Home hazard removal programs are effective in reducing falls among older adults, but delivery in the United States is limited.
Objectives:
We completed a process evaluation of the Home Hazard Removal Program (HARP), an intervention delivered by occupational therapists.
Methods:
Using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), we examined outcomes using descriptive statistics and frequency distribution. We examined differences between covariates using Pearson correlation coefficients and two-sample t tests.
Results:
79.1% of eligible older adults participated (reach); they experienced a 38% reduction in fall rates (effectiveness). Ninety percent of recommended strategies were completed (adoption), 99% of intervention elements were delivered (implementation), and 91% of strategies were still used at 12 months (maintenance). Participants received an average of 258.6 minutes of occupational therapy. An average of US$765.83 was spent per participant to deliver the intervention.
Conclusions:
HARP has good reach, effectiveness, adherence, implementation, and maintenance and is a low-cost intervention.
Plain Language Summary
Home hazard removal programs can prevent falls for older adults but are not standard practice in the US. The Home Hazard Removal Program (HARP) is a fall prevention program for older adults delivered by an occupational therapist (OT) who works with the participant to identify hazards and find strategies to resolve them. We completed a randomized controlled trial to test HARP’s effectiveness in reducing falls. This paper describes a process evaluation in which we looked at the additional outcomes of reach, adoption, implementation, maintenance, and cost. Almost 80% of eligible individuals participated (reach), and 90% of recommended strategies were carried out (adoption). Study OTs delivered 99% of the intervention elements (implementation), and 91% of strategies were still in use after 1 year (maintenance). HARP cost an average of $765.83 per participant. HARP is a low-cost fall prevention program that can be delivered among community-dwelling older adults in the US.
AbbottT.AhmadT.PhullM.FowlerA.HewsonR.BiccardB.PearseR. M. (2018). The surgical safety checklist and patient outcomes after surgery: A prospective observational cohort study, systematic review and meta-analysis. British Journal of Anaesthesia, 120(1), 146–155.
2.
AmbroseA. F.PaulG.HausdorffJ. M. (2013). Risk factors for falls among older adults: A review of the literature. Maturitas, 75(1), 51–61.
3.
ApplebaumR.KunkelS. (2018). The life and times of the aging network. Public Policy & Aging Report, 28(1), 39–43.
4.
BauerM. S.DamschroderL.HagedornH.SmithJ.KilbourneA. M. (2015). An introduction to implementation science for the non-specialist. BMC Psychology, 3(1), Article 32.
5.
BlochF.ThibaudM.DuguéB.BrèqueC.RigaudA.KemounG. (2010). Episodes of falling among elderly people: A systematic review and meta-analysis of social and demographic pre-disposing characteristics. Clinics, 65(9), 895–903.
6.
BraithwaiteJ.ChurrucaK.LongJ. C.EllisL. A.HerkesJ. (2018). When complexity science meets implementation science: A theoretical and empirical analysis of systems change. BMC Medicine, 16(1), Article 63.
7.
CarrollK. M.NuroK. F. (2006). One size cannot fit all: A stage model for psychotherapy manual development. Clinical Psychology: Science and Practice, 9, 396–406.
8.
CastroF. G.BarreraM.MartinezC. R. (2004). The cultural adaptation of prevention interventions: Resolving tensions between fidelity and fit. Prevention Science, 5(1), 41–45.
9.
CesariM.LandiF.TorreS.OnderG.LattanzioF.BernabeiR. (2002). Prevalence and risk factors for falls in an older community-dwelling population. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 57(11), M722–M726.
10.
ClemsonL.BundyA. C.CummingR. G.KayL.LuckettT. (2008). Validating the Falls Behavioural (FaB) scale for older people: A Rasch analysis. Disability and Rehabilitation, 30(7), 498–506.
11.
ClemsonL.DonaldsonA.HillK.DayL. (2014). Implementing person-environment approaches to prevent falls: A qualitative inquiry in applying the Westmead approach to occupational therapy home visits. Australian Occupational Therapy Journal, 61(5), 325–334.
12.
ClemsonL.FitzgeraldM. H.HeardR. (1999). Content validity of an assessment tool to identify home fall hazards: The Westmead Home Safety Assessment. British Journal of Occupational Therapy, 62(4), 171–179.
13.
ClemsonL.StarkS.PighillsA. C.FairhallN. J.LambS. E.AliJ.SherringtonC. (2023). Environmental interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2023(3), Article CD013258. https://doi.org/10.1002/14651858.CD013258.pub2
14.
CummingsS. M.CooperR. L.CassieK. M. (2009). Motivational interviewing to affect behavioral change in older adults. Research on Social Work Practice, 19(2), 195–204.
15.
CurranG. M.BauerM.MittmanB.PyneJ. M.StetlerC. (2012). Effectiveness-implementation hybrid designs: Combining elements of clinical effectiveness and implementation research to enhance public health impact. Medical Care, 50(3), 217–226.
16.
DeandreaS.LucenteforteE.BraviF.FoschiR.La VecchiaC.NegriE. (2010). Risk factors for falls in community-dwelling older people: A systematic review and meta-analysis. Epidemiology, 21(5), 658–668.
17.
DobkinB. H. (2004). Strategies for stroke rehabilitation. The Lancet Neurology, 3(9), 528–536.
18.
FillenbaumC. G. (1988). Multidemensional functional assessment of older adults. Hillsdale, NJ: Lawrence Erlbaum Associates.
19.
FlorenceC. S.BergenG.AtherlyA.BurnsE.StevensJ.DrakeC. (2018). Medical costs of fatal and nonfatal falls in older adults. Journal of the American Geriatrics Society, 66(4), 693–698.
20.
GillespieL. D.RobertsonM. C.GillespieW. J.SherringtonC.GatesS.ClemsonL. M.LambS. E. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2012(9), Article CD007146. https://doi.org/10.1002/14651858.CD007146.pub3
21.
GlasgowR. E.VogtT. M.BolesS. M. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89(9), 1322–1327.
22.
HarrisP. A.TaylorR.ThielkeR.PayneJ.GonzalezN.CondeJ. G. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381.
23.
HarveyL. A.CloseJ. C. (2012). Traumatic brain injury in older adults: Characteristics, causes and consequences. Injury, 43(11), 1821–1826.
24.
HaysR. D.BjornerJ. B.RevickiD. A.SpritzerK. L.CellaD. (2009). Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Quality of Life Research, 18(7), 873–880.
25.
KatzmanR.BrownT.FuldP.PeckA.SchechterR.SchimmelH. (1983). Validation of a short orientation memory concentration test of cognitive impairment. American Journal of Psychiatry, 140, 734–739.
26.
KeglovitsM.ClemsonL.HuY. L.NguyenA.NeffA. J.MandelbaumC.StarkS. (2020). A scoping review of fall hazards in the homes of older adults and development of a framework for assessment and intervention. Australian Occupational Therapy Journal, 67(5), 470–478.
27.
KendallF. P.McCrearyE. K.ProvanceP. G.RodgersM. M.RomaniW. A. (2005). Muscles: Testing and function with posture and pain (Vol. 5). Lippincott Williams & Wilkins.
28.
KlimaD. W.RabelM.MandelblattA.MiklosovichM.PutmanT.SmithA. (2021). Community-based fall prevention and exercise programs for older adults. Current Geriatrics Reports, 10(2), 58–65.
29.
KreuterM. W.SkinnerC. S. (2000). Tailoring: What’s in a name?Health Education Research, 15(1), 1–4.
30.
LawtonM. P.NahemowL. (1973). Ecology and the aging process. In EisdorferC.LawtonM. P. (Eds.), The psychology of adult development and aging (pp. 619–674). American Psychological Association. https://doi.org/10.1037/10044-020
31.
LiF.HarmerP.FitzgeraldK. (2016). Implementing an evidence-based fall prevention intervention in community senior centers. American Journal of Public Health, 106(11), 2026–2031.
32.
MorelandB.KakaraR.HenryA. (2020). Trends in nonfatal falls and fall-related injuries among adults aged ≥65 years—United States, 2012–2018. Morbidity and Mortality Weekly Report, 69(27), 875–881.
33.
NachreinerN. M.FindorffM. J.WymanJ. F.McCarthyT. C. (2007). Circumstances and consequences of falls in community-dwelling older women. Journal of Women’s Health, 16(10), 1437–1446.
34.
PalacioA.GarayD.LangerB.TaylorJ.WoodB. A.TamarizL. (2016). Motivational interviewing improves medication adherence: A systematic review and meta-analysis. Journal of General Internal Medicine, 31(8), 929–940.
35.
SchulzR.BurgioL.BurnsR.EisdorferC.Gallagher-ThompsonD.GitlinL. N.MahoneyD. F. (2003). Resources for Enhancing Alzheimer’s Caregiver Health (REACH): Overview, site-specific outcomes, and future directions. The Gerontologist, 43(4), 514–520.
36.
SelzerM. L.VinokurA.van RooijenL. (1975). A self-administered Short Michigan Alcoholism Screening Test (SMAST). Journal of Studies on Alcohol, 36(1), 117–126.
37.
SemrauK. E.HirschhornL. R.Marx DelaneyM.SinghV. P.SaurastriR.SharmaN.Dhingra-KumarN. (2017). Outcomes of a coaching-based WHO safe childbirth checklist program in India. New England Journal of Medicine, 377(24), 2313–2324.
38.
SheikhJ. I.YesavageJ. A. (1986). Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist: The Journal of Aging and Mental Health, 5(1), 165–173.
39.
StarkS.KeglovitsM.SomervilleE.HuY.-L.BarkerA.SykoraD.YanY. (2021). Home hazard removal to reduce falls among community-dwelling older adults: A randomized clinical trial. JAMA Network Open, 4(8), e2122044–e2122044.
40.
StarkS.LandsbaumA.PalmerJ. L.SomervilleE. K.MorrisJ. C.HarveyA.FriedmanD. H. (2009). Client-centered home modifications improve daily activity performance of older adults. Canadian Journal of Occupational Therapy, 76(Suppl.1), 235–245.
41.
SzantonS. L.LeffB.LiQ.BreysseJ.SpoelstraS.KellJ.GitlinL. N. (2021). CAPABLE program improves disability in multiple randomized trials. Journal of the American Geriatrics Society, 69(12), 3631–3640.
42.
TalbotL.MusiolR.WithamE.MetterE. J. (2005). Falls in young, middle-aged and older community dwelling adults: Perceived cause, environmental factors and injury. BMC Public Health, 5(1), Article 86.
43.
TinettiM. E. (1986). Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society, 34(2), 119–126.
WareJ.KosinskiM.KellerS. (2001). SF-36 physical and mental health summary scales: A user’s manual. Health Assessment Lab.
46.
WhyteJ.HartT. (2003). It’s more than a black box; it’s a Russian doll: Defining rehabilitation treatments. American Journal of Physical Medicine & Rehabilitation, 82(8), 639–652.
47.
YardleyL.BeyerN.HauerK.KempenG.Piot-ZieglerC.ToddC. (2005). Development and initial validation of the Falls Efficacy Scale International (FES-I). Age & Ageing, 34, 614–619.
