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HPPXXX10.1177/1 524839913514752Health Promotion PracticeSchrodt et al. / TRAINED COMMUNITY PROVIDERS CONDUCT SCREENINGS 2013
Trained Community Providers Conduct Fall Risk Screenings With Fidelity: An Effective Model for Expanding Reach Lori A. Schrodt, PT, MS, PhD1 Kathie C. Garbe, MCHES, PhD2 Tiffany E. Shubert, MPT, PhD3
Reliable and valid tools are available for health care providers to screen older adults for fall risk. Proficient administration of these tools by lay or community providers (individuals without formal medical training) may be a viable channel to expand the reach of fall risk screenings. However, the ability of community providers to administer screens is not known. This project examines community providers’ ability to proficiently administer a fall risk screening following a standardized training. Forty community providers were trained and then performed community screenings. Knowledge and confidence were assessed with pre- and postsurveys. A standardized skills checklist assessed proficiency in fall risk screening administration immediate posttraining and at onsite community screenings. Knowledge and confidence surveys demonstrated improvements pre- and posttraining (p < .001). In all, 66% of participants demonstrated screening skill proficiency at their first onsite screening. With further coaching, 91% participants demonstrated proficiency by their third onsite screening. Participants achieving early proficiency were on average younger. Community providers can reliably administer a fall risk screening algorithm with training and coaching. This is a low-cost model and can extend the reach and dissemination of fall risk screenings, potentially providing early identification and interventions to those at risk of falling. Keywords: aging; community-based participatory research; unintentional injury; rural health; college–community partnerships
Health Promotion Practice July 2014 Vol. 15, No. 4 599–607 DOI: 10.1177/1524839913514752 © 2013 Society for Public Health Education
Introduction >> Falls among older adults are a major public health concern. One third of community-dwelling older adults older than 65 years and half of those older than 80 fall 1
Western Carolina University, Cullowhee, NC, USA University of North Carolina at Asheville, NC, USA 3 University of North Carolina at Chapel Hill, NC, USA 2
Authors’ Note: We thank Rebecca Chaplin, MA (Land-of-Sky Regional Council); Carol Cook, MS (Appalachian State University); and Ellen Garrison, MEd (UNC Asheville), for their assistance with training and data collection and Sue L. McPherson, PhD (Western Carolina University), for her design and analysis assistance. We also thank the community agencies and providers who supported this work by hosting training workshops and/or screening events. This project was supported in part by the Mission Hospital Foundation and the North Carolina Center for Healthy Aging. The University of North Carolina (UNC) Center for Aging and Health, Carolina Geriatric Education Center also provided support for this activity. The Be Active–Appalachian Partnership donated supplies used during the project. We acknowledge the significant efforts of the Western North Carolina Fall Prevention Coalition and in particular the Screening and Risk Assessment subgroup for their contributions to this project. This project was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under Grant No. UB4HP19053, Carolina Geriatric Education Center. All contributors received funding from BHPr to complete this project. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS, or the U.S. Government. Address correspondence to Lori A. Schrodt, Associate Professor, Department of Physical Therapy, Western Carolina University, 246 Health & Human Sciences, 4121 Little Savannah Road, Cullowhee, NC 28723, USA; e-mail: [email protected].
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annually (Stevens, 2012). A fall is a sentinel event for an older adult, often resulting in depression, morbidity, and mortality (Hornbrook et al., 1994). Reliable and valid screening tools are available to identify older adults at increased fall risk. These tools, designed for health care professionals for use in a clinical setting, provide opportunities for early detection and intervention (Goodwin & Briggs, 2012; Stevens & Phelan, 2013; “Summary of the Updated American Geriatrics Society,” 2011). The American Geriatrics Society published a fall risk screening algorithm in 2001 (“Guideline for the Prevention of Falls in Older Persons,” 2001) and a revision in 2011 (“Summary of the Updated American Geriatrics Society,” 2011). However, use of these guidelines by health care professionals has been limited (Chou, Tinetti, King, Irwin, & Fortinsky, 2006; Shumway-Cook et al., 2009). Exploration of other models, such as the use of community and lay providers to offer screening services in nonclinical settings, may offer an expanded reach for screenings. Community providers often work in senior centers, meal sites, and other locations where older adults congregate. Although they typically do not have formal health care backgrounds, they often are trained to provide health screenings for diabetes, hypertension, and other chronic conditions. Researchers have demonstrated that trained community providers can effectively educate older adults about fall risk (Deery, Day, & Fildes, 2000), facilitate fall risk management behavior change (Scott, Votova, & Gallagher, 2006), and improve older adults’ self-efficacy in fall risk management (Healy et al., 2008). Community providers are strategically positioned to expand the reach of fall risk screening; however, it is not known if they can master skills required to administer a fall risk screen with fidelity. Our purpose was to determine if community providers who attend a standardized training curriculum could demonstrate the following: (a) improved fall risk knowledge, (b) improved confidence in screening administration, (c) proficiency in administration of a standardized fall risk screen, and (d) skill mastery for conducting community-based fall risk screenings with fidelity. The secondary purpose was to identify characteristics of community providers who could administer screens with minimal onsite coaching.
Method >>
Design and Context This study used a single-group design using a convenience sample of volunteer community providers. The training framework, content, and infrastructure for 600
the project were developed and piloted in 2010 in western North Carolina (Schrodt, Garbe, Chaplin, Busby-Whitehead, & Shubert, 2013). The project was conducted in conjunction with National Falls Prevention Awareness Week programming and activities. The Western North Carolina Fall Prevention Coalition (Coalition) worked with four partner organizations, Land-of-Sky Area Agency on Aging, Western Carolina University, University of North Carolina at Asheville, and the North Carolina Center for Healthy Aging (housed in the Mountain Area Health Education Center) to organize 16 screening events at 13 sites in seven counties from September through November 2011. Settings included senior centers, congregate meals sites, health fairs, retirement communities, and wellness/fitness centers. Participants Community providers who worked with older adults in any capacity were invited to attend the training workshops through advertisement on the Coalition’s website, e-mail correspondence to past screening event participants and aging services coordinators, and word of mouth. At the beginning of each workshop, researchers explained the purpose of the study and asked volunteers to review and sign an informed consent form approved by the Western Carolina University Institutional Review Board. Participation in the study was not mandatory to attend the workshop; however, all community providers who attended the workshops agreed to participate and met all inclusion criteria: (a) ability to speak, hear, and understand English; (b) able to attend at a 3-hour training workshop; (c) commitment to assist with at least one fall risk screening event; (d) physically able to walk with, and potentially steady, older adults (through selfassessment); and (e) completion of the posttraining screening skills check with 100% proficiency (repeated attempts permitted). The total number of participants was 40. Nine participated in the pilot training from the previous year (returning participants) and 31 were new to the training (novice participants). Intervention and Data Collection Training Workshops. Four 3-hour training workshops were offered in three counties during September and October 2011. Average attendance was 10 participants, with a range of 3 to 18. After they signed informed consent, but before training began, participants completed a demographic form, a written knowledge pretest (14 multiple-choice and true/false questions; maximum score = 14 points), and a confidence self-rating for conducting screenings (0 = no confidence, 10 = complete
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confidence). The confidence scale asked participants to rate their confidence in asking two questions and conducting a physical performance test for two paper cases. The average confidence rating across both case studies was used for analysis. Each workshop was conducted by the researchers (2-4 researchers were present for each training). The lead researcher was an academic and clinical physical therapist with expertise in fall prevention and community programs. The remaining researchers were also academic faculty with exercise science and community program expertise. The curriculum was based on theories of adult learning and incorporated experiential learning and problem solving in a cooperative atmosphere (Knowles, 1970; Merriam, 1996). Specific workshop components included the following: (a) presentation of the problem of falls, common risk factors, and effective interventions; (b) instruction in screening procedures, including demonstration and case-based application of the fall risk screening algorithm, and modeling of common screening errors; (c) hands-on practice of the screening skills (participants practiced screening with each other and the researchers) using collaborative learning and feedback; (d) step-by-step instruction and group discussion of community screening event logistics; (e) observation and a skills proficiency check of a simulated case; and (f) completion of the written knowledge posttest and confidence rating. Although time varied somewhat depending on workshop size and need for experiential practice of screening skills; approximately 1 hour was devoted to instructorled content and training in screening procedures, 30 minutes for problem-based demonstration and modeling of screening skills, 1 hour for hands-on practice and skills proficiency checks, and 30 minutes for group discussion and posttesting. Fall Risk Screening Algorithm. The fall risk screening algorithm (Figure 1) was based on the American Geriatrics Society screening guidelines (“Summary of the Updated American Geriatrics Society,” 2011). The algorithm was designed to identify an older adult at increased or lower risk for falls. Based on results from the pilot study (Schrodt et al., 2013), it was decided to include the screening questions and a simple physical performance assessment per the algorithm. The screening algorithm included questions about history of falls and difficulty with walking or balance, followed by performance of the Timed Up and Go (TUG; Podsiadlo & Richardson, 1991). The TUG is a valid and reliable screening tool for fall risk that times performance for rising from a chair, walking 10 feet at self-selected speed, and turning around and returning to the chair.
Older adults who indicated a positive fall history, difficulty with walking or balance, or required 12 seconds or longer (Bischoff et al., 2003) to complete the TUG screened positive. Older adults who appeared unsafe to perform the TUG were only asked the screening questions and then identified at an increased risk. Posttraining Skills Check. Participants notified the researchers when they felt prepared for the skills proficiency check. The skills check assessed participants administering a fall risk screen to a simulated case roleplayed by the researchers. A standardized skills checklist assessed proficiency. Participants were scored on their ability to (a) ask the screening questions in the correct order, (b) conduct all aspects of the TUG based on a standardized protocol (Podsiadlo & Richardson, 1991), (c) identify the correct fall risk category, and (d) provide appropriate referral information for given risk category (Figure 2). Participants were required to achieve 100% on the four skills to conduct screenings at community events. Participants not achieving 100% on their first skills check were provided feedback and practice, and could repeat the skills check as many times as necessary to demonstrate proficiency. At the end of the workshop, participants were encouraged to review screening procedures prior to their scheduled screening event, and received equipment to conduct screenings (a stopwatch or kitchen timer and clipboard). Fidelity Assessments at Onsite Screening Events. Each participant was required to complete an onsite skills check by a researcher to assess proficiency in implementing the screening algorithm with fidelity in a real world setting. Onsite skills checks allowed researchers an opportunity to provide additional feedback and coaching if necessary. A minimum of one skills check per participant was required; however, to assess skills on a variety of older adults, attempts were made to score three fall risk screens on as many participants as possible. If a participant did not achieve 100% proficiency on their skills check, the onsite researcher would review the protocol, let them practice the procedures again, and repeat the skills check with another older adult. As part of the onsite fidelity assessment, researchers asked participants if they had reviewed the screening materials prior to the event, and noted if participants requested review of procedures prior to the event. Data Analysis Descriptive statistics were used to analyze participant demographics. Pre–posttraining written knowledge
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Fall Risk Screening Algorithm for Community Dwelling Older Adults For use by trained healthcare and community service providers. Adapted from the American Geriatrics Society Guidelines for Fall Prevention
ASK the following questions: 1. In the past 12 months have you had a fall? YES or NO If YES, then ask: a) How many times have you fallen? ____ (record number) b) Were you injured from a fall?1 YES or NO 2. Do you have any difficulties with walking or balance? YES or NO Record responses on score sheet If screeners do not feel performance of the TUG will be safe (e.g. persons needing help to walk), the individual may skip the TUG and automatically be considered at increased risk.
PERFORM Timed Up and Go (TUG) Test according to the proper protocol2 Record score on score sheet
Individuals are considered increased risk if they answer YES to at least one of the questions OR score 12 seconds or longer on the TUG.
1 2
If TUG time 12 seconds or longer, then
If TUG time less than 12 seconds, then
Individuals are considered at lower risk of they answer NO to both questions AND score less than 12 seconds on the TUG
Individual considered at increased risk of falls
Individual considered at lower risk of falls
REFER to healthcare provider for multifactorial fall risk assessment
REFER to community programs for continued balance exercise and wellness
Injury defined as seeking medical attention (healthcare visit, urgent care, ER, etc) Refer to Building Better Balance Community Providers Manual and Training for equipment and procedures Contact Lori Schrodt, PT, PhD for questions regarding this fall risk screening ([email protected])
Figure 1 Fall Risk Screening Algorithm
score and confidence rating differences were examined for novice participants using paired t tests to determine if improvements were associated with attending the training. All assumptions for paired t tests, including normal difference distributions, were met. Returning participants were excluded from knowledge score and
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confidence rating analysis due to their previous exposure to similar training experiences. Examination of screening skills proficiency posttraining and during onsite fidelity assessments were conducted via descriptive statistics on both novice and returning participants. Posttraining skills and onsite fidelity proficiency of
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Fall Risk Screening Skills Checklist ID________ Rater _______ Date_________ Location ______________________ Case # _________ Rater Instructions: Place a “1” on the line next to each skill that is performed correctly, and a “0” on the line if the skill is missing or done incorrectly (includes needing cueing or guidance). Record “N/A” for questions/procedures not applicable to the case/individual. ASK the following questions: 1. In the past 12 months have you had a fall? YES or NO If YES, then ask:
Properly asks (as appropriate to case): Question 1: ____ Question 1a: ____ Question 1b: ____ Question 2: ____
a) How many times have you fallen? ____ b) Were you injured from a fall?1 YES or NO 2. Do you have any difficulties with walking or balance? YES or NO
Records responses on score sheet: ____
Record responses on score sheet If screeners do not feel performance of the TUG will be safe (e.g. persons needing help to walk), the individual may skip the TUG and automatically be considered at increased risk.
PERFORM Timed Up and Go (TUG) Test according to the proper protocol2
Individuals are considered increased risk if they answer YES to at least one of the questions OR score 12 seconds or longer on the TUG.
Record score on score sheet
TUG Standardized Protocol: ? Appropriate type of chair: _____ ? Appropriate distance marked with tape: _____ ? Chair placed against wall: _____ ? Unobstructed pathway: _____ ? Seats participant with back against chair: _____ ? Reads instructions: _____ ? Allows 1 practice trial: _____ ? Properly guards participant: _____ ? Corrects errors (e.g. not crossing tape line) and repeats trial if necessary: _____ ? Uses stop watch to time performance: _____ ? Starts & ends time appropriately: _____ ? Records score on score sheet: _____ ? TUG Score: _________ seconds
If TUG time 12 seconds or longer, then
If TUG time less than 12 seconds, then
Individual considered at increased risk of falls
Individual considered at lower risk of falls
REFER to healthcare provider for multifactorial fall risk assessment
REFER to community programs for continued balance exercise and wellness
Skills: ? Accurately Identifies as increased risk: ____ ? Refers to provider: _____
Individuals are considered at lower risk of they answer NO to both questions AND score less than 12 seconds on the TUG
Skills: ? Accurately identifies as lower risk: _____ ? Refers to community programs: ______
? Automatically refers individual unsafe to test (as appropriate): _____ General Scoring Criteria 1. Asks questions in correct sequence: _____ 2. Conducts TUG properly (all items correct): _____ 3. Identifies individual in correct risk category: _____ 4. Refers appropriately depending on risk category: _____
Onsite Notes: 1. Ask each screener, “Did you review the screening materials prior to screening event?” YES NO (circle) 2. Note if the screener requested review of procedures at beginning of screening event. YES NO (circle)
General Criteria Score: _________/ 4 © Lori Schrodt, PT, PhD 2011 Contact [email protected] for questions on use of the Fall Risk Screening Skills Checklist
Figure 2 Fall Risk Screening Skills Checklist
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novices and returning participants were compared using Fisher’s exact test to examine if returning participants demonstrated better proficiency. Fisher’s exact test was selected due to the limited cell sizes of categorical data in our analyses following examination for assumptions of dichotomous and independent observations. Secondary analyses examined characteristics of participants who scored 100% on their first onsite fidelity trial compared to those who did not. These analyses were conducted via independent t tests for mean age, posttraining knowledge test scores, and posttraining confidence rating. Fisher’s exact test examined if the categorical characteristics of education level, posttraining skills check proficiency, or self-review of procedures prior to onsite fidelity assessment were related to 100% proficiency on participants’ first onsite fidelity assessment. IBM SPSS Version 19 (Armonk, NY) was used for all analyses, and a p level of .05 was used to determine significance.
Results >> Participants included 36 women and 4 men with a mean age of 42.89 years (range 19-75). Half worked for aging and community service organizations (e.g., Council on Aging, Department on Aging, senior centers, etc.) and reported working at their current job a mean of 6.45 years (range 0-38; Table 1). Thirty-one participants were novices, and 9 were returning participants.
Table 1 Participant Characteristics (N = 40) Characteristic Employment or volunteer organization Aging or community organization Community wellness or fitness organization College student Health care (nonclinical role) Employment or volunteer experience Fitness/wellness instruction Community outreach and/or onsite aging programming Case management and/or support groups Highest education level completed High school diploma Associate degree or some college Bachelor’s degree Graduate degree Reasons selected for interest in training and screening program Work or volunteer responsibilities Community service Personal interest Falls history and prevention training Self-reported history of falls Attended other fall prevention training or educational programming
n 20 10 7 3 8 22 10 1 15 14 10
33 27 23 7 18
Fall Prevention Knowledge and Screening Skills Confidence Paired t tests indicated significant improvements following training for both knowledge test scores, t(30) = 10.25, p < .001, and confidence ratings, t(30) = 7.72, p < .001, in novice participants. Novice participants’ mean pretest knowledge score of 8.84 (SD = 1.73) improved by a mean difference of 3.74 points (27%), resulting in a mean posttest score of 12.58 (SD = 1.06) out of a maximum score of 14 points. Similarly, participants’ mean posttraining confidence rating of 8.98 (SD = 1.91) on the 0 to 10 rating scale demonstrated a significant mean difference improvement of 4.63 (46%) from their mean pretraining rating of 4.35 (SD = 2.53). Posttraining Screening Skills Proficiency Training Workshop. Twenty-five of the 40 participants (novice and returning) demonstrated 100% proficiency on the first case-based skills check immediately posttraining. An additional 14 participants achieved 100%
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proficiency on the second skills check, and 1 participant required a third skills check. The 1 participant requiring the third skills check was a returning participant. The most common errors were: incorrect fall risk assignment and referral, failure to ask the second of the screening questions, incorrect verbalization of standardized TUG instructions, and insufficient guarding during the TUG. Returning participants trended toward higher achievement of 100% proficiency during the first casebased skills check (8 of 9, 89%) compared with novice participants (17 of 31, 55%) immediately posttraining. However, this trend did not reach significance at the α = .05 level (p = .067, one-tailed Fisher’s exact test). Onsite Community Screening Fidelity. Thirty-two novice and returning participants were assessed during their first onsite screening with community older adults. Two participants were not assessed due to
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Table 2 Criterion Skill Proficiency for Novice and Returning Participants During Onsite Community Screening Events (Results From First Trial) Number of Participants Demonstrating Proficiency Screening Skills Assessment Criteria
Novice Participants (n = 25)
Returning Participants (n = 7)
All Participants (n = 32)
Asks questions in correct sequence Conducts Timed Up and Go properly Identifies correct risk category Refers appropriately based on risk category All criteria successfully met
22
7
29
20
6
26
20
6
26
23
7
30
16
5
21
illness of the researcher assigned to the screening event. The remaining 6 participants did not conduct screenings during onsite events due to schedule conflicts. Second screenings were assessed for 26 participants and third screenings for 19. Twenty-three participants reported reviewing procedures prior to the screening event. Three requested researchers review the procedures prior to implementing their first screen. Twenty-one of 32 participants administered the fall risk screen with fidelity (achieved 100% proficiency) on their first observed onsite screening. Proficiency for novice and returning participants on each observed criterion skill is presented in Table 2. The most common errors were for administration of the TUG and assigning the correct fall risk category. There was no difference in proficiency between novice and returning participants at the onsite screening events (p = .54, onetailed Fisher’s exact test). Sixteen of the 21 novice participants (76%) and 5 of the 7 returning participants (71%) achieved 100% proficiency on their first fidelity assessment. Participants (n = 11) who required onsite feedback and coaching demonstrated improvement. Five of these 11 participants scored 100% on the second observed screening, and 3 on the third. One individual did not achieve 100% by the third observed trial. An additional 2 participants who did not achieve 100% on their first screening were only observed once due to low attendance at their screening event. With structured skills observation and feedback, 29 of the 32 participants (91%) attained 100% proficiency by their
third observed screening during the onsite community events demonstrating screening fidelity. Characteristics of Proficient Screeners Secondary analyses examining characteristics of participants who scored 100% on their first onsite fidelity assessment supported that they were younger (mean age 39.35 years) compared with those who were not 100% proficient (mean age 52.60 years), t(28) = −2.15, p = .04. Education level, posttraining written knowledge scores, posttraining self-confidence ratings, posttraining skills check scores (first trial), and selfreview of procedures prior to screening events were not associated with earlier attainment of screening skill proficiency on fidelity assessments.
Discussion >> Our results support community providers can reliably administer an evidence-based fall risk screen to older adults in a community setting. The training curriculum, consisting of education, knowledge and confidence assessment, skills demonstration, practice, and observation, resulted in 66% of participants demonstrating full proficiency during their first onsite screening administration. Most of the remaining participants achieved proficiency with the addition of onsite feedback and coaching. Participants in this program screened 329 older adults during September through November 2011. Participants who demonstrated mastery of skills on their first onsite community screen (66%) were younger. However, no other key characteristics for
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early proficiency were identified. Nonetheless, 91% of participants were able to demonstrate mastery by their third screening trial with additional feedback and coaching. It may be that onsite coaching was a key component of obtaining skill proficiency, and coaching may be more indicative of success than provider characteristics or even knowledge assessment, particularly for older participants. For example, participants who reviewed the screening procedures prior to screening events did not perform better than those who reported not reviewing the procedures. Perhaps structured onsite coaching has a greater influence on skill acquisition than individual review. This notion is consistent with implementation science research supporting onsite coaching as a key component to assurance that a technique or skill is implemented by a trainee (Fixsen, Scott, Blase, Naoom, & Wagar, 2011). The role and impact of the onsite coach for widespread dissemination will be addressed in future studies. This model addresses many of the barriers associated with broad dissemination and implementation of fall risk screening. Though clinical practice guidelines recommend older adults be screened at least annually for fall risk, few health care providers have the time to offer this service to their older adult patients. Though efforts are being made to increase screening of older adults by health care providers, offering alternative entry points into fall risk management through the community provider may be a viable option. In addition to the time constraints of modern clinical settings, health care providers typically do not have an economic incentive to screen older adults for fall risk. Medicare has included fall risk screening as part of the initial wellness exam; however, there has been limited uptake of this program (Centers for Medicare and Medicaid Services, 2012; John A. Hartford Foundation, 2012). There are no billing codes for fall risk screening; however, health care providers can be reimbursed for fall risk assessment and intervention. The community screeners were able to streamline this process for health care providers by identifying individuals at lower risk of falls and providing education and resources, while prioritizing higher risk individuals and suggesting referral to health care providers for further assessment. In this model, health care billing for assessments would be focused on those with greater fall risk. Collaboration among the partner organizations in this study allowed development of this screening program using existing infrastructure and pooling of resources to maximize efficiency and minimize cost. The academic–community partnership also created opportunities for student engagement and service learning. Additionally, all community providers in this
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study volunteered their time or had support through their usual job responsibilities, and most resources were donated in kind. The community provider model offers a cost-efficient way to disseminate widespread fall risk screenings, and prioritize individuals who will benefit from further clinical assessment by a health care provider. Variability in the number of onsite fidelity assessments posed certain limitations on our analyses. An enhanced measure of skill proficiency would include observations over a variety of onsite trials, rather than relying predominantly on the first trial. We were unable to assess longer term retention beyond these initial onsite fidelity assessments. Our limited number of participants also prevented further exploration of characteristics associated with proficient screeners. Although older participants did not perform as well as younger participants on their first onsite screening, our limited sample size and fidelity observations constrained exploration of how older participants learned over several trials with additional coaching. Further examination of these characteristics and learning factors may help curriculum modifications better accommodate different learners. Limitations of this model include the need for and time commitment of skilled trainers to provide training and onsite coaching at start-up. Researchers in the program conducted four 3-hour training workshops (2-4 researchers per workshop). They attended each screening event to assess community providers’ screening skills and provide additional feedback and coaching as needed. Although use of a single skilled trainer to provide oversight and coaching for several community providers resulted in greater reach and numbers of older adults receiving screenings, the model has challenges to scale up as it still requires the time of skilled trainers. Health care providers familiar with fall risk screening guidelines and procedures are a natural fit for serving as skilled trainers; however, provider shortages and the time commitment may limit feasibility. Future research should examine the efficacy of using a trainthe-trainer model to provide advanced training to community providers who in turn could train others to be screeners. This model has proven successful with several other community-based programs (Druss et al., 2010; Lorig, Ritter, Villa, & Armas, 2009). The results of this study support that community providers can master the skills necessary to administer a fall risk screening with fidelity to older adults in community settings, appropriately stratify risk level based on a screening algorithm, and provide information for older adults to relay to their physician. Future projects
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Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. (2011). Journal of the American Geriatrics Society, 59(1), 148-157. doi:10.1111/j.1532-5415.2010.03234.x
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HPPXXX10.1177/1 524839913514752Health Promotion PracticeSchrodt et al. / TRAINED COMMUNITY PROVIDERS CONDUCT SCREENINGS 2013
Trained Community Providers Conduct Fall Risk Screenings With Fidelity: An Effective Model for Expanding Reach Lori A. Schrodt, PT, MS, PhD1 Kathie C. Garbe, MCHES, PhD2 Tiffany E. Shubert, MPT, PhD3
Reliable and valid tools are available for health care providers to screen older adults for fall risk. Proficient administration of these tools by lay or community providers (individuals without formal medical training) may be a viable channel to expand the reach of fall risk screenings. However, the ability of community providers to administer screens is not known. This project examines community providers’ ability to proficiently administer a fall risk screening following a standardized training. Forty community providers were trained and then performed community screenings. Knowledge and confidence were assessed with pre- and postsurveys. A standardized skills checklist assessed proficiency in fall risk screening administration immediate posttraining and at onsite community screenings. Knowledge and confidence surveys demonstrated improvements pre- and posttraining (p < .001). In all, 66% of participants demonstrated screening skill proficiency at their first onsite screening. With further coaching, 91% participants demonstrated proficiency by their third onsite screening. Participants achieving early proficiency were on average younger. Community providers can reliably administer a fall risk screening algorithm with training and coaching. This is a low-cost model and can extend the reach and dissemination of fall risk screenings, potentially providing early identification and interventions to those at risk of falling. Keywords: aging; community-based participatory research; unintentional injury; rural health; college–community partnerships
Health Promotion Practice July 2014 Vol. 15, No. 4 599–607 DOI: 10.1177/1524839913514752 © 2013 Society for Public Health Education
Introduction >> Falls among older adults are a major public health concern. One third of community-dwelling older adults older than 65 years and half of those older than 80 fall 1
Western Carolina University, Cullowhee, NC, USA University of North Carolina at Asheville, NC, USA 3 University of North Carolina at Chapel Hill, NC, USA 2
Authors’ Note: We thank Rebecca Chaplin, MA (Land-of-Sky Regional Council); Carol Cook, MS (Appalachian State University); and Ellen Garrison, MEd (UNC Asheville), for their assistance with training and data collection and Sue L. McPherson, PhD (Western Carolina University), for her design and analysis assistance. We also thank the community agencies and providers who supported this work by hosting training workshops and/or screening events. This project was supported in part by the Mission Hospital Foundation and the North Carolina Center for Healthy Aging. The University of North Carolina (UNC) Center for Aging and Health, Carolina Geriatric Education Center also provided support for this activity. The Be Active–Appalachian Partnership donated supplies used during the project. We acknowledge the significant efforts of the Western North Carolina Fall Prevention Coalition and in particular the Screening and Risk Assessment subgroup for their contributions to this project. This project was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under Grant No. UB4HP19053, Carolina Geriatric Education Center. All contributors received funding from BHPr to complete this project. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS, or the U.S. Government. Address correspondence to Lori A. Schrodt, Associate Professor, Department of Physical Therapy, Western Carolina University, 246 Health & Human Sciences, 4121 Little Savannah Road, Cullowhee, NC 28723, USA; e-mail: [email protected].
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annually (Stevens, 2012). A fall is a sentinel event for an older adult, often resulting in depression, morbidity, and mortality (Hornbrook et al., 1994). Reliable and valid screening tools are available to identify older adults at increased fall risk. These tools, designed for health care professionals for use in a clinical setting, provide opportunities for early detection and intervention (Goodwin & Briggs, 2012; Stevens & Phelan, 2013; “Summary of the Updated American Geriatrics Society,” 2011). The American Geriatrics Society published a fall risk screening algorithm in 2001 (“Guideline for the Prevention of Falls in Older Persons,” 2001) and a revision in 2011 (“Summary of the Updated American Geriatrics Society,” 2011). However, use of these guidelines by health care professionals has been limited (Chou, Tinetti, King, Irwin, & Fortinsky, 2006; Shumway-Cook et al., 2009). Exploration of other models, such as the use of community and lay providers to offer screening services in nonclinical settings, may offer an expanded reach for screenings. Community providers often work in senior centers, meal sites, and other locations where older adults congregate. Although they typically do not have formal health care backgrounds, they often are trained to provide health screenings for diabetes, hypertension, and other chronic conditions. Researchers have demonstrated that trained community providers can effectively educate older adults about fall risk (Deery, Day, & Fildes, 2000), facilitate fall risk management behavior change (Scott, Votova, & Gallagher, 2006), and improve older adults’ self-efficacy in fall risk management (Healy et al., 2008). Community providers are strategically positioned to expand the reach of fall risk screening; however, it is not known if they can master skills required to administer a fall risk screen with fidelity. Our purpose was to determine if community providers who attend a standardized training curriculum could demonstrate the following: (a) improved fall risk knowledge, (b) improved confidence in screening administration, (c) proficiency in administration of a standardized fall risk screen, and (d) skill mastery for conducting community-based fall risk screenings with fidelity. The secondary purpose was to identify characteristics of community providers who could administer screens with minimal onsite coaching.
Method >>
Design and Context This study used a single-group design using a convenience sample of volunteer community providers. The training framework, content, and infrastructure for 600
the project were developed and piloted in 2010 in western North Carolina (Schrodt, Garbe, Chaplin, Busby-Whitehead, & Shubert, 2013). The project was conducted in conjunction with National Falls Prevention Awareness Week programming and activities. The Western North Carolina Fall Prevention Coalition (Coalition) worked with four partner organizations, Land-of-Sky Area Agency on Aging, Western Carolina University, University of North Carolina at Asheville, and the North Carolina Center for Healthy Aging (housed in the Mountain Area Health Education Center) to organize 16 screening events at 13 sites in seven counties from September through November 2011. Settings included senior centers, congregate meals sites, health fairs, retirement communities, and wellness/fitness centers. Participants Community providers who worked with older adults in any capacity were invited to attend the training workshops through advertisement on the Coalition’s website, e-mail correspondence to past screening event participants and aging services coordinators, and word of mouth. At the beginning of each workshop, researchers explained the purpose of the study and asked volunteers to review and sign an informed consent form approved by the Western Carolina University Institutional Review Board. Participation in the study was not mandatory to attend the workshop; however, all community providers who attended the workshops agreed to participate and met all inclusion criteria: (a) ability to speak, hear, and understand English; (b) able to attend at a 3-hour training workshop; (c) commitment to assist with at least one fall risk screening event; (d) physically able to walk with, and potentially steady, older adults (through selfassessment); and (e) completion of the posttraining screening skills check with 100% proficiency (repeated attempts permitted). The total number of participants was 40. Nine participated in the pilot training from the previous year (returning participants) and 31 were new to the training (novice participants). Intervention and Data Collection Training Workshops. Four 3-hour training workshops were offered in three counties during September and October 2011. Average attendance was 10 participants, with a range of 3 to 18. After they signed informed consent, but before training began, participants completed a demographic form, a written knowledge pretest (14 multiple-choice and true/false questions; maximum score = 14 points), and a confidence self-rating for conducting screenings (0 = no confidence, 10 = complete
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confidence). The confidence scale asked participants to rate their confidence in asking two questions and conducting a physical performance test for two paper cases. The average confidence rating across both case studies was used for analysis. Each workshop was conducted by the researchers (2-4 researchers were present for each training). The lead researcher was an academic and clinical physical therapist with expertise in fall prevention and community programs. The remaining researchers were also academic faculty with exercise science and community program expertise. The curriculum was based on theories of adult learning and incorporated experiential learning and problem solving in a cooperative atmosphere (Knowles, 1970; Merriam, 1996). Specific workshop components included the following: (a) presentation of the problem of falls, common risk factors, and effective interventions; (b) instruction in screening procedures, including demonstration and case-based application of the fall risk screening algorithm, and modeling of common screening errors; (c) hands-on practice of the screening skills (participants practiced screening with each other and the researchers) using collaborative learning and feedback; (d) step-by-step instruction and group discussion of community screening event logistics; (e) observation and a skills proficiency check of a simulated case; and (f) completion of the written knowledge posttest and confidence rating. Although time varied somewhat depending on workshop size and need for experiential practice of screening skills; approximately 1 hour was devoted to instructorled content and training in screening procedures, 30 minutes for problem-based demonstration and modeling of screening skills, 1 hour for hands-on practice and skills proficiency checks, and 30 minutes for group discussion and posttesting. Fall Risk Screening Algorithm. The fall risk screening algorithm (Figure 1) was based on the American Geriatrics Society screening guidelines (“Summary of the Updated American Geriatrics Society,” 2011). The algorithm was designed to identify an older adult at increased or lower risk for falls. Based on results from the pilot study (Schrodt et al., 2013), it was decided to include the screening questions and a simple physical performance assessment per the algorithm. The screening algorithm included questions about history of falls and difficulty with walking or balance, followed by performance of the Timed Up and Go (TUG; Podsiadlo & Richardson, 1991). The TUG is a valid and reliable screening tool for fall risk that times performance for rising from a chair, walking 10 feet at self-selected speed, and turning around and returning to the chair.
Older adults who indicated a positive fall history, difficulty with walking or balance, or required 12 seconds or longer (Bischoff et al., 2003) to complete the TUG screened positive. Older adults who appeared unsafe to perform the TUG were only asked the screening questions and then identified at an increased risk. Posttraining Skills Check. Participants notified the researchers when they felt prepared for the skills proficiency check. The skills check assessed participants administering a fall risk screen to a simulated case roleplayed by the researchers. A standardized skills checklist assessed proficiency. Participants were scored on their ability to (a) ask the screening questions in the correct order, (b) conduct all aspects of the TUG based on a standardized protocol (Podsiadlo & Richardson, 1991), (c) identify the correct fall risk category, and (d) provide appropriate referral information for given risk category (Figure 2). Participants were required to achieve 100% on the four skills to conduct screenings at community events. Participants not achieving 100% on their first skills check were provided feedback and practice, and could repeat the skills check as many times as necessary to demonstrate proficiency. At the end of the workshop, participants were encouraged to review screening procedures prior to their scheduled screening event, and received equipment to conduct screenings (a stopwatch or kitchen timer and clipboard). Fidelity Assessments at Onsite Screening Events. Each participant was required to complete an onsite skills check by a researcher to assess proficiency in implementing the screening algorithm with fidelity in a real world setting. Onsite skills checks allowed researchers an opportunity to provide additional feedback and coaching if necessary. A minimum of one skills check per participant was required; however, to assess skills on a variety of older adults, attempts were made to score three fall risk screens on as many participants as possible. If a participant did not achieve 100% proficiency on their skills check, the onsite researcher would review the protocol, let them practice the procedures again, and repeat the skills check with another older adult. As part of the onsite fidelity assessment, researchers asked participants if they had reviewed the screening materials prior to the event, and noted if participants requested review of procedures prior to the event. Data Analysis Descriptive statistics were used to analyze participant demographics. Pre–posttraining written knowledge
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Fall Risk Screening Algorithm for Community Dwelling Older Adults For use by trained healthcare and community service providers. Adapted from the American Geriatrics Society Guidelines for Fall Prevention
ASK the following questions: 1. In the past 12 months have you had a fall? YES or NO If YES, then ask: a) How many times have you fallen? ____ (record number) b) Were you injured from a fall?1 YES or NO 2. Do you have any difficulties with walking or balance? YES or NO Record responses on score sheet If screeners do not feel performance of the TUG will be safe (e.g. persons needing help to walk), the individual may skip the TUG and automatically be considered at increased risk.
PERFORM Timed Up and Go (TUG) Test according to the proper protocol2 Record score on score sheet
Individuals are considered increased risk if they answer YES to at least one of the questions OR score 12 seconds or longer on the TUG.
1 2
If TUG time 12 seconds or longer, then
If TUG time less than 12 seconds, then
Individuals are considered at lower risk of they answer NO to both questions AND score less than 12 seconds on the TUG
Individual considered at increased risk of falls
Individual considered at lower risk of falls
REFER to healthcare provider for multifactorial fall risk assessment
REFER to community programs for continued balance exercise and wellness
Injury defined as seeking medical attention (healthcare visit, urgent care, ER, etc) Refer to Building Better Balance Community Providers Manual and Training for equipment and procedures Contact Lori Schrodt, PT, PhD for questions regarding this fall risk screening ([email protected])
Figure 1 Fall Risk Screening Algorithm
score and confidence rating differences were examined for novice participants using paired t tests to determine if improvements were associated with attending the training. All assumptions for paired t tests, including normal difference distributions, were met. Returning participants were excluded from knowledge score and
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confidence rating analysis due to their previous exposure to similar training experiences. Examination of screening skills proficiency posttraining and during onsite fidelity assessments were conducted via descriptive statistics on both novice and returning participants. Posttraining skills and onsite fidelity proficiency of
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Fall Risk Screening Skills Checklist ID________ Rater _______ Date_________ Location ______________________ Case # _________ Rater Instructions: Place a “1” on the line next to each skill that is performed correctly, and a “0” on the line if the skill is missing or done incorrectly (includes needing cueing or guidance). Record “N/A” for questions/procedures not applicable to the case/individual. ASK the following questions: 1. In the past 12 months have you had a fall? YES or NO If YES, then ask:
Properly asks (as appropriate to case): Question 1: ____ Question 1a: ____ Question 1b: ____ Question 2: ____
a) How many times have you fallen? ____ b) Were you injured from a fall?1 YES or NO 2. Do you have any difficulties with walking or balance? YES or NO
Records responses on score sheet: ____
Record responses on score sheet If screeners do not feel performance of the TUG will be safe (e.g. persons needing help to walk), the individual may skip the TUG and automatically be considered at increased risk.
PERFORM Timed Up and Go (TUG) Test according to the proper protocol2
Individuals are considered increased risk if they answer YES to at least one of the questions OR score 12 seconds or longer on the TUG.
Record score on score sheet
TUG Standardized Protocol: ? Appropriate type of chair: _____ ? Appropriate distance marked with tape: _____ ? Chair placed against wall: _____ ? Unobstructed pathway: _____ ? Seats participant with back against chair: _____ ? Reads instructions: _____ ? Allows 1 practice trial: _____ ? Properly guards participant: _____ ? Corrects errors (e.g. not crossing tape line) and repeats trial if necessary: _____ ? Uses stop watch to time performance: _____ ? Starts & ends time appropriately: _____ ? Records score on score sheet: _____ ? TUG Score: _________ seconds
If TUG time 12 seconds or longer, then
If TUG time less than 12 seconds, then
Individual considered at increased risk of falls
Individual considered at lower risk of falls
REFER to healthcare provider for multifactorial fall risk assessment
REFER to community programs for continued balance exercise and wellness
Skills: ? Accurately Identifies as increased risk: ____ ? Refers to provider: _____
Individuals are considered at lower risk of they answer NO to both questions AND score less than 12 seconds on the TUG
Skills: ? Accurately identifies as lower risk: _____ ? Refers to community programs: ______
? Automatically refers individual unsafe to test (as appropriate): _____ General Scoring Criteria 1. Asks questions in correct sequence: _____ 2. Conducts TUG properly (all items correct): _____ 3. Identifies individual in correct risk category: _____ 4. Refers appropriately depending on risk category: _____
Onsite Notes: 1. Ask each screener, “Did you review the screening materials prior to screening event?” YES NO (circle) 2. Note if the screener requested review of procedures at beginning of screening event. YES NO (circle)
General Criteria Score: _________/ 4 © Lori Schrodt, PT, PhD 2011 Contact [email protected] for questions on use of the Fall Risk Screening Skills Checklist
Figure 2 Fall Risk Screening Skills Checklist
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novices and returning participants were compared using Fisher’s exact test to examine if returning participants demonstrated better proficiency. Fisher’s exact test was selected due to the limited cell sizes of categorical data in our analyses following examination for assumptions of dichotomous and independent observations. Secondary analyses examined characteristics of participants who scored 100% on their first onsite fidelity trial compared to those who did not. These analyses were conducted via independent t tests for mean age, posttraining knowledge test scores, and posttraining confidence rating. Fisher’s exact test examined if the categorical characteristics of education level, posttraining skills check proficiency, or self-review of procedures prior to onsite fidelity assessment were related to 100% proficiency on participants’ first onsite fidelity assessment. IBM SPSS Version 19 (Armonk, NY) was used for all analyses, and a p level of .05 was used to determine significance.
Results >> Participants included 36 women and 4 men with a mean age of 42.89 years (range 19-75). Half worked for aging and community service organizations (e.g., Council on Aging, Department on Aging, senior centers, etc.) and reported working at their current job a mean of 6.45 years (range 0-38; Table 1). Thirty-one participants were novices, and 9 were returning participants.
Table 1 Participant Characteristics (N = 40) Characteristic Employment or volunteer organization Aging or community organization Community wellness or fitness organization College student Health care (nonclinical role) Employment or volunteer experience Fitness/wellness instruction Community outreach and/or onsite aging programming Case management and/or support groups Highest education level completed High school diploma Associate degree or some college Bachelor’s degree Graduate degree Reasons selected for interest in training and screening program Work or volunteer responsibilities Community service Personal interest Falls history and prevention training Self-reported history of falls Attended other fall prevention training or educational programming
n 20 10 7 3 8 22 10 1 15 14 10
33 27 23 7 18
Fall Prevention Knowledge and Screening Skills Confidence Paired t tests indicated significant improvements following training for both knowledge test scores, t(30) = 10.25, p < .001, and confidence ratings, t(30) = 7.72, p < .001, in novice participants. Novice participants’ mean pretest knowledge score of 8.84 (SD = 1.73) improved by a mean difference of 3.74 points (27%), resulting in a mean posttest score of 12.58 (SD = 1.06) out of a maximum score of 14 points. Similarly, participants’ mean posttraining confidence rating of 8.98 (SD = 1.91) on the 0 to 10 rating scale demonstrated a significant mean difference improvement of 4.63 (46%) from their mean pretraining rating of 4.35 (SD = 2.53). Posttraining Screening Skills Proficiency Training Workshop. Twenty-five of the 40 participants (novice and returning) demonstrated 100% proficiency on the first case-based skills check immediately posttraining. An additional 14 participants achieved 100%
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proficiency on the second skills check, and 1 participant required a third skills check. The 1 participant requiring the third skills check was a returning participant. The most common errors were: incorrect fall risk assignment and referral, failure to ask the second of the screening questions, incorrect verbalization of standardized TUG instructions, and insufficient guarding during the TUG. Returning participants trended toward higher achievement of 100% proficiency during the first casebased skills check (8 of 9, 89%) compared with novice participants (17 of 31, 55%) immediately posttraining. However, this trend did not reach significance at the α = .05 level (p = .067, one-tailed Fisher’s exact test). Onsite Community Screening Fidelity. Thirty-two novice and returning participants were assessed during their first onsite screening with community older adults. Two participants were not assessed due to
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Table 2 Criterion Skill Proficiency for Novice and Returning Participants During Onsite Community Screening Events (Results From First Trial) Number of Participants Demonstrating Proficiency Screening Skills Assessment Criteria
Novice Participants (n = 25)
Returning Participants (n = 7)
All Participants (n = 32)
Asks questions in correct sequence Conducts Timed Up and Go properly Identifies correct risk category Refers appropriately based on risk category All criteria successfully met
22
7
29
20
6
26
20
6
26
23
7
30
16
5
21
illness of the researcher assigned to the screening event. The remaining 6 participants did not conduct screenings during onsite events due to schedule conflicts. Second screenings were assessed for 26 participants and third screenings for 19. Twenty-three participants reported reviewing procedures prior to the screening event. Three requested researchers review the procedures prior to implementing their first screen. Twenty-one of 32 participants administered the fall risk screen with fidelity (achieved 100% proficiency) on their first observed onsite screening. Proficiency for novice and returning participants on each observed criterion skill is presented in Table 2. The most common errors were for administration of the TUG and assigning the correct fall risk category. There was no difference in proficiency between novice and returning participants at the onsite screening events (p = .54, onetailed Fisher’s exact test). Sixteen of the 21 novice participants (76%) and 5 of the 7 returning participants (71%) achieved 100% proficiency on their first fidelity assessment. Participants (n = 11) who required onsite feedback and coaching demonstrated improvement. Five of these 11 participants scored 100% on the second observed screening, and 3 on the third. One individual did not achieve 100% by the third observed trial. An additional 2 participants who did not achieve 100% on their first screening were only observed once due to low attendance at their screening event. With structured skills observation and feedback, 29 of the 32 participants (91%) attained 100% proficiency by their
third observed screening during the onsite community events demonstrating screening fidelity. Characteristics of Proficient Screeners Secondary analyses examining characteristics of participants who scored 100% on their first onsite fidelity assessment supported that they were younger (mean age 39.35 years) compared with those who were not 100% proficient (mean age 52.60 years), t(28) = −2.15, p = .04. Education level, posttraining written knowledge scores, posttraining self-confidence ratings, posttraining skills check scores (first trial), and selfreview of procedures prior to screening events were not associated with earlier attainment of screening skill proficiency on fidelity assessments.
Discussion >> Our results support community providers can reliably administer an evidence-based fall risk screen to older adults in a community setting. The training curriculum, consisting of education, knowledge and confidence assessment, skills demonstration, practice, and observation, resulted in 66% of participants demonstrating full proficiency during their first onsite screening administration. Most of the remaining participants achieved proficiency with the addition of onsite feedback and coaching. Participants in this program screened 329 older adults during September through November 2011. Participants who demonstrated mastery of skills on their first onsite community screen (66%) were younger. However, no other key characteristics for
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early proficiency were identified. Nonetheless, 91% of participants were able to demonstrate mastery by their third screening trial with additional feedback and coaching. It may be that onsite coaching was a key component of obtaining skill proficiency, and coaching may be more indicative of success than provider characteristics or even knowledge assessment, particularly for older participants. For example, participants who reviewed the screening procedures prior to screening events did not perform better than those who reported not reviewing the procedures. Perhaps structured onsite coaching has a greater influence on skill acquisition than individual review. This notion is consistent with implementation science research supporting onsite coaching as a key component to assurance that a technique or skill is implemented by a trainee (Fixsen, Scott, Blase, Naoom, & Wagar, 2011). The role and impact of the onsite coach for widespread dissemination will be addressed in future studies. This model addresses many of the barriers associated with broad dissemination and implementation of fall risk screening. Though clinical practice guidelines recommend older adults be screened at least annually for fall risk, few health care providers have the time to offer this service to their older adult patients. Though efforts are being made to increase screening of older adults by health care providers, offering alternative entry points into fall risk management through the community provider may be a viable option. In addition to the time constraints of modern clinical settings, health care providers typically do not have an economic incentive to screen older adults for fall risk. Medicare has included fall risk screening as part of the initial wellness exam; however, there has been limited uptake of this program (Centers for Medicare and Medicaid Services, 2012; John A. Hartford Foundation, 2012). There are no billing codes for fall risk screening; however, health care providers can be reimbursed for fall risk assessment and intervention. The community screeners were able to streamline this process for health care providers by identifying individuals at lower risk of falls and providing education and resources, while prioritizing higher risk individuals and suggesting referral to health care providers for further assessment. In this model, health care billing for assessments would be focused on those with greater fall risk. Collaboration among the partner organizations in this study allowed development of this screening program using existing infrastructure and pooling of resources to maximize efficiency and minimize cost. The academic–community partnership also created opportunities for student engagement and service learning. Additionally, all community providers in this
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study volunteered their time or had support through their usual job responsibilities, and most resources were donated in kind. The community provider model offers a cost-efficient way to disseminate widespread fall risk screenings, and prioritize individuals who will benefit from further clinical assessment by a health care provider. Variability in the number of onsite fidelity assessments posed certain limitations on our analyses. An enhanced measure of skill proficiency would include observations over a variety of onsite trials, rather than relying predominantly on the first trial. We were unable to assess longer term retention beyond these initial onsite fidelity assessments. Our limited number of participants also prevented further exploration of characteristics associated with proficient screeners. Although older participants did not perform as well as younger participants on their first onsite screening, our limited sample size and fidelity observations constrained exploration of how older participants learned over several trials with additional coaching. Further examination of these characteristics and learning factors may help curriculum modifications better accommodate different learners. Limitations of this model include the need for and time commitment of skilled trainers to provide training and onsite coaching at start-up. Researchers in the program conducted four 3-hour training workshops (2-4 researchers per workshop). They attended each screening event to assess community providers’ screening skills and provide additional feedback and coaching as needed. Although use of a single skilled trainer to provide oversight and coaching for several community providers resulted in greater reach and numbers of older adults receiving screenings, the model has challenges to scale up as it still requires the time of skilled trainers. Health care providers familiar with fall risk screening guidelines and procedures are a natural fit for serving as skilled trainers; however, provider shortages and the time commitment may limit feasibility. Future research should examine the efficacy of using a trainthe-trainer model to provide advanced training to community providers who in turn could train others to be screeners. This model has proven successful with several other community-based programs (Druss et al., 2010; Lorig, Ritter, Villa, & Armas, 2009). The results of this study support that community providers can master the skills necessary to administer a fall risk screening with fidelity to older adults in community settings, appropriately stratify risk level based on a screening algorithm, and provide information for older adults to relay to their physician. Future projects
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