Development & Testing to Prevent Falls in Long Term Care (LTC) Facilities

LTC Falls Prevention Toolkit

Executive Summary

The primary cause of traumatic injuries in older adults is falls. A goal of Healthy People 2020 is to reduce emergency department visits due to falls in older adults. The prevalence of falls for older adults in long term care facilities (LTCF) is estimated to be 50-60%. Older adults in LTCF are more likely than community-dwelling older adults to be injured when they fall. In the U.S., a number of evidence-based programs aim to reduce falls in community-dwelling older adults. These programs focus primarily on exercise, home safety, clinical interventions (e.g. medication reduction) and multifaceted strategies. Dr. Elizabeth Phelan, a member of our investigative team, participated in the development of the Centers for Disease Control and Prevention (CDC) evidence-based Stopping Elderly Accidents, Deaths and Injury (STEADI) toolkit, an initiative to increase screening and assessment for fall risk and risk factors and interventions to reduce falls in community-dwelling older adults. However, STEADI has not been validated for use in LTCF. Lacking are screening, assessment, and decision-support tools for the LTCF context. Fall prevention interventions for residents of LTCF require not only adaptation, but also a systems-level approach that partners with providers, administrators, and managers. Our project seeks to address the problem of falls and fall-related injury by adapting and enhancing the CDC STEADI toolkit for use in LTCFs and then test feasibility and impact of the adapted toolkit in a matched pair cluster-randomized control trial. If proven successful, the toolkit could provide a powerful, scalable tool for fall prevention in older adults, given the growing use and success of the CDC’s STEADI efforts. The proposal integrates best evidence along with feedback from providers in support of development of a toolkit for fall prevention activities.

Study Overview

Specific Aims include:

1 – Using a modified Delphi process, adapt the STEADI toolkit for use in long term care facilities (LTCF).

2 – Determine feasibility and acceptability of the adapted Fall Prevention Toolkit including identification of barriers, facilitation, and usage in LTCF.

3 – Assessing the impact of the Fall Prevention Toolkit on rates of falls and fall-related injury in LTCF.


The Centers for Disease Control and Prevention (CDC)

The National Center for Injury Prevention and Control (NCICP)

Study Team

Principal Investigator

Hilaire Thompson, PhD, RN, ARNP

Dr. Thompson is a Joanne Montgomery endowed professor of Biobehavioral Nursing and Health Informatics in the University of Washington (UW) School of Nursing. She is a registered nurse, adult/gerontology acute care nurse practitioner. Her program of research focuses on preventing and improving outcomes from traumatic brain injury (TBI), with a particular emphasis on older adults. She is interested in understanding why disparities in rate of injury (as well as injury outcomes) occur and is developing interventions. She is a fellow of the American Academy of Nursing (AAN) and the Gerontological Society of America (GSA).


Elizabeth A. Phelan, MD, MS

Dr. Phelan is a professor of Gerontology and Geriatric Medicine at the University of Washington (UW) School of Medicine, an adjunct professor of Health Systems and Population Health at the UW School of Public Health, and an affiliate investigator at the Kaiser Permanente Washington Health Research Institute (KPWHRI). She is also the director of the Northwest Geriatrics Workforce Enhancement Center (NW GWEC) and founding director of the UW Medicine Fall Prevention Clinic at Harborview. As a board-certified geriatrician, her clinical work encompasses both inpatient and outpatient settings and involves teaching principles of internal and geriatric medicine to students, residents, and fellows.


Ellen McGough, PhD, RPT

Dr. Ellen McGough currently teaches therapeutic exercise, seminar and research topics. She is the didactic director of the acute care residency program and has clinical experience in the areas of musculoskeletal, neurological rehabilitation, acute care, and geriatric physical therapy. Dr. McGough studies functional markers of disability and the effects of exercise in individuals with Alzheimer’s and Parkinson’s disease. She uses motion analysis technology, performance-based assessment, and magnetic resonance imaging (MRI) to identify early motor and non-motor impairments. Her research also investigates innovative community-based exercise interventions aimed at reducing functional decline secondary to age-related and neurodegenerative disease processes.

Additional Team Members

Research Coordinator

Adrienne James, MS

Graduate Research Assistant

Sungwon Lim, MSN, RN


Wonkyung (Kelly) Jung, MSN, RN, PhD

Practicum Student

Andrew Ustach, MPH


Dahee Wi, PhD

Study Background

There are both negative personal and societal consequences of falls in older adults, which are the primary cause of traumatic injuries in older adults. Of those who fall, up to 20% experience a significant injury such as fracture or traumatic brain injury.

In 2016, 3.1 million non-fatal fall injuries among older adults were treated in emergency departments and more than a quarter of these patients were hospitalized. The impact of injury is substantive as older trauma patients are more likely to experience a longer hospital stay, increased number of complications, higher costs of care and a higher mortality rate for any specific injury than their younger counterparts. Studies examining post-fall outcomes in older adults have noted increased use of health care resources, reduced function and higher rates of disability. Even when no injury occurs, older adults may develop a fear of falling which results in self-imposed activity restriction, leading to reduced mobility and loss of muscle mass, which in turn increases the actual risk of falling.

There is a higher prevalence of falls and fall-related injury (FRI) in older adults living in long term care facilities (LTCF). Facilities include assisted living, skilled nursing, nursing homes and adult family homes. In 2014, there were 1.4 million Americans living in LTCF. At least 35% of adults over 65 years of age are likely to enter a LTCF before they die. Residents of LTCF often have significant income disparity, as they are more likely to be at or near the poverty line than community-dwelling older adults (40% vs. 9.3%). They are also an exceptionally vulnerable population due to higher prevalence of cognitive impairment, multi-morbidity, frailty, and functional dependency, which is related to the need for such individuals to move from the community to LTCF.

The average annual frequency of falls among LTCF residents is reported to be 1.7 per person, with many falling recurrently. The Centers for Disease Control and Prevention (CDC) estimates that 10% of persons ages 65 and older sustain an injury after a fall. However, older adults in LTCF are more likely than community-dwelling older adults to be injured when they fall.

FRIs range from bruising and lacerations to hip fracture and traumatic brain injury. Persons residing in LTCF are at higher risk for fall and FRI than non-residential counterparts. They are a vulnerable population and have been excluded from the majority of work to date, interventions to address this risk is imperative.

Learn more about Older Adult Falls >>