In the United States, one in three older adults fall annually (National Council on Aging, 2005).Of those who fall, 30% suffer injuries that decrease mobility and independence and result in high medical costs (National Council on Aging, 2005; Stevens, Corso, Finkelstein & Miller, 2006). The rate of fatal falls for persons aged 65 and older increased about 35% from 1990 to 2002 (Merck Institute on Aging & Centers for Disease Control, 2006). In addition, fear of falling is associated with a spiraling risk of falls and functional decline (Friedman, Munoz, West, Rubin & Fried, 2002; Howland & Lachman, 1998), and it is estimated that up to 55% of community-dwelling older adults experience a fear of falling (Lach, 2003; Peterson, Murphy, Hammel, 2003). Because so many older adults do not inform anyone of their fear of falling, it is important that interventions to prevent falls be easily accessible to older adults in their own communities (Baker et al., 2005).
Although there are a number of evidence-based programs to reduce fall prevalence, a common challenge is how to effectively disseminate and sustain these initiatives. How do you deliver a program in a cost-effective manner? How do you overcome barriers of access or the need for advanced expertise? How do you adapt a program for the real-world environment without straying so far from the original research model that you reduce its effectiveness? Addressing these challenges requires an in-depth understanding of the delivery environment, innovative thinking, strategic planning, careful monitoring and, of course, a financial commitment.
A prime example of tackling these challenges is The Matter of Balance/Volunteer Lay Leader model (MOB/VLL). This program has earned accolades from the American Society on Aging (2006 Innovation and Quality in Healthcare and Aging Award) and the National Association of Area Agencies on Aging (2006 Aging Innovations and Achievement Award) and has been featured in numerous publications for its effective, sustainable, and highly replicable model.
The MOB/VLL program is an adaptation of the evidence-based A Matter of Balance (MOB). MOB is a program specifically designed to reduce fear of falling, stop the fear-of-falling cycle, and increase activity levels among community-dwelling older adults (physical inactivity is cited as a significant risk for falls and fall-related injuries in older adults).
The original program is designed for small groups of older adults living independently in community settings or senior housing. A trained facilitator (health care professional) conducts the classes using an extensively detailed training manual and two instruction videos. The program focuses on practical coping strategies to reduce both the fear of falling and the risk of falling. Activities address physical, social, and cognitive factors affecting fear of falling.
Early sessions focus on changing attitudes and self-efficacy before attempting changes in actual behavior. Later sessions introduce exercises to improve balance and strength.
Strategies to reduce the fear of falling include:
- Promoting a view of falls and fear of falling as controllable;
- Setting realistic goals for increasing activity;
- Changing the environment to reduce fall risk factors; and
- Promoting exercise to increase strength and balance (Tennstedt, S., et al, 1998).
Adapting the Program for Lay Leaders
Following the initial effort to employ A Matter of Balance in Maine, the Partnership for Healthy Aging (PFHA) sought to make it more broadly available. To this end, Maine’s Office of Elder Services and the Bureau of Health, for whom falls are a major concern, partnered with PFHA. These state agencies worked with PFHA to disseminate the program to older adults in the service areas of three area agencies on aging (AAA): Seniors Plus, Eastern Area Agency on Aging, and Aroostook Area Agency on Aging. Through this effort, we piloted training AAA outreach staff to offer the program in collaboration with community health providers instead of having the health professionals deliver the program directly. This would allow MOB to be delivered by a wider variety of aging professionals and in a more economical manner. Although very well received and less expensive than the health-care professional model, the AAA budgets still could not sustain this model on an ongoing basis.
To make A Matter of Balance even more accessible and more economical, PFHA then adapted the program further, while remaining true to the model itself, so it can be taught by volunteer lay leaders, who are referred to as coaches. In particular, the following components were developed:
- A participant workbook
- Coaching curriculum and training
- A volunteer lay leader manual including modified exercises that are safe for older adults with joint replacements and/or osteoporosis
- The addition of a Guest Therapist handbook, which creates connections to health care providers via a guest therapist who attends one class to address concerns around assistive devices, how to get up from a fall, and other clinical issues
- A Master Trainer curriculum and training
In order to implement A Matter of Balance/VLL, key staff from a community organization interested in the program must attend a Master Trainer session. It is recommended that organizations identify two staff members who will assume responsibility for the program. The session addresses core concepts such as fall risks and prevention and cognitive restructuring, implementation strategies, class logistics, the materials and how to use them, training strategies for volunteer lay leaders, the class curriculum, recruitment of lay leaders, participants and sites, and program evaluation.
There are three important roles in the implementation of A Matter of Balance: the Lead Trainer, the Master Trainer, and the Volunteer Lay Leader.