Geriatric Care in the Community Setting: Assessment and Management of Fall Risk and Impaired Mobility.

Falls are the leading cause of injury among patients 65 years and older in the United States. Many falls are preventable, and clinicians can help patients reduce the risk of falls. This involves screening for fall risk, assessing for modifiable risk factors, and implementing evidence-based interventions for prevention. Screening for fall risk is required as part of the Welcome to Medicare visit and Annual Wellness Visits. Screening involves asking patients if they have had 2 or more falls in the past 12 months, if they are presenting because of an acute fall, and if they have difficulty with walking or balance. A "yes" response to any of these questions indicates fall risk. If fall risk is identified, patients can be further evaluated with the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) algorithm. Evaluation also should include a Timed Up & Go, assessment for orthostatic hypotension, identification and management of conditions that might contribute to fall risk, vision and hearing assessment, and review of the patient's drugs to ensure none is associated with falls. Referral to a physical therapist or community fall prevention program has been shown to reduce fall risk. Some patients may benefit from prescription of mobility assistive devices, such as canes, walkers, or wheelchairs. Patients may be referred to a physical therapist for selection of and counseling on use of these devices. Documentation of need is required for Medicare reimbursement.

Improving Advance Care Planning Documentation Using Reminders to Patients and Physicians: A Longitudinal Study in Primary Care.

OBJECTIVE: Documenting advance care planning (ACP) in primary care requires multiple triggers. New Medicare codes make it easier for providers to bill for these encounters. This study examines the use of patient and provider reminders to trigger advance care planning discussions in a primary care practice. Secondary outcome was billing of new ACP billing codes. METHODS: Patients 75 years and older scheduled for a primary care appointment were screened for recent ACP documentation in their chart. If none was found, an electronic or mail message was sent to the patient, and an electronic message to their provider, about the need to have discussion at the upcoming visit. Chart review was performed 3 months after the visit to determine if new ACP discussion was documented in the chart. RESULTS: In the 3 months after the reminder had been sent to patients and providers, new ACP documentation or billing was found in 28.8% of the patients. Most new documentation was health care decision maker (75.6% of new documentation) with new DNR orders placed for 32.3% of these patients. The new Medicare billing code was filled 10 times (7.8%). CONCLUSION: Reminders sent to both patients and providers can increase documentation of ACP during primary care visits, but rarely triggers a full ACP conversation.