Academy Comments to Administration for Community Living re Evidence-Based Falls Prevention Program

December 4, 2017

Shannon Skowronski, MSW MPH
U.S. Department of Health and Human Services
Administration for Community Living
Washington, DC 20201

Re: Public Comment Request; Proposed Extension With Changes of a Currently Approved Collection; Evidence-Based Falls Prevention Program (Extension of OMB Control Number, 0985-0039)

Dear Ms. Skowronski,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Administration for Community Living (ACL) at the United States Department of Health and Human Services (HHS) related to its October 3, 2017 information collection, "Proposed Extension With Changes of a Currently Approved Collection; Evidence-Based Falls Prevention Program (extension of OMB Control Number 0985-0039)" Representing more than 100,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation's health through food and nutrition across the lifecycle. Our members coordinate, oversee, and provide Older Americans Act (OAA) nutrition programs' critical services intended to promote health and quality of life while delaying adverse health conditions, such as malnutrition and injuries from falls, as well as declines in mood and cognitive function.

The Academy supports the data collection as vital to monitoring program operations and outcomes of the Evidence-Based Falls Prevention Programs, which we agree "have been proven to reduce the incidence of falls for older adults and adults with disabilities (including Tribal elders)."

A. Suggested Specific Survey Modifications

The Academy believes the proposed collection of information is necessary for the proper performance of not only the ACL's functions, but also the functions of the providers at the state and local levels. Pre- and post-session data is imperative for evaluation of the program. The Academy does not have substantial overall concerns with the current forms and surveys, but suggests that data may be more accurate and useful if some questions are reworded or better explained so as to eliminate confusion for participants. We believe these modifications will not be over-burdensome, and indeed, we feel that the additional information is highly beneficial to the program's success. Specific suggestions for improving the instruments are below.

1. Participant Information Form

The Academy suggests that in total, the Participant Information Form (PIF) should include more information about nutritional status given that dehydration and lack of food can cause dizziness and falling, although we are cognizant of the impact of such changes on the survey's length. Understanding respondents' current use of assistive devices, such as a walker or a cane, would also be helpful. We suggest the ACL consider the following regarding specific questions on the PIF:

  • Question #4: Only asks Male or Female designation and provides no option for those identifying as an alternate gender. \
  • Question #8: Remove or reword option of "None (no chronic conditions) Yes No." We note this is confusing since the question asks "Has a health care provider ever told you that you have any of the following…" In addition, we encourage the ACL to add a category (and definition) for unintentional weight loss to help identify people with probable loss of lean body mass, placing them at increased risk.
  • Question #9: Reword to "Are you limited in any way in performing any activities…"
  • Question #10: Reword question to read "In general, would you describe your health as:"
  • Question #11: The ACL might want to get more detail about where indoors the falls are occurring to identify whether there may be a trend if more people are falling in the bathroom as opposed to the living room or somewhere else. A brief list of rooms (e.g., bathroom, kitchen, bedroom, living/dining room, stairs) could be added if they indicated falls happened indoors.
  • Question #12: Change the word "fearful" to "concerned." We are concerned that clients may not want to have to admit to being fearful as this indicates weakness, may be perceived as sounding demeaning, and may invite concerns of being removed from their home.
  • Question #13: Add the word "independently" or other clarifying terms that better indicate whether or not they can perform these functions without assistance.
  • Question #14: We question whether the text should read "past" 4 weeks rather than "last 4 weeks."
  • Question #15: Question should more clearly indicate safety modifications to the home so that the client does not mistakenly count minor home updates and standard home modifications. In addition, we recommend changing "at home" to "in my home" and adding "installing grab bars" as an example of modifications.
  • Question #16: The ACL should make available definitions of Vigorously, Moderately and Seldom to reduce existing subjectivity.

2.Falls Prevention Program Information Cover Sheet

The Academy suggests the ACL consider the following regarding specific questions on the Falls Prevention Program Information Cover Sheet:

  • Question #6: Change the name of "Session 0" to "Introductory Session," as we believe "Session 0" to be confusing for participants.
  • Question #7: Change wording to "Name of program offered." We suggest that asking participants what type of program it is leads to confusion, and thus a better solution would be to to ask for the name of the program.

3. Host Organization Information Form

The Academy suggests that the Host Organization Information Form requires better explanation of who is to be indicated as being the host. For example, "A Matter of Balance" is provided by individuals. Is this individual the host, or is the senior center or library the host? Likewise, for "Stepping On," the lead must be an organization, so is this organization the host, or again, is the host the senior center or library? We encourage the ACL to provide greater clarity. In addition, the Academy suggests the ACL consider the following regarding specific questions on the Host Organization Information Form:

  • Question #2: We have the same concerns here for "site" as noted above for "host." We encourage greater clarity as to what the CLA wants to ascertain (i.e., is it the actual location of the program, the host agency, or the individual?). We note that, as written, the options do not naturally lend themselves to a clear answer.
  • Question #3: We have the same concerns here as noted above. For example, an individual who is a prevention and wellness professional by trade would coordinate several programs, but the certifications and licenses would be held by multiple sources. They would personally hold the license for A Matter of Balance, but would either be contracted through an aging unit to provide Stepping On, in which case the aging unit or other entity such as a local non-profit organization would hold that license. Is the intention that they fill out multiple forms? We note that the presence of all options on one form makes it confusing for the provider and increases the potential for inaccurate responses.

4. Participant Post Program Survey

The Academy suggests the ACL consider the following regarding specific questions on the Participant Post Program Survey:

  • Question #1: Reword question to ask participant to "Describe your health as:"
  • Question #2: In the section, "If you fell since the program began," change the word "caused" to "results in," as in "How many of these falls resulted in injury? (for example, the fall limited your regular activities…)."
  • Question #3: Change the word "fearful” to “concerned." We are concerned that clients may not want to have to admit to being fearful as this indicates weakness, may be perceived as sounding demeaning, and may invite concerns of being removed from their home.
  • Question #4: Add the word "independently" to indicate whether or not they can perform these functions without assistance.
  • Question #5: Replace "During the last 4 weeks…" with "Since completing the program…" Given that this is a post-program survey, time during the four weeks prior to receiving the survey could still have been during active session time.
  • Question #6 a: Remove "…my medications and other…". There are multiple risks for falls, and we are concerned that focusing on medications may eliminate clients' identification of other fall risks in the home.
  • Question #6 c: Define activity (e.g., Is this activity outside the home? Is this physical activity? Is this increased social engagement?).
  • Question #6 d: Add "generally speaking" regarding satisfaction with life, or indicate satisfaction as related to hopefully a decreased risk of falling.
  • Question #8: Question should indicate safety modifications to the home so that the client does not mistakenly count minor home updates and standard home modifications. In addition, change "at home" to "in my home" and add "since this program began, I have made modifications. . ." and mirror same changes made to the PIF.
  • Question #9: The ACL should make available definitions of Vigorously, Moderately and Seldom to reduce existing subjectivity.

5. Semi-Annual Performance Report Directions and Sample Template

We note that this report seems lengthy and potentially cumbersome. The directions are helpful, although we note that the suggested limit of 15 pages (which may be appropriate for a program that received a very large amount of funding) would exceed that appropriate for a smaller grant award. It might be reassuring to indicate that for smaller grants (e.g., less than X amount), a different limit exists.

B. Conclusion

The Academy appreciates the opportunity to comment on the proposed information collection for the Evidence-Based Falls Prevention Program docket. Please contact either Jeanne Blankenship at 312-899-1730 or by email at jblankenship@eatright.org or Pepin Tuma at 202-775-8277 ext. 6001 or by email at ptuma@eatright.org with any questions or requests for additional information.

Sincerely,

Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
Academy of Nutrition and Dietetics


1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.