From the Guidelines
For Medicare patients, comprehensive falls prevention documentation should include a thorough falls risk assessment, medication review, home safety evaluation, and documentation of any previous falls, as recommended by the USPSTF 1. To prioritize morbidity, mortality, and quality of life, it is essential to follow the guidelines set by the USPSTF, which recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls 1. The following elements should be included in the documentation:
- A thorough falls risk assessment, including factors such as age, history of falls, mobility problems, and performance on the timed Get-Up-and-Go test 1
- Medication review focusing on drugs that increase fall risk, such as benzodiazepines, antipsychotics, and certain antihypertensives
- Home safety evaluation and documentation of any recommended modifications, such as grab bars, improved lighting, and removal of trip hazards
- Documentation of any previous falls and interventions implemented, including physical therapy referrals, medication adjustments, and vision assessments
- Patient education provided about falls prevention strategies and assistive device recommendations, if appropriate
- A follow-up plan to reassess fall risk, which can be conducted during the Annual Wellness Visit, an ideal opportunity to document falls risk assessment 1. Proper documentation is crucial not only for quality patient care but also for Medicare reimbursement, as falls prevention is a key quality measure, and it supports care coordination among providers and demonstrates compliance with Medicare's quality reporting requirements 1.
From the Research
Documentation Requirements for Falls Prevention in Medicare Patients
The documentation requirements for falls prevention in Medicare patients involve screening for fall risk, assessing for modifiable risk factors, and implementing evidence-based interventions for prevention 2.
- Screening for fall risk is required as part of the Welcome to Medicare visit and Annual Wellness Visits, and involves asking patients if they have had 2 or more falls in the past 12 months, if they are presenting because of an acute fall, and if they have difficulty with walking or balance.
- If fall risk is identified, patients can be further evaluated with the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) algorithm, and documentation of need is required for Medicare reimbursement 2.
- Evaluation should also include a Timed Up & Go, assessment for orthostatic hypotension, identification and management of conditions that might contribute to fall risk, vitamin D and calcium supplementation, and review of the patient's drugs to ensure none is associated with falls 2, 3.
- Referral to a physical therapist or community fall prevention program has been shown to reduce fall risk, and patients may benefit from prescription of mobility assistive devices, such as canes, walkers, or wheelchairs 2, 3.
Risk Factors for Falls
Several risk factors for falls have been identified, including:
- A history of falls 3, 4
- Frailty, sedative and anticholinergic drugs, polypharmacy, and a variety of medical conditions 3
- Muscle weakness, use of four or more prescription medications, use of an assistive device, arthritis, depression, age older than 80 years, and impairments in gait, balance, cognition, vision, and activities of daily living 4
- Environmental hazards, such as home hazards 3, 4
Interventions for Falls Prevention
Effective interventions for falls prevention include:
- Multifactorial interventions targeting identified risk factors 4
- Exercises for muscle strengthening combined with balance training 4
- Withdrawal of psychotropic medication 4
- Home hazard assessment and modification by a health professional 4
- Use of a comprehensive fall risk program, such as I'M SAFE, which identifies patients at increased risk for falls and links them to a tiered-intervention falls prevention program 5