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October 15, 2019

Should you help a patient regain mobility—or protect them from falls? Sometimes, it's a tough choice.

Daily Briefing
    Editor's note: This popular story from the Daily Briefing's archives was republished on May 13, 2021.

    Falls are the leading cause of fatal and nonfatal injuries for older Americans, but hospitals seeking to prevent falls are facing a conundrum, Melissa Bailey reports for Kaiser Health News: Should patients remain bedbound to avoid dangers? Or should they move to regain their mobility?

    Get best practices for preventing patient falls


    About 10 years ago, CMS declared that patient falls should never happen in the hospital, and in 2008 the agency began penalizing hospitals for them. Under CMS' policy, hospitals receive payment for the cost of the patient's underlying care, but the agency does not cover the cost of fall-related conditions, according to Bailey.

    CMS has since developed new penalties for falls. For instance, the Affordable Care Act established the Hospital-Acquired Condition (HAC) Reduction Program, which launched in 2014. The HAC program evaluates hospitals based on their rates of several avoidable complications, including falls.

    Every year, the facilities in the worst-performing 25% are penalized by losing 1% of their Medicare payments. So far, the program has penalized 1,756 hospitals since it was established in 2014, and 110 of those hospitals have been penalized all five years.

    Are the penalties creating a 'climate of fear of falling'?

    Some observers have raised concerns that fall-related penalties have led to a "climate of fear" around patient falls, according to Kenneth Covinsky, a geriatrician and researcher at the University of California, San Francisco. He explained that some nurses "feel that if somebody falls on their watch, they'll be blamed for it."

    Some research suggests he might be right. Barbara King, an associate professor at the University of Wisconsin-Madison School of Nursing, for instance, found the penalties implemented in 2008 created pressure to reduce patient falls to zero, which made some nurses adjust their behavior and prevent patients from moving.

    According to Bailey, CMS declined a request for an interview and "did not directly answer a written question about whether its falls policy has limited patient mobility."

    Meanwhile, keeping patients in bed for an extended period of time can potentially undermine their recovery, Covinsky explained. He noted that patients who do not move can become weaker and more likely to become injured if they fall. Similarly, research has shown older patients who walk at least 275 steps a day in the hospital have lower rates of readmission after 30 days.

    How some hospitals are getting patients moving

    Despite concerns around fall-related penalties, some hospitals are launching initiatives to get patients moving.

    For example, hospitals around the country have launched special wings—often called Acute Care for Elders—to help older patients maintain a sense of independence and to prevent hospital-acquired disabilities, Bailey reports. Another initiative is called the Hospital Elder Life Program (HELP), which promotes mobility and aims to reduce hospital-acquired delirium.

    But King said cited several barriers to getting patients to walk more, including staff shortages, a lack of walking equipment, no clear way to document walking in electronic health records, and the current mindset around patient mobility. "If we think that a patient walking is a patient who will fall, we have to shift that culture," King said (Bailey, Kaiser Health News/Washington Post, 10/13).

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