Fall Risk Evaluation an essential part of Chronic Care Management (CCM)

Chronic Care Management using CPT code 99490, can be used for preliminary fall risk evaluation of patients for providers, helping maintain patients’ safety and independence. Each year, millions of people 65 and older are treated in emergency departments because of falls, and Medicare pays for only about 78% of the costs of falls ⁽¹⁾. A care coordinator who specializes in upholding patient’s optimum well-being should routinely assess for fall risks and need of interventions, which ultimately prevent any occurrences of patient falls.

Fall Assessment

Patients participating in CCM services should have a thorough fall evaluation completed. Items to discuss with these patients should include:

• Ambulation status
• Access to assistive devices
• Activities of daily living

Most fall cases result from a complex interplay of predisposing and precipitating factors in a person’s environment. One half to two thirds of falls occur in or around the patient’s home ⁽²⁾. Over the phone, a patient’s CCM coordinator should complete an assessment, with questions pertaining to the patient’s living arrangement, environment, and ability to complete household tasks. Questions that should be considered consist of:

• Are you living alone? Or is someone there to assist you daily?
• How do you handle your household maintenance? (e.g., laundry, cooking, trash)
• Do you have grab bars and railing in the bathrooms and on steps?
• Have you ever not been able to get to a specific area of the home due to clutter, or an obstacle in your way?
• Is there a phone accessible to you at all times?

Identify Risk Factors

Chronic Care Management provides a means for providers and CCM coordinators to recognize an individual patient’s risks for a fall. Independent risk factors for falling include the following (arranged in order of evidence strength):

1. Previous falls, balance impairment
2. Decreased muscle strength
3. Visual impairment
4. Polypharmacy (more than 4 medications) or psychoactive drugs
5. Gait impairment and walking difficulty
6. Depression
7. Dizziness or orthostasis
8. Functional limitations
9. Age older than 80 years
10. Female sex
11. Incontinence
12. Cognitive impairment
13. Arthritis
14. Diabetes
15. Pain⁽³⁾

Using the above risk factors as a guideline, CCM coordinators can continuously monitor the patient’s risk for fall, reiterate safety precautions, and suggest other interventions to lower occurrence of falls – such as in the case example below:

Stephanie, a CCM care coordinator, has received a new CCM patient, Ms. M. During Ms. M’s intake there should be a review of Ms. M’s medical history and the last office visit note. A few observations stand out that should be addressed with the patient:

• Patient is taking more than 4 medications
• History of depression from recent loss of husband
• No daily exercise activity noted
• Past due on Annual Eye Exam
• Uses cane for ambulation assistance

Upon calling the patient, the care coordinator discussed the aforementioned concerns during a fall evaluation, Ms. M stated that she had fallen 2 months ago, but was not injured.  Patient reported frequently missing doses of medications, sleeping most of the day, and noticing more weakness. Initially, the CCM coordinator, should address medication adherence and possibly introduce a pillbox for administration. This should benefit the patient in preventing missed medications or incorrect doses that could result in dizziness or drowsiness potentially leading to falls. After consulting her primary care provider, Ms. M began walking daily and implementing other physical activity, as tolerated, promoting strength and combat complaints of weakness.

When Ms. M. presented to her family doctor, she did not volunteer her history of falls, which is not uncommon. To identify fall risks, therefore behooves medical professionals to be proactive in inquiring about falls, given the prevalence of the problem, the high likelihood of recurrence, and the severity of the consequences. Risk factors for falls should be viewed as potentially reversible, and falls should not be perceived as an inevitable part of aging ⁽³⁾. This shows the necessity for Chronic Care Management, delivered through CPT 99490 or other means, for complete care, outside of the provider’s face-to-face contact, to address risk factors and reduce future occurrences of falls.

References

1. Centers for Disease Control and Prevention. Home and Recreational Safety. [Online] Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Preventio, September 21, 2015. [Cited: August 09, 2016.] http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html.
2. Waleed Al-Faisal, M.D. of Public Health. Falls Prevention for Older Persons. s.l. : Eastern Mediterranean Regional Review, URL: http://www.who.int/ageing/projects/EMRO.pdf, 2006.
3. PMC US National Library of Medicine, National Institutes of Health. National Center for Biotechnology Information, U.S. National Library of Medicine. [Online] College of Family Physicians of Canada, March 2014. [Cited: August 09, 2016.] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135440/#b26-0570771.