Satisfying the MIPS Falls Risk Assessment Requirements

We have all heard the stories. The elderly patient wobbles in on a walker or cane stating, “Doc, I just missed the curb and went down,” or “Doc, I didn’t see the dishwasher door and I fell into it,” or the more dangerous “Doc, I blacked out in the bathroom and just collapsed.” Sometimes patients tell these stories at the initial visit to see us in the wound center, but often these patients are already seeing us for a different wound, and in the course of the months seeing us, they have a fall and open a new traumatic wound in their fragile skin.
 
Many wound centers screen for falls in patients over 65 years old as part of the Clinical Quality Measures (CQMS) for the Merit-Based Incentive Payment System (MIPS). Measures #154 and #155 combine the falls risk assessment with the falls plan of care for a positive screen.^1,2 If the patient is presenting to the wound center due to injury from a fall, technically this is already a positive screen, and therefore the falls risk assessment and plan of care should be done.
 
However, if the wound center would like to standardize screening to catch all those patients over 65 who are at risk for falls, they can use the Centers for Disease Control and Prevention’s (CDC) “Three key questions,” part of the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) program.³ Patients have a positive screen if they answer yes to any of the following three questions:

• Do you feel unsteady with standing or walking?
• Do you worry about falling?
• Have you fallen in the last year? If so, how many times? If so, were you injured? 

The electronic medical record (EMR) used in the wound center may already have these screening questions as part of the intake questions for the staff rooming the patients. If the EMR does have these questions, they can be added to the note template for providers, helping to notify providers when there has been a positive screen and when the falls risk assessment should be completed.

Conducting the Falls Risk Assessment

To satisfy MIPS the falls risk assessment and plan of care should be done once yearly; however, this may be difficult to track. You may want to consider doing the falls screen for each patient over 65 at every visit and reassessing their falls risk as appropriate throughout the year. As our patients age, their health can easily change, so their falls risk may increase before a year’s time.
 
The requirement for the falls risk assessment is very basic—you must do a balance and gait assessment, which could be as simple as documenting gait and transfers in your physical exam, along with only one of the following: orthostatics, evaluation of vision, home environment safety assessment, and a medication review of whether or not the patient’s medications could be contributing to their falls.
 
Theoretically, as a provider, you would tailor this to how the patient presented. The patient who reported blacking out in the bathroom would be the ideal candidate for orthostatics that day in clinic. If positive, you may have the answer as to why they fell, although if they have not had the broader syncopal workup prior to arrival at your wound clinic, you may want to send them back to their primary care provider or cardiologist for the full evaluation.
 
These required elements for the falls risk assessment barely touch on why patients fall. The MIPS documentation does acknowledge this, stating that they started out with limited scope to help facilitate the implementation of the measure. But I would not be surprised if this measure becomes less limited, and the falls risk assessment component may be expanded to completing the full assessment. Some wound centers may find it easier to implement a standardized fall risk assessment which includes all the components right from the start.
 
The CDC’s STEADI program does include a standardized assessment and then recommendations for the plan of care. This might be the easiest to implement.
 
Unfortunately, there are no falls risk assessments in the outpatient setting that have been proven to be better than the others.⁴ I still use the fall risk assessment that I learned in my geriatrics fellowship at Duke, which has not been validated, but yet includes almost all of the components. We used the acronym SOMME—Sensory, Orthostasis/Cardiac, Medications/Vitamin D, Mobility, and Environment.
 
Sensory includes vision, hearing, and touch, especially in the context of neuropathy limiting the sensation of being in contact with the floor. Orthostasis and cardiac causes include orthostatic hypotension along with heart block, arrythmias, and simply hypotension. Medications include the Beer’s List (potentially inappropriate medications or PIMs) and low vitamin D levels increase the risk for falls. Mobility is the balance and gait assessment—do they have Parkinson’s disease, age related debility, history of stroke, or benign paroxysmal positional vertigo? Environment is the home environment—is there clutter, do they have throw rugs, do they live in an old home with multiple levels, do they have the appropriate railings and grab bars?

Implementing a Plan to Reduce Falls Risk

Of course, all of this assessment then sparks the plan of what we can do about our patients’ high fall risk.
 
Sensory. Poor vision or poor hearing should be an ophthalmology or audiology referral. Neuropathy may mean an endocrinology referral for better control of the patient’s diabetes or referral to podiatry for more appropriate footwear.
 
Orthostasis/cardiac. With orthostatic hypotension, patients likely need to come off some of their blood pressure medications, or if they are not on any blood pressure medications, they may need midodrine or fludrocortisone. If the wound care provider does not feel comfortable making these adjustments, then they need to document that they have reached out to the patient’s primary care provider or cardiologist or are having the patient contact them to adjust medications.
 
Medications/vitamin D. If patients are on multiple potentially inappropriate medications for older adults, then your plan could be to discontinue these one at a time until you see which one is contributing to their falls. Or if you do not feel comfortable managing these medications, refer them to geriatrics for a medication review or send them back to their PCP listing your concerns and the specific medications about which you are worried. If patients have low vitamin D, you may want to consider supplementing, especially in light of data showing that low vitamin D correlates with poor wound healing.⁵ However, vitamin D supplementation is a hot topic in geriatrics at the moment, as many studies have shown that though low vitamin D can increase risk of falls, supplementing vitamin D may not help with fall risk, and high dose supplementation may increase risk of falls.⁶ More to come on that, I am sure.
 
Mobility. For poor balance and gait, likely a referral to physical therapy is in order. If they are already receiving home health for their wound care, this is an easy add on to the home health order.
 
Environment. If you suspect the home environment is not safe, then occupational therapy needs to get involved for a home safety assessment—this could be another add on to your home health orders.
 
Monica A. Stout, MD is an Assistant Professor of Medicine in the Division of Geriatric Medicine at Vanderbilt University Medical Center. She is board-certified in family medicine and geriatrics, and has completed a fellowship in wound care. She sees patients in the Geriatrics Primary Care Clinic and in the Vanderbilt Wound Center. Her particular academic interest is in geriatrics and wound care curriculum development for medical students, residents, and fellows.

References
 
1. Centers for Medicare and Medicaid Services. Quality ID #154 (NQF: 0101): Falls: Risk Assessment.
2. Centers for Medicare and Medicaid Services. Quality ID #155 (NQF: 0101): Falls: Plan of Care.
3. Centers for Disease Control and Prevention. Stopping Elderly Accidents, Deaths, and Injuries (STEADI).
4. Strini V, Schiavolin R, Prendin A. Fall risk assessment scales: a systematic literature review. Nurs Rep. 2021 Jun 2;11(2):430-443. doi:
5. Smith K, Hewlings S. Correlation between vitamin D levels and hard-to-heal wounds: a systematic review. J Wound Care. 2020 Jul 1;29(Sup7):S24-S30. doi: 10.12968/jowc.2020.29.Sup7.S24. PMID: 32654618.
6. Appel LJ, Michos ED, Mitchell CM, et al. The effects of four doses of vitamin D supplements on falls in older adults. A response-adaptive, randomized clinical trial. Ann Intern Med. 2021;174:145-56. doi:10.7326/M20-3812