INTERPROFESSIONAL PRACTICE AND EDUCATION
Physical and Occupational Therapy Practice Improvement
Following Interprofessional Evidence-Based
Falls Prevention Training
Emma Wheeler, DPT
Constance L. Coogle, PhD
Robert C. Fix, OTR/L
Myra G. Owens, PhD
Leland H. Waters, PhD
AIMS: Evaluate changes in physical therapy (PT) and occupa-
tional therapy (OT) practice following evidence-based prac-
tice (EBP) interprofessional modules that teach assessments
and interventions to reduce falls in community-dwelling older
adults. METHODS: Medical records of post-fall patients in
three Programs of All-Inclusive Care for the Elderly (PACE)
sites were analyzed to assess differences in documented falls
and the OT and PT use of EBP assessment and interventions
implemented following fall prevention training. RESULTS: In
training year 1, PT demonstrated a 34.6% practice improve-
ment in risk assessments performed (z=3.0, p<0.005). In train-
ing year 2, PT demonstrated a 66.7% practice change in the
implementation of EBP interventions (z=2.1, p<0.05) and OT
demonstrated a 22.2% practice improvement in the imple-
mentation of recommended EBP interventions (z=2.0,
p<0.05). In training year 3, OT achieved a 6.8% increase in the
execution of home environment modifications (z=2.0,
p<0.05), and PT demonstrated a 23.3% practice improvement
in the implementation of recommended EBP interventions
(z=3.1, p<0.005). CONCLUSION: The delivery of EBP assess-
ment and intervention training modules for falls prevention
resulted in PT and OT practice changes and improved adher-
ence to published guidelines. J Allied Health 2018; 47(1):9–18.
ADULTS OVER AGE 65 will comprise 20% of the
United States population by 2030, and the future
healthcare workforce may not be adequately trained to
Dr. Wheeler is with the Department of Physical Therapy, Drs. Coogle,
Owens, and Waters are with the Virginia Center on Aging, and Mr. Fix
is with the Department of Occupational Therapy, School of Allied
Health Professions, Virginia Commonwealth University, Richmond, VA.
Funding for this research provided by the Bureau of Health Profes-
sions (BHPr), Health Resources and Services Administration (HRSA),
Dep. of Health and Human Services (DHHS), under grant no.
UB4HP19210 (Virginia Geriatric Education Center). Funding for
REDCap provided by grant award no. UL1TR000058 from the
National Center for Research Resources (NCRR). The authors report
no conflicts of interest related to this study.
IP1790—Received Oct 15, 2016; accepted Mar 7, 2017.
Address correspondence to: Dr. Emma Wheeler, Dep. of Physical
Therapy, Virginia Commonwealth University, 1200 East Broad Street,
Richmond, VA 23298-0224, USA. Tel 804-828-0234, fax 804-828-8111.
ewheeler@vcu.edu.
© 2018 Association of Schools of Allied Health Professions, Wash., DC.
9
meet their healthcare needs.1 Thirty percent of older
adults fall each year, resulting in over $30 billion spent
annually in medical costs.2 Falls in older adults are the
leading cause of fractures and injuries that result in hos-
pitalization, disability, and increased nursing home
admissions.3 The cause of falls in older adults is multi-
factorial, stemming from intrinsic and extrinsic factors,
some of which are modifiable.4,5
A growing body of research on risk factors, interven-
tions, and strategies to prevent falls has provided evi-
dence for the development of best practice recommenda-
tions for fall risk screening. The American Geriatrics
Society/British Geriatrics Society (AGS/BGS) have pub-
lished a clinical practice guideline for the prevention of
falls in older persons.6 The guideline emphasizes multifac-
torial fall risk screening, targeted assessment, and individ-
ualized interventions that are effective for reducing falls.6
The Centers for Disease Control and Prevention
published a toolkit called the STEADI (Stopping Eld-
erly Accidents, Deaths & Injuries) that outlines best
practice recommendations for fall risk screening and
interventions.7,8 The STEADI guidelines recommend
all health care providers ask older adults if they have
fallen in the previous year and if they have concerns
about balance or walking. Elders identified at risk for
falling should be referred for a multifactorial assess-
ment that includes measures of balance, mobility,
vision, safe performance of daily activities, and home
environment safety. Physical therapists (PT) and occu-
pational therapists (OT) routinely evaluate these fall
risk factors and then prioritize findings into an individ-
ualized client-centered plan of care.
Additional guidelines published by The American
Physical Therapy Association (APTA) and the Ameri-
can Occupational Therapy Association (AOTA) fur-
ther outline the role of these professionals in the pre-
vention of falls in older adults.9,10 One criticism of the
current published clinical practice guidelines for PT and
OT is that they lack specificity. The APTA recom-
mends that more precise screening and assessment
measures with validated cut points and more guidance
for interventions such as exercise dosage are needed in
PT.9 Leland et al.11 recommended a more defined and
perhaps expanded role for OT in fall prevention, with
additional research needed to evaluate OT’s role in
managing postural hypotension and medications and
in modifying risk behaviors to reduce fear of falling.
Although substantial evidence demonstrates screen-
ing for risk factors and applying targeted interventions
to reduce risk can prevent falls, falls in older adults con-
tinue to be a persistent problem. Success in fall reduc-
tion may be limited because many elders are not aware
of fall prevention measures and the adoption and appli-
cation of the published evidence-based guidelines is not
widespread in clinical practice.12–14
Medical record review has been used by other
researchers to demonstrate also that fall practice guide-
lines are not fully embraced by practitioners. Said et
al.15 found that patients at risk for falling often did not
receive a comprehensive assessment. Rubenstein et al.16
found community-based physicians do not fully evalu-
ate and document patient falls, which could lead to
inadequate recommendations; the authors advocated
for more adherence to published guidelines. Phillips et
al.13 suggested that the lack of dedicated training of
healthcare professionals and access to appropriate
resources can be significant barriers to implementation
of guideline recommendations in clinical practice.
Thomas et al.14 showed that in acute care assessment of
patients post-hip fracture, PTs documented fall risk fac-
tors less than 10% of the time and only 8% made a refer-
ral to a community service provider to further address
fall prevention strategies.
Interprofessional geriatrics education has been suc-
cessfully used to disseminate fall prevention evidence
and enhance practice changes among health profes-
sionals.12 Yet, training programs to teach health profes-
sionals how to best implement the published guideline
recommendations in clinical practice need to be better
evaluated.17
Falling continues to be a significant problem among
older adults, even though substantial research evidence
has shown fall reduction interventions targeted to older
adults at highest risk are effective when individually pre-
scribed by knowledgeable professionals.6 PTs and OTs are
uniquely positioned to become team leaders for evaluat-
ing fall risk factors and delivering individualized patient
interventions. Therefore, interprofessional instruction
designed to modify PT and OT practice behaviors and
improve adherence to published fall reduction guidelines
may result in fewer falls in older adults.
Purpose: The purpose of this study was to evaluate
PT and OT practice change following instruction in
evidence-based practice (EBP) interprofessional teach-
ing modules focused on EBP assessment and interven-
tions shown to reduce falls in community-dwelling
older adults.
10
Methods
Training Intervention
Six, 2-hour, face-to-face training sessions covering 7
learning modules (Table 1) were used to deliver the EBP
fall prevention content. EBP module content was derived
from the AGS/BGS community-based guideline,6 the
STEADI,7 and the APTA9 and AOTA10 best practice
guidelines for elderly fall prevention and management.
The seven training modules were provided to Vir-
ginia Programs of All-Inclusive Care for the Elderly
(PACE) sites. PACE provides interprofessional compre-
hensive medical and social services for community-
based adults 55 years of age or older who are nursing
home-eligible.18 In years 1 and 2, the training was pro-
vided at two separate PACE health systems. In year 3,
the training series was conducted on site at one PACE
site and simultaneously broadcasted to four additional
PACE sites within the same health system.
The sessions were taught by interprofessional teams
of faculty/clinicians and could include presenters from
social work, pharmacy, medicine, nursing, PT, and OT.
This interprofessional approach for training was
designed to mimic the interprofessional teams deliver-
ing patient care at the different PACE sites.
Interprofessional clinical practice sites were recruited
because the training focused on promoting interprofes-
sional practice. Interprofessional team training was
designed to increase the number of different professions
engaged in falls assessment and intervention as well as
to improve interprofessional team communication and
the development of interprofessional care plans. In
total, 70 professionals were trained across three training
sites, one site each year over the course of 3 years. How-
ever, only 26 professionals (see Table 2 for demograph-
ics) produced post fall documentation. Over the 3 years
of the study, 10 PTs and 1 PTA and 5 OTs and 1 OTA
produced post fall patient documentation. Physicians
and nursing were not included in the analysis to narrow
the focus of this paper on PT and OT practice changes.
The remaining professionals trained, such as adminis-
trators and transportation, did not document in the
medical chart.
Data Abstraction
An evaluation team (comprised of two doctoral-level
faculty and three research assistants) assessed clinician
practice change by abstracting medical records informa-
tion to a secure web-based application (Research Elec-
tronic Data Capture, REDCap).19 The evaluation team
employed a consensus review process20,21 for abstracting
information contained in medical charts. Each case note
was simultaneously reviewed by at least two data
abstractors and an arbitrator to reach a consensus judg-
WHEELER ET AL., Practice Improvement with Falls Prevention Training
 TABLE 1. EBP Learning Modules
Overall Objectives
Provide a definition of falls that can be operationalized in an interprofessional setting.
List at least 5 potentially modifiable risks for falls.
Conduct an interprofessional assessment specific to falls, including gait assessment.
Identify 5 evidence-based interventions that can reduce future falls.
Develop an interprofessional plan of care that can reduce the rate of falls and reduce falls.
Module Presenter Disciplines Objectives
The Evidence Base Gerontology/medicine/ U.S. Preventative Services Task Force (USPSTF) recommendations
pharmacy AGS guidelines when working with older adults
Design, results, and conclusions of Tinetti’s FICSIT trial
Findings of key systematic reviews that pertain to reducing falls in the elderly
Elements of successful programs that have reduced falls in clinical trials
Defining Falls, Risk Factors, Nursing/SW Strategies for achieving consistency in the classification and reporting of falls
and Teamwork Strongest predictors of fall risk among community-living older adults
Potentially modifiable risk factors for falling in older adults
The advantages to working on interprofessional teams
Barriers to overcome when working on interprofessional teams
Responsibilities of interprofessional team members
Stages of team formation
Establishing team norms
Traits of effective interprofessional teams
Falls Assessment Part I Pharmacy/SW Differentiate falls from other causes of involuntary postural change
Assessment tools that measure FOF
Key elements of screening for medication-related fall risk
Fear of falling as part of ongoing, interdisciplinary geriatric assessment
Empirically tested assessment tools that measure FOF
Important elements of a medication history
Key elements of screening for medication-related fall risk
Falls Assessment Part II Nursing/ medicine/PT/OT Nursing tools used in fall risk assessment
Role of the primary care clinicians in falls assessment
Common assessment tools used by PTs and OTs
Interventions Part I Pharmacy/OT/PT EBP interventions related to medication management and alcohol risk reduction
EBP interventions that address sensory deficit and environmental hazards
EBP interventions to improve muscle weakness, gait, and balance
Interventions Part II Nursing/SW Intrinsic and extrinsic risk factors
and Care Planning Individualized care planning strategies that target specific risk factors
Value of an interdisciplinary approach to care planning
Review of quality improvement data
FOF, fear of falling; SW, social work.

ment on what should be recorded. The arbitrator, as the
most knowledgeable member of the team about falls,
clinical practice guidelines, and medical charting prac-
tice, took the lead in facilitating agreement about case
note items. Operational assumptions underlying this
process were: 1) multiple perspectives were more likely to
be free from researcher bias, 2) no preconceived notions
existed about findings, and 3) the potential for group-
think was minimized by encouraging diverse interpreta-
tion of information and establishing a collegial environ-
ment of mutual respect and equal involvement.
All data were abstracted from patient medical
records at least 1 year after delivery of EBP training to
healthcare practitioners. The abstractors compared
three time intervals: T1 (baseline), patients who had
experienced at least one fall in the 3 months prior to the
site training; T2, the 3-month period immediately fol-
lowing the completion of the training; and T3, the next
3-month period ending 6 months post-training. Only
patients who fell and received post-fall assessment/
intervention from practitioners who received the EBP
training were included for analyses. A nonexperimental
within-subjects pre-post intervention design was uti-
lized. The goal of analyses was to determine whether
practitioner use of EBPs significantly increased in fall
patients as a result of the training intervention.
The data collection process was changed over the
course of the 3-year process. It was determined in the
second year that it would be more advantageous to doc-
ument implemented as well as recommended interven-
tions. Therefore, recommended interventions were
counted in years 1 and 2 only, while implemented inter-
ventions were only counted in years 2 and 3. Figures 1
and 2 show the formulas used to evaluate practice

Journal of Allied Health, Spring 2018, Vol 47, No 1 11

 TABLE 2. Demographic Characteristics of Practitioners Included in the Medical Chart Review by Training Year
All Years Year 1 Year 2 Year 3
(n = 26)
_________________ (n = 6)
_________________ (n = 7)
_________________ (n = 3)
_________________
Characteristic N % N % N % N %
Gender
Female 22 85% 5 83% 6 86% 11 85%
Male 4 15% 1 17% 1 14% 2 15%
Age Categories
20-29 3 12% 2 33% 0 0% 1 8%
30-39 9 35% 2 33% 2 29% 5 38%
40-49 4 15% 2 33% 0 0% 2 15%
50-59 8 31% 0 0% 4 57% 4 31%
60 or older 2 8% 0 0% 1 14% 1 8%
Race/Ethnicity
African American, non-Hispanic 4 17% 0 0% 1 14% 3 23%
Asian 2 9% 1 17% 1 14% 0 0%
Caucasian, non-Hispanic 18 69% 4 67% 5 71% 9 69%
Hispanic 2 8% 1 17% 0 0% 1 8%
Unknown 0 0% 1 17% 0 0% 1 8%
Highest Degree
Associate’s 2 8% 1 17% 0 0% 1 8%
Bachelor’s 7 27% 1 17% 3 43% 3 23%
Diploma 2 8% 0 0% 2 29% 0 0%
Doctorate 6 23% 2 33% 0 0% 4 31%
Master’s 6 23% 1 17% 2 29% 3 23%
MD 3 12% 1 17% 0 0% 2 15%
Occupation
Nurse practitioner 1 4% 1 17% 0 0% 0 0%
OT 4 15% 1 17% 1 14% 3 23%
OTA 1 4% 0 0% 0 0% 1 8%
PTA 1 4% 1 17% 0 0% 0 0%
PT 10 38% 2 33% 1 14% 7 54%
Physician 4 15% 2 33% 0 0% 2 15%
Registered nurse or BSN 5 19% 0 0% 5 71% 0 0%

change. Practice changes for each assessment or inter-
vention were calculated (Figure 1). The improvement in
our data collection process after the first year also
allowed us to implement a measure of practice change
based on the cumulative number of AGS/BGS inter-
ventions implemented (Figure 2).
Virginia Commonwealth University’s Institutional
Review Board (IRB) approved the training and evalua-
tion protocol for years 1 and 3 by expedited review
(IRB# HM14409). Year 2 training and evaluation proto-
col was approved by the IRB for Eastern Virginia Med-
ical School (IRB# 13-04-Ex-0071) and included an IRB
reliance agreement. Health Insurance Portability and
Accountability Act (HIPAA) waiver of patient authori-
zation was requested and approved by both IRBs for
review of medical records.
Analysis Approach
Practice change outcomes were calculated for “All Post-
Fall Patient Encounters” and for “All Post-Fall PT and OT
Patient Encounters.” “All Post-Fall Patient Encounters” rep-
resented the number of patients who fell and had chart
documentation by at least one or more of the following
disciplines: physician, nurse, PT, or OT. “All Post-Fall
PT and OT Patient Encounters” represented the number
of patients who fell and had chart documentation by
PT and OT practitioners. The proportion of post-fall

% Practice Change = T2 # of patients receiving EBP

____________________________ Interventions implemented at T2
% Practice Change = _________________________________
T2 # of post-fall patients T2 # of post-fall patients
T1 # patients receiving EBP × 100
– __________________________ Interventions implemented at T1 × 100
– ________________________________
T1 # of post-fall patients T1 # of post-fall patients

FIGURE 1. Practice change formula for each assessment or FIGURE 2. AGS/BGS cumulative practice change.
intervention.

12 WHEELER ET AL., Practice Improvement with Falls Prevention Training

patients with documented information related to
assessments or interventions was calculated as a per-
centage of all post-fall patients who received assess-
ment or intervention from at least one practitioner
who participated in the training (“All Post-Fall Patient
Encounters”).
All post-fall patients were eligible for evaluation
and/or treatment by the healthcare team. It was rea-
soned that not all post-fall patients would be referred
for rehabilitative assessment, so a more precise
denominator would allow us to consider practice
changes as a proportion of only those patients exam-
ined or treated by the providers of interest (i.e., PT or
OT). Therefore, a second set of analyses was per-
formed (“All Post-Fall PT and OT Patient Encounters”).
Pre- and post-training data were collected and ana-
lyzed using descriptive and inferential statistics. Two-
tailed z-statistics were used to determine whether the
proportional differences in pre- and post-training use
of EBPs were statistically significant.
Results
Tables 3 to 6 summarize PT and OT practice changes
measured through data abstraction. Percent change and
frequency counts of the number of patients PT and OT
documented related to assessment or intervention vari-
ables in each category are listed for T1, T2, and T3 for
years 1, 2, and 3.
Assessment and Intervention Practice Changes
for All Post-Fall Patient Encounters
Year 1—Abstracted data included a total of 7 providers
(PT or PT assistant = 3, OT = 1, medicine = 2, advanced
nursing practice = 1) who collectively encountered 33
post-fall patients during T1, 43 post-fall patients during
T2, and 35 during T3. The OT assessed at least 1
patient at T1, but no patients were seen during T2 or T3
and medical records were therefore not reviewed.
The proportion of all post-fall patients who had risk
factors assessed by the PTs increased 34.6% (z=3.0,
p<0.005) from T1 to T2. This practice change improve-
ment was sustained at 33.1% (z=2.8, p<0.005) during T3.
The PT also showed statistically significant improve-
ment in the proportion of documented fall causes for all
post-fall patients from T1 to T2 with an increase of
54.6% (z=4.7, p<0.001). An increase of 50.6% was docu-
mented from T1 to T3, indicating that the improve-
ment had been maintained (z=4.2, p<0.001). Similarly,
the proportion of post-fall patients with the fall circum-
stances documented increased by 46.2% from T1 to T2
(z=4.0, p<0.001). This improvement was sustained into
T3 with a 38.8% increase from T1 (z=3.2, p<0.001). No
statistically significant practice improvements in the
implementation of the recommendation of EBP inter-
ventions were found (p>0.05).
Journal of Allied Health, Spring 2018, Vol 47, No 1
Year 2—Medical record reviews included a total of 7
providers (nursing = 5, PT = 1, OT = 1) who collectively
encountered 21 post-fall patients during T1 and 26 post-
fall patients during T2. The medical record review did
not reveal any statistically significant practice improve-
ments related to any of the assessment measures (p>0.05).
Consequently, practice changes during T3 were not
examined.
Practice change for the PT’s implementation of
AGS/BGS recommended interventions was not statis-
tically significant (p>0.05). The OT demonstrated a
22.2% practice improvement in the number of interven-
tions implemented (z=2.0, p<0.05). Examination of the
individual interventions implemented by the OT did
not result in statistical significance (p>0.05).
Year 3—Medical record reviews included a total of 13
providers (medicine = 2, PT = 7, OT or OT assistant = 4)
who collectively encountered 85 post-fall patients
during T1, 87 during T2, and 65 during T3. The PTs
and OTs did not show any statistically significant prac-
tice improvements related to assessment (p>0.05).
The PTs also did not show any statistically signifi-
cant practice improvements related to the cumulative
number of implemented AGS/BGS interventions, and
examination of the individual interventions imple-
mented by the PTs similarly did not reveal any statisti-
cally significant changes (p>0.05). The OTs did not
show a statistically significant practice improvement in
the cumulative number of implemented EBP interven-
tions (p>0.05), but an examination of individual inter-
ventions revealed a 6.8% improvement in the imple-
mentation of home modifications between baseline and
T2 that was statistically significant (z=2.0, p<0.05). This
improvement was not sustained into T3 (p>0.05).
Assessment and Intervention Practice Changes
for All Post-Fall PT and OT Patient Encounters
Year 1—The PTs demonstrated a robust practice
improvement (37.5%) from T1 to T2 in documented fall
causes (z=3.5, p<0.001). This improvement was sus-
tained at T3 (z=3.1, p<0.005). No statistically significant
practice improvements in recommendations for the
implementation of AGS/BGS interventions were
revealed (p>0.05).
Year 2—There were no statistically significant practice
changes related to any of the assessment measures. This
was primarily a consequence of the small number of
patients encountered by the providers. The PT encoun-
tered 3 patients at T1 and 5 at T2, while OT encoun-
tered only a single patient at T1 and the increase at T2
was merely one more. As a consequence, no statistical
testing was feasible for the OT. The PT demonstrated a
66.7% practice improvement in the number of imple-
mented EBP interventions from T1 to T2 (z=2.1,
13
 14
TABLE 3. PT Practice Change Outcomes for All Post-Fall Patient Encounters
Year 1
_____________________________________________ Year 2
_____________________________________________ Year 3
_____________________________________________
T1 to T2 T1 to T3 T1 to T2 T1 to T3 T1 to T2 T1 to T3
T1 = 33 T1 = 33 T1 = 85
Total patient count, n T2 = 43 T3 = 35 T2 = 43 T3 = 0 T2 = 87 T3 = 65
Intervention outcome T1/T2, n %∆ z T3, n %∆ z T1/T2, n %∆ z T3, n %∆ Z T1/T2, n %∆ z T3, n %∆ z
AGS/BGS intervention(s) implemented – – – – – – 1/5 14.5 1.5 – – – 34/44 10.6 1.4 36 15.4 1.8
Home modification(s) – – – – – – 0/2 7.7 1.3 – – – 6/9 3.3 0.7 4 –0.9 0.2
Individually tailored exercise – – – – – – 1/2 2.9 0.9 – – – 7/10 3.3 0.7 9 5.6 1.2
Patient/family education – – – – – – 0/1 20.0 0.8 – – – 20/21 0.6 0.0 21 8.8 1.1
Documented fall causes 5/30 54.6 4.7‡ 23 50.6 4.2‡ 1/2 2.9 0.9 – – – 38/38 –1.0 0.1 34 7.6 0.9
Fall circumstances 7/29 46.2 4.0‡ 21 38.8 3.2‡ 2/4 5.9 0.6 – – – 40/41 0.1 0.0 29 –2.4 0.2
EBP interventions recommended 6/8 0.4 0.0 4 –6.7 0.8 1/4 10.6 1.2 – – – 15/16 0.7 0.0 13 2.4 0.3
Assessed risk factors 7/24 34.6 3.0† 19 33.1 2.8† 2/4 0.0 – – – – 28/36 8.4 1.1 28 10.1 1.3
*p<0.05, †p<0.005, ‡p<0.001.

TABLE 4. OT Practice Change Outcomes for All Post-Fall Patient Encounters

Year 1
_____________________________________________ Year 2
_____________________________________________ Year 3
_____________________________________________
T1 to T2 T1 to T3 T1 to T2 T1 to T3 T1 to T2 T1 to T3
T1 = 33 T1 = 33 T1 = 85
Total patient count, n T2 = 43 T3 = 35 T2 = 43 T3 = 0 T2 = 87 T3 = 65
Intervention outcome T1/T2, n %∆ z T3, n %∆ z T1/T2, n %∆ z T3, n %∆ Z T1/T2, n %∆ z T3, n %∆ z
AGS/BGS intervention(s) implemented – – – – – – 1/7 22.2 2.0* – – – 4/10 6.8 1.4 2 –1.6 0.6
Home modification(s) – – – – – – 0/1 3.9 0.9 – – – 2/8 6.8 2.0* 1 –0.8 0.0
Individually tailored exercise – – – – – – 1/2 6.8 0.8 – – – 1/0 –1.2 0.9 0 –1.2 0.8
Patient/family education – – – – – – 0/2 7.7 1.3 – – – 1/2 1.1 0.5 1 0.36 0.5
Documented fall causes 0/0 – – – 0/1 3.9 0.9 – – – 2/6 4.5 1.6 3 2.3 1.0
Fall circumstances 1/0 –3.0 1.1 – – – 0/1 3.9 0.9 – – – 2/6 4.5 1.6 2 0.7 0.4
EBP interventions recommended 1/0 –3.0 1.1 – – – 1/2 2.9 0.4 – – – 4/9 5.6 1.2 1 –3.2 1.0
Assessed risk factors 1/0 –3.0 1.1 – – – 0/2 7.7 0.4 – – – 3/8 5.7 1.5 2 –1.6 0.5
*p<0.05.

WHEELER ET AL., Practice Improvement with Falls Prevention Training

 TABLE 5. PT Practice Change Outcomes for All Post-Fall PT Patient Encounters
Year 1
_____________________________________________ Year 2
_____________________________________________ Year 3
_____________________________________________
T1 to T2 T1 to T3 T1 to T2 T1 to T3 T1 to T2 T1 to T3
T1 = 8 T1 = 3 T1 = 47
Total patient count, n T2 = 30 T3 = 23 T2 = 5 T3 = 0 T2 = 46 T3 = 36
Intervention outcome T1/T2, n %∆ z T3, n %∆ z T1/T2, n %∆ z T3, n %∆ Z T1/T2, n %∆ z T3, n %∆ z
AGS/BGS intervention(s) implemented – – – – – – 1/5 66.7 2.1* – – – 34/44 23.3 3.1† 36 27.7 3.4‡
Home modification(s) – – – – – – 0/2 40.0 1.3 – – – 6/9 6.8 0.9 4 –1.7 0.3
Individually tailored exercise – – – – – – 1/2 0.0 – – – – 7/10 6.9 0.9 9 10.1 1.2
Patient/family education – – – – – – 0/1 3.8 0.9 – – – 20/21 3.1 0.3 21 15.8 1.4

Journal of Allied Health, Spring 2018, Vol 47, No 1

Documented fall causes 5/30 37.5 3.5‡ 23 37.5 3.1‡ 1/2 6.7 0.2 – – – 38/38 1.76 0.3 34 13.6 1.7*
Fall circumstances 7/29 9.17 1.0 21 3.8 1.0 2/4 13.3 0.4 – – – 40/41 4.0 0.6 29 –4.6 0.5
EBP interventions recommended 6/8 –48.3 2.5 4 –57.6 3.0 1/4 46.7 1.3 – – – 25/26 –7.5 0.6 32 11.8 1.1
Assessed risk factors 7/24 –7.5 0.5 19 –4.9 .03 2/4 13.3 0.4 – – – 28/36 18.7 1.9* 28 18.2 1.8*
*p<0.05, †p<0.005, ‡p<0.001.

TABLE 6. OT Practice Change Outcomes for All Post-Fall OT Patient Encounters

Year 1
_____________________________________________ Year 2
_____________________________________________ Year 3
_____________________________________________
T1 to T2 T1 to T3 T1 to T2 T1 to T3 T1 to T2 T1 to T3
T1 = 1 T1 = 1 T1 = 4
Total patient count, n T2 = 0 T3 = 0 T2 = 2 T3 = 0 T2 = 12 T3 = 3
Intervention outcome T1/T2, n %∆ z T3, n %∆ z T1/T2, n %∆ z T3, n %∆ Z T1/T2, n %∆ z T3, n %∆ z
AGS/BGS intervention(s) implemented – – – – – – 1/7 155.0 – – – – 4/12 –16.7 0.9 2 –8.3 0.2
Home modification(s) – – – – – – 0/1 50.0 – – – – 2/8 16.7 0.6 1 –17.0 0.4
Individually tailored exercise – – – – – – 1/2 0.0 – – – – 1/0 –25.0 1.8 0 –25.0 0.9
Patient/family education – – – – – – 0/2 100.0 – – – – 1/2 –8.3 0.4 1 8.3 0.2
Documented fall causes 0/0 – – – – – 0/1 50.0 – – – – 2/6 0.0 1.0 3 50.0 1.4
Fall circumstances 1/0 – – – – – 0/1 50.0 – – – – 2/6 0.0 0.0 2 16.7 0.4
EBP interventions recommended 1/0 – – – – – 1/2 0.00 – – – – 4/9 –25.0 1.1 1 –33.3 1.1
Assessed risk factors 1/0 – – – – – 0/2 100.0 – – – – 3/8 –8.3 0.3 2 –8.3 0.2

15
p<0.05). OT also demonstrated a drastic practice
improvement in this regard (155%), but a z statistic
could not be computed for this result (p>0.05) because of
the small number of patient encounters.
Year 3—The PTs documentation of risk factors
assessed increased by 18.7% from T1 to T2 (z=1.9,
p<0.05), and this improvement was maintained into T3
(18.2%; z=1.8, p<0.05). The PTs demonstrated a 23.3%
practice improvement in the cumulative number of
AGS/BGS interventions implemented from T1 to T2
(z=3.1, p<0.005). By T3, a recommended intervention
was implemented 36 times among the 36 post-fall
patients encountered (z=3.4, p<0.001). The recom-
mended interventions were predominantly education
and information (15.8%) and individually tailored exer-
cise (10.1%); however, the effects for these individual
interventions did not reach the level of statistical signif-
icance (p>0.05). No statistically significant practice
improvements were uncovered for OT (p>0.05).
Discussion
This study demonstrated that interprofessional EBP
assessment and intervention training modules for falls
prevention and management seem to have had a signif-
icant effect on PT and OT practice. Specifically, PTs
increased documentation of fall causes, fall circum-
stances, and fall assessment. OTs increased interven-
tions provided and home modification recommenda-
tions. Patients received more fall risk assessments and a
higher volume of evidence-based interventions pro-
vided by PT and OT post-training.
PT assessment of risk factors as well as both the cir-
cumstances and causes of falls improved during year 1
and was sustained over time. This may be a result of
better internalization of practice guidelines and prioriti-
zation of the need for documentation of fall risk criteria
because of enhanced understanding post-training.
However, it could also reflect the increase in the
number of patients seen by PT from T1 to T2 in “all
post-fall patient encounters.”
Although site personnel limitations did not allow us
to observe practice improvements for OT during train-
ing year 1, during training year 2, OT adopted increased
implementation of EBP recommended interventions.
The number of PT and OT “all post-fall patient encoun-
ters” for training year 2 was small for both PT and OT
and may explain why the documented assessment and
intervention changes did not reach significance. Both
PT and OT showed improvements in interventions
from T1 to T2 during training year 3; however, practice
changes for OT did not reach statistical significance at
T3 due to extremely small patient encounter numbers
compounded by small numbers of OTs. Again, in addi-
tion to the relatively smaller number of therapeutic
encounters by OT during T3 in relation to T2, another
16
possible explanation for the lack of change in practice is
time and resource constraints. These constraints may
have allowed OTs to revert to previous behavior. It is
also possible that practice changes may have continued
without being explicitly documented.
The assessment module content for both PT and OT
provided an evidence-based strategy to identify elders at
greatest risk of falling, which may have increased the
OT home safety. Chase et al.22 challenged OTs to con-
duct research evaluating the impact of home modifica-
tions on preventing falls and to produce outcome meas-
ures that include activities of daily living (ADL) and
instrumental activities of daily living (IADL). OTs play
an important role on interprofessional teams by
addressing the multifactorial impact of falls, including
fear of falling, environmental hazards, cognition,
depression, anxiety, personal interests, and visual
acuity on fall risk.8 The systematic review by Chase et
al.22 reported moderate evidence that individually
implemented physical activity and home modification
interventions reduce falls and impact ADL and IADL
performance. OT reflected similar practice implementa-
tion in our study demonstrated by a significant
improvement in home modification interventions.
More comprehensive evidence-based curricula to
better educate healthcare providers on fall prevention
guidelines could help improve compliance. Implementa-
tion of such a curriculum has been shown to significantly
increase learning and produce practice changes.23 Our
study also engaged a broad range of healthcare practition-
ers and employed an interprofessional training approach
to inform them about fall prevention guidelines. Chart
review data demonstrated an increased adoption of these
guidelines with patients. This approach could be repli-
cated in the future to improve healthcare providers’
adherence to fall prevention guidelines.
Following the success of the initial EBP training pro-
gram, the medical director recognized the advantages of
expanding the training systemwide. With the goal of
more widely enhancing team care communication and
facilitating quality improvement, the Virginia Geriatric
Education Center Consortium (VGEC) made the 24-
hour training series simultaneously available to all five
PACE programs in the health system during the third
year. The value of this training, however, could have
been underreported in this study by the data collection
process used to describe change.
The challenges of delivering the curriculum remotely
may partly explain why the assessment changes at these
training sites were less robust. The remote nature lead to
inconsistent attendance, and there were different profes-
sionals represented each time as the expectation for atten-
dance was lower than for face-to-face sessions. Technical
difficulties with sound and video also impacted the
receipt of module information and led to decreased com-
munication and interaction between participants.
WHEELER ET AL., Practice Improvement with Falls Prevention Training
Limitations
There were several limitations to this study. Medical
records may or may not truly reflect some of the details
about what happened. Documentation may not differ-
entiate subtle overlaps of assessment and intervention.
For example, home modifications are typically
addressed once identified. They were coded as a recom-
mended need when identified, as a planned interven-
tion when there was a stated intention to address the
need, and then as an implemented AGS/BGS inter-
vention once accomplished. Additionally, some
changes in PT and OT behavior, such as spending more
time discussing fall risk factors, may have been viewed
as educational or elementary and not specifically docu-
mented in the chart. Thus, adherence to practice guide-
lines may be better than actual chart documentation.
Therefore, we would recommend future researchers
perform direct observation of practitioners, conduct
pre and post practitioner interviews on all training par-
ticipants, including those who do not document in the
medical record, and employ outside observers to meas-
ure team communication. Qualitative measures of prac-
tice change and knowledge gains may not have been
captured by medical chart reviews.
Another limitation related to our constrained eval-
uation method, which did not include a determination
of whether the interventions and assessments chosen
by PT and OT were the most appropriate. The data
collection process counted the frequency of interven-
tions without judgment of quality or appropriateness
of chosen interventions. For example, PT may have
prioritized ambulation over balance retraining or OT
may have prioritized adaptations to self-care routines
over home modifications. Appropriate prioritization
of targeted interventions is most effective for decreas-
ing fall risk.6 The EBP instruction provided could have
helped PT and OT select better interventions without
them necessarily doing more interventions, and this
would not have been coded as a positive change in
practice.
The development and delivery of interprofessional
training modules in this study as well as the method-
ological approach for chart reviews were time intensive.
This may limit opportunities to replicate the study. This
study trained health providers in PACE settings only. It
would be interesting to see if such training improves
adherence to published guidelines in other settings.
Poor documentation of risk factors may limit the
recommendations provided to the patient. Further
investigation needs to focus on the development of
easy-to-use checklists and more efficient ways to docu-
ment fall risk factors and recommendations. This
could lead to improved chart reviews and better under-
standing of assessment and interventions delivered to
the patient.
Journal of Allied Health, Spring 2018, Vol 47, No 1
Conclusion
This study demonstrates that PT and OT provide more
fall risk assessments and interventions after robust EBP
fall prevention training. Increased knowledge of fall
prevention guidelines and recommendations translate
to PT and OT’s increased identification and documen-
tation of risk factors and interventions. Educational
programs that emphasize best practice recommenda-
tions for fall prevention, like the one outlined in this
paper, show potential to improve PT and OT adher-
ence to published guidelines and thus improve their
skills in caring for older adults.
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