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We’ve talked about Falls a couple of times on this podcast, most recently with Tom Gill about the STRIDE study and before that with Sarah Szanton about the CAPABLE study.  A takeaway from those podcasts is that fresh innovative thinking in the falls prevention space is welcome.

Today we talk with the twin sister power duo of Carmen Quatman and Katie Quatman-Yates about an intervention that is both brilliant and (in retrospect) should have been obvious.  The insight started when Carmen, an orthopedic surgeon-researcher, and Katie, a physical therapist- researcher participated in ride-alongs with EMS providers to patient’s homes.   They were stunned by the number of calls for lift assistance for older adults who had fallen. Going into patient’s homes was eye opening. There were trip hazards, loose carpets, some people were hoarders. And yet, after assisting the older adult to their feet, the EMS providers would leave. Their job was done. It’s not surprising that the number of repeat calls for falls is alarmingly high.  Addressing the root environmental causes of falls was not part of EMS providers’ job description.  In addition to stigma, practical barriers to older adults addressing environmental issues themselves abound. For example, Carmen and Katie found thousands of grab bars on Amazon (overwhelming), and when they called installation companies (handypersons), received different quotes if the person calling was a man or a woman.

So Carmen and Katie developed an EMS Community Partnership program.  EMS providers were trained to provide practical home modifications: installation of grab bars, removal of carpets, removal of other obstacles. They created a seamless link between this Community Partnership program and 911 calls for falls.  People who had grab bars installed through the program called their neighbors and say, hey you should get this too.  Word of mouth spread rapidly.  And the number of calls for falls dropped.

Eric and I enjoyed talking with Carmen and Katie about this innovative and common sense approach to addressing falls in the community.

In addition to the podcast, you can see more about this in Carmen’s TEDx talk.

Thanks to my wife Cindy Hsu for piano on Eye of the Tiger. Enjoy!



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Moderators Drs Widera and Smith have no relationships to disclose.  Panelists Carmen Quatman and Katie Quatman-Yates have no relationships to disclose.

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Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, who do we have with us today?

Alex: Today we are delighted to welcome Carmen Quatman, who’s an orthopedic surgeon and associate professor at the Ohio State University, and loser of three straight football games to my Michigan Wolverines. [laughter]

Carmen, welcome to the GeriPal podcast!

Carmen: Thank you. I’m excited to be here.

Alex: And we’re delighted to welcome Carmen’s sister, Katie Quatman-Yates, who’s a physical therapist and is also associate professor at the Ohio State University.

Welcome, Katie, to the GeriPal podcast.

Katie: Thanks for the opportunity.

Eric: Well, what are the odds that two family members focus on a similar topic and do research together? This is a first for our GeriPal podcast, right, Alex?

Alex: I think this is a first.

Carmen: Have you guys ever wondered if you could clone yourself? I have to tell you, it’s a very powerful tool. We’ll be able to be in two places at once. It works really well for us. [laughter]

Alex: We love the family theme. My wife is actually going to play piano on the version that people are listening to on the audio podcast.

Katie: Awesome.

Eric: Well, before we jump into the topic, which we’re going to be talking about falls today, who has a song request for Alex?

Katie: I suggest “Eye of the Tiger.

Eric: Why “Eye of the Tiger”?

Katie: Well, relative to the fall topic, I think whether we’re trying to prevent them, which takes kind of a fight in of itself, being prepared and making sure our environment is set up for success, or if after an injurious fall, it’s a fight to get back to pre-injury levels, and so I just feel like “Eye of the Tiger” speaks to that journey well.

Eric: I imagine now Sylvester Stallone doing his… Yeah.

Alex: That is true. Well, I remember this song, playing this in band in sixth grade. I’m dating myself here. I think it was Rocky IV, right?

Eric: Rocky IV was great. That was the montage of montages.

Katie: Yeah, running up the steps.

Carmen: Yep.

Alex: All right, here we go. Here’s a little bit of “Eye of the Tiger.”


Carmen: Nice.

Alex: Oh, that’s fun.

Eric: That was fabulous. That reminds me of, again, Rocky IV. Was it Ivan Drago, Captain Ivan Drago? Yeah.

So let’s jump into the topic about falls. I’d love to ask both of you, I’ll start off with Carmen, how did you get interested in this as a topic?

Carmen: Yeah, I think that’s a great question. Katie and I both had the opportunity to play sports in college. We played volleyball. And when I went into orthopedics, I was really excited about helping athletes stay safe and healthy. And as I was going through residency, I ended up having to have surgery on both my knees at the same time. And when I was going through that journey, I came home to three stairs and I realized I didn’t know how to get into my own home safely.

And as I was recovering through it, I had this just really rocked worldview where I just felt so unsafe in my own home, and all of a sudden, I felt like I didn’t relate to athletes anymore. I just could see how hard it was for patients who had trauma or especially our older adults who were trying to navigate their home safely, how fearful it is to be in your own home. And that really transitioned to this idea of I wanted to understand falls, help prevent them, how people live safely in their home, and not have so much fear, whether they’ve had a fall or they’re recovering from something. And so that really triggered my interest.

And then I did a geriatric orthopedic fellowship and that was really an exciting opportunity to help hip fracture patients, but then someone knocked on our door.

Eric: What’s a geriatric orthopedic fellowship?

Carmen: Yeah, that’s a great question. We helped start one of the first ones. So orthopedics, it’s a great specialty, but within it, we treat people of all ages. We have a pediatric specialty, and on the flip side, we have many, many of our patients are in the older adult population and we don’t really take into account some of the complexities of that care in the same way, and I really wanted to learn about hospice and palliative care and how to best guide patients. So I got to help create one of the first geriatric orthopedic fellowships. It was a great opportunity to really explore new spaces too.

Eric: Oh, that’s fabulous.

Carmen: Yeah. And so someone knocked on my door when I was in fellowship and said, it was the EMS coordinator, the emergency medical service coordinator next door, our educator, and said, “Hey, we have this really weird problem. People keep calling 911 for falls and then we go out and we help them because they fell and then they weren’t able to get back up again. They weren’t hurt, they didn’t need transport, and we were seeing the same people over and over again. What do you think of that?” And I was fascinated, I’d never really thought about it. I was on the receiving end of fixing the problem.

And so I asked to go on a route lift assist, and it was just eyeopening. It was eyeopening to see patients in their own home. I think, as providers, we don’t get to see that. So that was great.

Eric: We got a lot to break down there because there’s some words I may not have known before, like lift assist, but before we do, I want to give the same question to Katie. Katie, how did you get interested in this topic?

Katie: Well, actually I got a PhD before I became a physical therapist, and my coinciding efforts with Carmen really stem from the fact that my interest is in systems thinking, systems modeling, and doing research on complex systems and how we leverage our knowledge of complex systems to solve big problems. And then the physical therapist component, we’re always helping people recover from injury, and as they’re recovering, we’re still worried about them falling again.

So when Carmen and I both started at Ohio State together, September 1, 2017, and we started our first day as faculty members here, she started pursuing this topic. She started during her fellowship and she shared with me one of her areas that she was going to write toward a grant. And I said, “Wow, this is really an awesome system solution. Can we work together on this?” And that was kind of the combination of our research in this space together.

Eric: That is an amazing dynamic duo story right there.

Alex: Yeah. I think it’s particularly interesting for our listeners that one of the things that fascinates me about this, and there are many things, is that Carmen, as an orthopedic surgeon who’s mostly hospital-based and OR-based, you are really interested in this issue of what happens to people, what’s happening with people who are falling at home, which might seem at first incongruous, but it shows that you have that wider lens of trying to appreciate and improve health for older adults wherever they are and prevent their orthopedics issues so that they don’t end up in your operating room.

Eric: How much of orthopedic fellowship or residency is focused, or I guess fellowship, is focused on prevention of falls? I know there’s probably a lot on how to do the actual hip fracture surgery.

Carmen: Yeah. I think of sometimes I’m in direct contracts with myself because it’s like I went into trauma to fix broken things and the prevention is not in that space, but I pursued, out of curiosity, my PhD earlier, so I’d say very few. We don’t do enough of that kind of multicenter approach to the patient. But thankfully, I think the osteoporosis edge that has kind of come out is we do spend a lot of time educating about bone health optimization. I wouldn’t say that people will call themselves fully skilled in it, but I think at least we bridge that gap and people are starting to think of osteoporosis and preventing that second fracture or at least think about it.

Alex: And Katie, how about in PT? How much of the education there is focused on prevention of falls?

Katie: Actually quite a bit. I mean, like I said, whether it’s primary prevention, meaning we don’t want it to happen in the first place, or secondary or tertiary, it’s a really big part of what we’re always looking for. So our students are trained heavily in looking for factors that are contributing to falls and how we can put in physical therapy solutions to try to mitigate their risk for falls.

Eric: Well, maybe we can dive into that. So in particular, I’m interested in falls at home. What do we know about how common they are and what happens with falls at home?

Carmen: Yeah, I think that’s a really great question. I think part of my even own interest is we don’t really know what goes on in the home. When you look at the people who actually call 911, for example, about a fall, most of the time that falls occur in their own home about 80% of the time. There’s still things that happen in parking lots and things like that. And one of the first early misconceptions I made was, even early in this work, was most people were older adults that were calling for falls. And the truth is, we all fall, we all trip, we all have accidents and people are embarrassed about falls regardless, so I think it’s very under-reported regardless.

What we have found even going into this is more and more older adults are actually less likely to report that they had a fall if they were able to get back up again. They don’t want to even acknowledge to themselves that they’re having issues potentially.

Eric: Why do you think that is?

Carmen: Yeah, I think I still remember a quote someone said, “Why would we talk about this? It’s embarrassing when you fall regardless of how old you are.” And that hit home. I was like, “Yeah, when you fall outside, you look around, like, ‘Who just saw me?'” But I think even more so, it’s sticky if you’re really trying to hold on to quality of life and living in place, you don’t want to let go of even your decor or things like that that might be at risk. Admitting to yourself is hard, admitting to others in case that might mean you have to leave your home is really, really scary. And so I think that that underreporting is a real thing. You can hide it easier in your home than you can externally.

Eric: Yeah.

Katie: Yeah, and when we talked to people about it, we’ve done a lot of interviews of older adults and people at a high risk for falls and even caregivers and people who are concerned about their own loved ones being at risk for falls, and a lot of times they talk about, “I’m willing to put in prevention solutions, but I don’t want to talk about it in the negative like, ‘I’m vulnerable,’ or, ‘I’m at risk.’ I would rather talk about it like, ‘Make me stronger,’ or, ‘make my house more friendly.'” They want to hear it in the positive, not in the negative because then it feels like they’re doing something on the positive rather than reacting to the negative.

So that’s always been a lens I try to keep in mind as I think about it and talk about it is that it’s not even that fall sounds like a negative thing and if we frame it the right way, it actually… We all want to be stronger, we all want to be safer, we all want to, if we fall, be able to get back up and get back up on our own. So if we could just kind of kick it in that direction, we have some good momentum.

Eric: And then Carmen, I interrupted you when you were talking about doing, what was it, a ride along with EMS for a fall?

Carmen: Yeah, yeah.

Eric: What happened? What happens on one of these, if 911 is called, EMS goes to see somebody?

Carmen: Yep. So I think it’s an enigma to everybody, right? We only know about it if we’ve ever had to call 911 and many of us may have. But what’s really interesting is to take it from the perspective of the EMS. So when they show up at the door, if they don’t know the patient, it’s a very first episode, they’re just kind of walking into this entirely new environment to a room that may or may not have been seen by people for years sometimes. People have pets, some people are hoarding, some people have packages in front of the door because they are very immobile because they can’t even move from bed to chair. So it’s just a wide-opening lens that most of us never really get to see if we’re on the hospital-based side.

And so for me, that was just transformative. I was like, “I have all these things I’m doing in the hospital to try to make people better and then I might be sending them right back to a big hazardous environment.” So from my lens, it was just eyeopening.

From their lens, it’s really tough because either they’re starting from scratch every time if it’s a new patient, but if you talk to them as you’re going along, you just hear this expression of frustration because a lot of times you’re going to the same person over and over and over again. And one of my favorite exercises to do is if I’m talking to an EMS group, “Everybody sit down and take a piece of paper, write the top five names you’re going to see this week,” and they all chuckle and they all have the same names. And so to them, the real frustrating part is they’re supposed to be treating people like it’s a one-time event the very first time, and the system of EMS is not designed to be longitudinal complex care, and yet that’s basically what we’re seeing happening. More and more people have been having to call 911 for falls and they’re not able to get up.

Eric: So you both published a paper in JAGS, what, 2018, ’19 looking at what happens to people? Wait, first of all, what’s the incidence of calling EMS for falls over almost a decade, I think like 2007 to 2016, and what happens to people afterwards? You want to go back, I know this is pre-pandemic. You got to go way back in your memory.

Alex: The Wayback Machine.

Eric: Yeah.

Carmen: The Wayback Machine, yeah. No, this was that first look when the EMS talked to me, I said, “Can we look at your data? This is fascinating.” They’re like, “Yeah, we just keep getting more and more calls.” So I had the opportunity to put my scientist hat on and help them look at their actual data.

I will start off with, from a scientist hat, it’s very hard to look at EMS data. Like any place else, they don’t use the same operational definition of what we might. So if I was like, “So if someone calls 911 for a fall, what does that look like?” And they’re like, “Well, it could be a heart attack and they fell, it could be a they actually fell over the dog, or it could be that they’ve been down for a long time.” And I said, “Oh. Well, that’s really tough. How do we analyze this data?”

So we had to go back to the drawing board and really define what that might look like, so if someone dialed 911 and they said they fell and if they got transferred to the hospital or not. So that’s what we looked at, and we looked at it over a decade. And we have an aging population, it’s not unexpected that that number would be going up, but it was going up exponentially.

But what was really interesting is the transport to the hospital was actually going down in their system. So what we found is up to 30% of people would call 911 again for a fall, and of those calls, some people became very high-utilizers and so they would call 911 over and over again. And one person even called the system 75 times and that was just a light-bulb event for me. I had no idea that people were calling 911 that much sometimes. To me, that was like a smoke detector, like this opportunity in a space that are there things we could do to stop that process? That’s when Katie got involved. She was like, “This is crazy. How do we not know that this is all going on?”

So I want to define lift assist for you real quick, if that’s okay.

Eric: That’d be wonderful.

Carmen: Again, the definition could be a little bit vague in the real world, but essentially people will call 911 if they fell on the ground, sometimes they were getting ready for a shower or they’re too weak to get up, they got into a position that they’re not capable of getting up out of, plus or minus having support at home. So if they have a… What you might often see is a larger male fell at home, their spouse couldn’t help lift them up or their spouse is just as sick and not able to do things, they’ll call 911 frequently because they know the action’s going to happen. They don’t have any ways to stop it.

And so the idea of a lift assist is where they get call 911 for help, they lift them up to a position of mobility, and then they leave again, but nothing was addressed to stop them from happening again. So that same pattern can just repeat over and over and over again and the patients even know it’s going to happen. It could be something-

Eric: And a third of people, that’ll happen relatively quickly afterwards, and many, on the same day, they got called out for another lift assist. Is that right?

Alex: Oh, wow.

Carmen: In the same spot, yeah. So that, to me, was the most fascinating part is to hear the frustrations on the end of the 911 providers who were going out and like, “We see this happening, we actually know there are some solutions, and there is nothing we can do.”

Eric: Yeah, it just shocked me. I think one of them was… The other thing that shocked me, half of all calls happened within another two weeks of the-

Carmen: Yes.

Eric: Yeah, that is amazing.

Carmen: Yeah. I think once someone becomes kind of a high-utilizer, it’s a slippery slope. There might be some space between the first or second call, but then if you start to see that second, third call come in, they really go very quickly down that slippery slope of high utilization.

Eric: Hm. So Katie, I got to ask a question, as a doctor, this is like, “Oh my gosh, this is happening. This is eyeopening.” As a physical therapist, is this new news or-

Alex: Are you like, “Duh”?

Eric: … you just want to slap the doctors and say, “What do you think is happening?”

Katie: Yeah. I mean, we work at a different part of the health system a lot of times, although we have acute care therapists who do the same thing, but the gap in information flow is similar. We require, especially if they’re coming to us, we’re often making them come to our clinics if they’re going to get treatment, and we’re relying upon what they report to us, and are they going to tell us, “Oh, my steps are uneven and actually my railing’s all rickety and I’ve got boxes everywhere”? They may not think to ask or provide that information. We may not think to ask the details that would make them report that information.

So I also went along on some ride-alongs and it was relatively eyeopening, and not just from the sense of the state in which they’re at risk or living in sort of a hazardous environment, that wasn’t what was surprising to me. It was how broken the information streams were because they knew so much and they could tell you so much and many of them had skills to do something about it. Sometimes it’s unskilled things. It’s just removing the rug. They need just somebody to physically help remove the rug or remove this piece of furniture.

Other things that are kind of eyeopening are the ways that people find to compensate around their house to get by. So they’ll have a chair here and they’ll sit and then they know that they can stay here for a little bit while they get this done and then go to the next thing. They have their house set up to navigate it, but that doesn’t make it safe. It just makes it so that they can function and get the things done for the daily things that they need to get done. So they’ve come up with their own solutions. We even talked to a couple ones where one of them had fallen and broken their arm, the other one had leg issues, and they had set up their kitchen so that if they had to take a pot from the stove to somewhere else, they each would take a side and they’d set it on this thing and then they’d shift around and then they’d move it to the next counter. So they’ve come up with solutions together, but to see it in action as really eyeopening.

Alex: Just like creative accommodation, which may not be and oftentimes is not optimal accommodation.

Katie: Right, right. Yep.

Eric: Well, I guess what do we know about the evidence for reducing or preventing falls at home? The one thing I remember, way back from fellowship too, is just telling somebody or educating them about fall safety and what they should be doing at home never works. I’m not sure if that’s still true, but that’s what I remember. What do we know about evidence-based solutions for fall reductions at home?

Carmen: I think education and action are two different things regardless from a human behavior standpoint, and even our own problem of did they understand what we just acknowledged?

One of the things that was… I mean, if you told me today, and I’ve done this, to go get a grab bar installed, that’s overwhelming to me and I have all the financial means of doing it and friends and family that could keep it, but even that action sounds overwhelming, like which one do I pick? Where do I put it? What does it look like? Is it safe to trust it? All those things kind of go through my mind and that happens to everybody regardless of your means. So we can tell them, great education, we know that some of these solutions work, but the action part is a huge gap.

Eric: Didn’t you do a study on that, getting quotes on grab bars?

Carmen: Yes, we did.

Eric: The only thing I remember from that is when the female researcher called, they were quoted $30 higher than when the male researcher called. Is that right?

Carmen: That’s right. Yeah, yeah, absolutely. So we did it only out of frustration. So one of the solutions we can get into, we talked about it with our fire department, is we had a small grant to study putting grab bars, home modifications in place if it was identified, essentially philanthropy money. But that was a small pot of money and we went to first call a handy person, it was going to be $500 for a consultation, let alone the installation, and we were like, “This is absolutely cost-prohibitive. We’ll get four people done.”

So when we were talking with, this is that kind of co-creation, when we talked with the paramedics that we work with, they were like, “Well, we put in smoke detectors all the time. We’re legally approved to do that,” and they call themselves the ladder experts. They’re like, “So why can’t we install grab bars? Half of us are doing it on the side anyway.” And so we were able to work with the legal department and get that solution in place and that was great.

But in that first action of calling those places, we’re like, “Well, this is actually kind of horrifying.” Someone’s about to discharge from a hospital, we tell them they need to get grab bars. If they’re going to get their total knee done, they need grab bars or something like that, and you can’t even find a place that we can do it. So then we just started calling around locally to figure out what that would be like, and it was just almost insurmountable. Most people, they were advertising but not doing, or at some point if you called one day, they would say they do it and the next day, they said they don’t. But the most striking thing to me was definitely that they would give you different quotes based on who called. So just-

Eric: Terrible.

Carmen: … crazy.

Eric: Okay. So let’s go back to evidence. What works in reducing falls at home or preventing or reducing?

Katie: Well, if we just look at what we can do ourselves for our bodies, I mean strengthening, balance training, working on motor control, keeping ourselves fed so that we maintain our proper nutrients in our body so we can maintain an upright position, those are all key things an individual hopefully would be trying to do as best as they could. Same thing with kind of medication management. All of these are factors that are on the individual level.

When you start to move up the scale about beyond what an individual can do and what we can look around in the environment and who can provide those resources, we also know that there’s evidence out there to support that doing something in your home from the environmental standpoint, like installing grab bars or removing rugs or even just looking at the key places where we expect a fall would happen, like in the bathroom, hallways where there’s poor lighting, there are factors we can work on in the home. So the evidence is there for that.

Increasingly, we’re seeing people try to move a little bit more to the community level. What can we do as a community? And this is where the evidence for the community paramedic or the EMS partnerships are starting to show that we can do something collectively to try to affect change at the community level by providing things like easy access to grab bar installation or making sure we have solutions that people can call to in a non-emergency situation for the help around fall prevention. So I think that’s kind of the state of where we’re at right now that allows us to wrap our arms around people and create the safety net, a layering of protections across the factors that might contribute to falls.

Eric: So let’s break that down. Maybe I’m going to start off with the last one is I know you all are working around working with, on this higher community systems level, working with EMS. Do you have any data to support working with EMS to do fall prevention actually helps with fall prevention? Seems right, but is there any evidence?

Katie: Yeah. So we’ve published a couple of studies ourselves and we’re finding more and more groups that are trialing in different capacities. So I think that the evidence is starting to get there.

It’s complicated because you need a way of resourcing it, and we’ve actually talked a lot to the EMS programs, and depending upon the state that you’re in, they’re funded in different ways, and if they… Fall calls and then transports to the hospital, if they’re funded by taking people to the hospital, they’re actually defunding themselves by reducing the number of calls and the transports to the hospital on the fall front.

Eric: Oh, no.

Katie: Yeah, so there’s some societal factors and policy factors that can directly inhibit people from A, studying it, and B, actually putting it into place.

But there’s some other studies. I’ll let Carmen talk a little bit more about where the foundation of the work came out of actually her interest in looking at what the UK was doing. And Canada has a whole model around community paramedics, but it doesn’t actually result. They’re not necessarily targeting falls. They’re targeting other things, like chronic care. And so that was the foundation of it. We have a lot of evidence around chronic care conditions, but not necessarily in the fall space.

Carmen, you want to contribute to the question?

Carmen: Yeah, I think I’d like to add that I think the biggest piece that we were learning from this, also in the UK data shows us too, is the time of a 911 call is a really intense event and acting in the moment can be very overwhelming to anybody in that space. So what the UK data has shown, regardless of what it is, an intervention can be really challenging. So one of the big pieces of this is that idea of a referral at a second time when they’re less overwhelmed and stressed to figure out what happened. We do that in medicine all the time. We do the breakdown of the sentinel event, but we don’t do it right then. We establish what we need to do right no, and then we go back and we review. And that’s kind of how I view this as being an opportunity intervention.

And we’ve been doing… Whether it needs to be the paramedic doing the intervention or not, I don’t know. I think one of the things we’re most interested in is how can we leverage these 911 calls and these collaborations with people who have… Patients love the paramedics, the EMS team. They’ll open that door for them over anybody almost, a police officer. When you ask stakeholders, they just feel safe. And many of them, they have a rapport. They know what their dog’s name are sometimes, which we don’t even have from a primary care level, and so that’s kind of a fascinating lens of opportunity.

The other space we hear a lot is like, “Well, my doctor told me this,” or, “my kids told me this,” but for some reason people seem a little bit more receptive from the paramedics because that event was scary enough to trigger something but also feel safe for them. So it’s a very interesting trust dynamic there.

But I think you asked about solutions. There’s some really great studies that have come out looking at this STRIDE, CAPABLE, I think are really good studies that have come out talking about other interventions in this space. What triggers that to those systems I think could look different. The effectiveness looks different. I think the biggest-

Eric: Who’s going to pay for it’s always a question, right? Because-

Carmen: Yeah, who’s going to pay for it? The biggest jump we’re seeing is evidence into action. We all know, we see flags coming up left and right. Katie is a complex system scientist. What do we need to do to be “precision medicine” at the point of care in a meaningful, feasible, fundable way? And I think that that takes a lot of creativity and it may not be… One of the things people talk about in the paramedic world or the EMS world is every department looks different. If you’re rural, your team may be entirely volunteer-based and kind of skill sets vary drastically. And if you are in an urban city and gun violence is the biggest thing you’re tackling, you may have a community that’s falling, but that’s really not your focus.

So community-based solutions look different everywhere, but if we can define a model for a flag to an intervention that’s effective, it could be a really powerful thing.

Eric: Well, let’s talk about that because we actually did a podcast on CAPABLE. God, I forget how long ago. So two years ago, three years ago, I forgot when CAPABLE came out?

Alex: Something like that, yeah.

Eric: What I remember from CAPABLE, you had three main interventions. You had a nursing intervention that looked like pain, goal setting. You had an occupational therapy intervention where they actually, I think they went to people’s homes. And the most interesting thing is they actually paid for a handyman to do these things like these installs, which was probably the most novel component of it. And in that, they found it significantly improved ADL function and life space. And what we see is with falls, you see a significant contraction of life space, which is probably one of the mechanisms.

What are your thoughts of CAPABLE and is there a scalability to that?

Carmen: Yeah, I think it goes back to when I first saw CAPABLE data, it was coming out at the same time we were starting our work and I was so excited about it. And I think it has such… Again, models work differently everywhere. If you have a community where you can find a handyperson that can put it in for $25 to $30 bucks an hour, that might actually work really well.

The model that has been working for us for doing intervention for home modifications was honestly that we could do it at cost with wholesale products on a quick turnaround time period, which can be really, really difficult with a handy, as we published in that community-based thing. CAPABLE is really cool though because I think they also bring out different… The idea is they’re bringing a group of people, a lot of perspectives to tackle the problem. I don’t think, when we work in silos, we’re doing that. And so I think that that’s one of the most exciting parts about CAPABLE too is that we’re able to… They’re starting to break down some of those communication barriers.

Katie: Yeah, creating that team. And I think just to add to what Carmen was saying, and one of the differences in the way that we approached it is again, kind of thinking from that complex systems piece, when you can situate it in the community because the municipalities, the cities that the fire department and the EMS units are usually affiliated with, that creates a boundary. And then you just have to set up that particular boundary space with the resources that they need to be able to identify who needs the help and then to put processes in place for making sure they get the help. And so the community paramedic model or the EMS model creates that unit, even outside of our own health systems because in our given city space, they can hit up multiple health systems and their primary care might be in one place and we don’t have the same knowledge of the resources in that immediate community area.

So by resourcing that particular community and then setting them up for sustainability, I think that’s the other key. CAPABLE and others, they’re kind of grant-dependent, and then you’re hopeful that some unit will take that on and carry it forward, as opposed to maybe reversing the thinking and saying, “Okay, let’s create this unit for the vision of them carrying it forward once the grant funding runs out,” and making sure that those processes and resources that we put into play is something they could keep going.

Alex: Sustainability.

Katie: I think that’s the difference between sustainability, yeah, of those things.

I think one of the reasons we were successful is we were able to partner with a group or a community that was ready to take that on. They already had some resources and they knew this was a problem for them, they had an aging community. And once we were able to help set them up to use their own data for identifying who was at risk and then helping them develop some processes for it, it became pretty apparent to the city officials that they wanted to keep it going. So they weren’t going to be as dependent on grant funding because the city itself started to realize the benefits and the potential of it. So it became something they wanted to keep resourcing themselves, as opposed to our classic research model, which might be we’re resourcing from a university or an academic medical center or maybe a community group that isn’t necessarily in a defined unit, and so then they’re just hoping, “We’ve learned something. You should embrace it.” You know?

Alex: Mm-hmm. I don’t want to bury the lead because we’re in the last quarter or so, last 15 minutes of the podcast. We’ve talked a lot about kind of around what you’ve done. I wonder if you could just describe in detail for our listeners what it is that your intervention does. Clearly, it works with the EMS providers. What do they do?

I love… Carmen has a TED Talk that we’ll put a link to in the podcast, TEDx Talk where she has pictures of EMS providers learning how to put in grab bars and things like that. Can you tell us, but if you could use in words for the majority of people who are listening to this podcast, what you did?

Carmen: Sure. Yeah, I think that’s great. So I think the first piece of this is building rapport all the way around. So one of the first things we mentioned that we went on ride-alongs, we had the team that we were working with come with us to the hospital and see what the patients’ experience were and just really give everybody the lens in the background. I think that that’s just laying the foundation. That’s where rapport-building. I could go in as somebody and tell the patient something in their office, but I will tell you how much more it meant to them when I went on a ride-along and I started talking with them in their home.

And so what we started with was ground-building. We tried to really make this community stakeholder base. I had a lot of ideas, but I didn’t know if that would be adoptable. So we built a stakeholder team that really informed a lot of our early work. We called it an agnostic group of gritty people focused on fixing the gap, and we asked everybody to just bring a friend. And that has grown astronomically. And the co-created solutions have been awesome because all of a sudden, we’re hearing what the state of blah, blah, blah is doing and everybody’s partnering with each other. So that’s kind of that community-based, participatory research model where you just generate ideas that will be adoptable. We need them to want to adopt it.

Probably the most powerful intervention really has been the grab bar piece of it. This is home modification. And I will tell you that from three arms. One, when I, as a doctor, tell somebody, “You need a grab bar,” I don’t know what happens with that, but some of the people that participated early on became the biggest champions of this program. They’re like, “Listen to this. You can get a free grab bar by these really great people,” and then people started handing out flyers within their own condo complexes and community base. People would move and they would bring it over. So it was like this kind of plant the seed of dissemination was really fascinating, and we haven’t been able to publish any of that. So I think that capturing in a research lens what actually has been possible is so hard because the intervention has just spoked out in every wheelhouse.

So one of the first things that we did was we identified within the firehouse who felt comfortable, safe, and has done grab our installation. Some of the people were running their own handyperson services along the side. They offered to basically hold a teaching session where we talked to, I think, Lowe’s or Home Depot, and they gave us free stuff to basically practice on tiles and see where their studs are and make sure that they knew how to install based on different types of textures. We learned a lot, like don’t let patients pick their own grab bars because we got these weird decor ones that just wouldn’t grab, and we wanted to make sure that they were safe. So we basically said, “This is what you get. If you want it, you get it. This is what you get.”

And then they were teaching each other and now they’re teaching other firehouses. And what’s even more interesting is that they’ve moved from the model of the fake walls to actually, before they do their training sessions and burn down a house, they’ll do the training within the houses that they’re about to do their fire training in. So that’s this kind of win-win-win cycle.

Alex: That’s great.

Carmen: And now they’re teaching rural volunteer services as well. So it’s kind of an interesting thing. There’s a legal component, but I would say grab bars are probably one of the highest lifts. There’s so easy modifications, or moving rugs, putting in motion detector lights, and it’s not even…

One of the things we also learned, to be honest, I wanted to share before we close, is that we can’t move the needle on everybody. The highest utilizers are probably not going to be able to become non-fallers. And so we help people develop their triaging system about where can they take the people who are in this very vulnerable state that we can still move them back into not calling often? And that’s a really big win. The paramedics as a whole adopt it when they’re like, “What happened to so-and-so? We haven’t had a call from them in forever.” And one of our teammates, she always says one of the best things was like, “Did so-and-so die?” And they took that to heart as an amazing success story because if that high-utilizer is not even calling 911 anymore, then they moved that needle.

So I think the intervention still has to be at somewhat of an individual level and the intervention on individuals may not be able to move the needle as far as you want, but some people, with just a little bit of education and rapport and team-building, you can move that needle really far. And that’s where you start to see that bigger community shift.

Eric: Is there a component at all of feedback? I mean, because we started off talking about people don’t like to bring this up with their healthcare providers, but there’s an important role for the primary care provider to think about de-prescribing, thinking about orthostasis, there’s a lot of medical things that we can do in the office that potentially are really important with recurrent falls. Is there any feedback in any of these to the PCP?

Katie: I was going to jump in. In addition to the grab bars, we have also helped train the EMS professionals in different lenses about screening. Is the environmental space, what does it look like and what are the potential hazards? Or just watching the person walk and does it look like they have unsteadiness in their gait? Who might you refer to in the health system to address the unsteadiness of the gait? Or does it look like their medicine is out of control and they need somebody to help reconcile that? Get them back in the PCP office.

And then they’ve also been able to work on their own communication streams with the PCP offices, even more so than we from the health system where we have people coming in from all over to the different offices. Because they’re in their community, they have a pretty small pool of PCPs that most of their community members are seeing. And so once they build their own relationships with the PCPs, they’d be able to track down and see what their network of most common primary care offices are and build their relationship out to the PCPs. That creates information streams for them that weren’t their previously.

So yes, I think that’s the biggest. But the lens that we’ve been able to offer is this added safety net feature, and then how can they help facilitate communication streams and interventions that should be hopefully going on just by augmenting them, making sure that, “Hey, did you follow up with your PCP? Did you know that they can help you with X, Y, and Z? When’s the last time you saw your PCP? Do you even have a PCP?” They can ask those questions.

Or we had some success too with if they know somebody has now been referred to a physical therapist or is being treated by a physical therapist or occupational therapist, communicating with that occupational physical therapist about, “Where do you think the grab bar should be? How high should it be? Which room do they need it in?” Or, “We see their equipment’s a little bit old, should we help them get it updated?” That kind of thing. So helping them just know how to leverage their own resources because historically, that’s not the space of EMS. They’re not worried about necessarily communicating with these other allied health services in ways that we’re asking them to. So just kind of expanding their lens about the healthcare system and how they can leverage it better.

Alex: And what did you find? Did falls fall?

Katie: Yeah. Well, they had a lot, in the particular community we were working with with the study I think you’re referring to, they had a significant decrease in the number of fall calls that they had as well as the number of fall calls that resulted in transport to the hospital.

And so part of that for them was getting together and understanding who their highest utilizers were because before, their ability to use their own data for finding that was shift one would see it, shift two would see it, shift three would see it, but they weren’t necessarily coordinating across the shifts to do anything about it. The other part of it was creating a mechanism where they would send a team back in in the non-emergency state. So the patient maybe has fallen, all they asked the people on site to do is put a little referral in for the team that would come back in a non-emergency situation to evaluate the home and help coordinate the resources.

Carmen: That’s another one of our JAGS studies actually, I think it came out in 2021 or ’22, I can’t remember, that talks exactly like that, like creating a connection of communication. We basically gave the 911 providers a button to push. If they could hit that button to say, “Refer,” just like we do in the hospital, all of a sudden they can upsurge the connections that need to happen. It happened so fast and so quickly, we actually had to shut down the grab bar installations so they could recalibrate the help because all of a sudden that telephone game, we just stopped it and said, “Direct line.” That was a really powerful, cool thing to see too.

Katie: So as a result, they didn’t have to transport as many people to the hospital if they did fall. And a lot of times, the fall wasn’t injurious in the first place. It was just a person who’s at risk, who’s going to maybe be falling, maybe injured later or not, but will likely call again, but putting some different resources in so they’re not having to use EMS for whatever health condition that they’re actually struggling with.

So the fall-related calls lessened because they have resources to use at different places. And then the transports lessened because they were able to put solutions where they didn’t have to transport to the hospital even though they weren’t injured. They were transporting because they needed coordination of care that previously they weren’t able to help with.

Eric: Okay. In our last kind of lightning-round question, what’s next for you?

Carmen: Oh, I think the biggest piece is we have to start to see policy change. There’s no… I didn’t say this number, but if you call 911 for a fall and they come out and help you for a lift assist, there’s no reimbursement to the transport team because-

Eric: If you had a magic wand, what would your policy change be then?

Carmen: Yep. One, reimburse for lift assist. Policy change two is identify EMS as an opportunity in this space to do intervention.

Katie: Yes, and reimburse them for doing the intervention.

Carmen: Reimburse them too.

Katie: Help pay for them to go and do the evaluations and provide the resources and care coordination as part of the healthcare team.

My one would be on the acute care space. I think there’s a lot we can do while people are actually hospitalized on educating them and setting them up to go home in a more successful way. A lot of times, it’s like, “How fast can we get them discharged?” And they’re getting passed through the admission to discharge and they have a lot going on, but they also have a lot of wait time and a lot of opportunity for us to intervene if we, as a health system, could set ourselves up. So what is that layering of the lens while somebody’s actually even in the hospital to set them up to go home and be as successful as possible for not falling again?

Eric: Well, I love both of what you’re doing, and I want to thank you for being around. But before we end, I think Alex is going to give us a little rah, rah, rah.

Alex: (Singing).

Eric: I love watching Alex play the piano with one finger because that’s the only finger he has because he… Speaking of falls.

Well, with that, Katie, Carmen, thank you for being on the GeriPal podcast.

Carmen: Yeah, thank you so much.

Katie: Thank you, guys.

Eric: And thank you for all of our listeners, and don’t forget, you can claim CME credit for this episode.

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