% CI on estimating fall risk. Johnston et al. [36] conducted a quantitative cohort study, examined the effects of STEADI and found that older adults with a fall prevention plan of care are 0.6 times less likely to have fall-related hospitalization than those without one (p=.041). These evidenced-based tools provide a roadmap to implement fall prevention interventions and employee training. Greater patient safety awareness through pre-post testing, decrease fall incidences, results will determine the efficacy of both tools used and project outcome achievement [37].