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Operationalizing MRC Volunteers to Implement Matter of Balance

State: OH Type: Promising Practice Year: 2019

*The Lake County General Health District (LCGHD) services Lake County in Northeast Ohio. Lake County is a suburban community and has a population of 228,614 which is medically underserved with 11.87% Medicaid recipients and 7.6% uninsured. There are 51,488 older adults over the age of 60. 

* The public health issue is that fall-related deaths among older adults has been rising steadily over the past decade. One in three older adults aged 65 and older experiences a fall, and people who fall once, are two to three times more likely to fall again (CDC, 2015). One out of ten falls causes a serious injury, such as a hip fracture or head injury, which requires hospitalization (CDC, 2015). Each year, in the U.S., at least 25,000 older adults die as a result of a fall (CDC, 2015).

* First goal was to recruit and train individuals to become a coach in the Matter of Balance (MOB) program. Second goal is to implement the MOB program at five Lake County senior centers twice a year by end of 2019. The objectives are: 1.) Recruit Medical Reserve Corps (MRC), Retired Senior Volunteer Program (RSVP), and community volunteers to be trained as MOB coaches; 2.) Register recruited individuals as new MRC and/or RSVP volunteers; 3.) Conduct a train the trainer course for the volunteers through Fairhill Partners; 4.) Work with participating Lake County Senior Centers to facilitate the MOB program.

*The practice was implemented by LCGHD, RSVP and the Lake County Commissioners, by recruiting volunteers and community members to be trained as MOB coaches. The recruitment phase brought in fifteen volunteers. Coach participant books were supplied through Fairhill Partners with LCGHD organizing the volunteers and providing other supplies for the class. MOB classes were posted at senior centers that had trained coaches and interested participants registered for the class.

* Short-term outcome of the MOB training yielded fifteen trained MRC volunteers for the program, of which, twelve were newly-recruited MRC volunteers. The volunteers conduct the class with little to no cost to LCGHD or the senior centers. Since the start of the MOB program, a total of nine MOB classes with a total of 95 participants have been completed. Data was supplied by the Lake County Sheriff's Communication Director and from June 2016 to June 2017 reported 2,870 falls in Lake County averaging about 239 falls each month. After MOB classes were implemented, data from June 1, 2018 to November 5, 2018, showed number of falls causing an injury in Lake County was 1,033, averaging about 207 falls each month, showing overall 13% decrease in falls.

* The objectives of recruiting and training volunteers have been fully met with fifteen individuals trained as a MOB coach. A trainer the trainer course was held at the Lake County General Health District with the other volunteers begin trained at Fairhill Partners. The MOB program was held at The Fairport Harbor and Willowick Senior Centers in 2017 with three MOB classes. In 2018, Mentor Senior Center was added and six MOB programs were held in Lake County. To date, there has been nine MOB programs held in three different senior centers.

* The MOB program is successful due to community partnerships of LCGHD working with the MRC, RSVP and the Lake County Commissioners Office. Partners actively recruited current and new volunteers to participate in the MOB program through informational meetings, email notifications and recruitment fliers. LCGHD provided the training venue, snacks and lunch for the volunteers. Fairhill Partners were instrumental in providing Master Trainers and all the training materials (i.e. the coach handbook, participant handbook, and healthcare professional handbook) to the new volunteers to coach the MOB program. Fairhill Partners have also provided all of the handbooks to the participants engaged in taking the MOB program. Lastly, the senior centers and the volunteer coaches have provided the facilities and healthy snacks to the participants. 

* The public health impact of the MOB program has provided a collaboration between community partners that focused on five dimensions of reach, efficacy, adoption, implementation, and maintenance for a public health intervention and has occurred on multiple levels such as individual, organizational and community. The public health impact from the MOB program has seen a reduction in falls in the Lake County community. Additionally, for every preventable fall of an older adult has the potential savings of $5,000 - $30,000 depending on the extent of injury.

Fairhill Partners http://fairhillpartners.org/

Lake County Commissioners https://www.lakecountyohio.gov/commissioners/SENIOR-SERVICES

Lake County General Health District https://www.lcghd.org/

Retired Senior Volunteer Program (RSVP) http://rsvplc.org/

Problem/public health issue

Fall-related deaths among older adults has been rising steadily over the past decade. One in three adults aged 65 and older experiences a fall, and people who fall once, are two to three times more likely to fall again. One out of ten falls causes a serious injury, such as a hip fracture or head injury, which requires hospitalization. Falls often require a lengthy recovery of at least one year and some who fall are never able to live independently again. Each year in the United States, at least 25,000 older adults die as a result of a fall. Healthy People 2020 goal for injury prevention is addressed in IVP-23.2 to prevent an increase in fall related deaths among adults aged 65 years and older. Fall-related death rates among persons aged 65 years and older increased 54 percent between 1999 and 2007. Baseline data shows that 47.0 deaths per 100,000 population aged 65 years and over were caused by unintentional falls in 2007. The Health People 2020 target is to maintain that baseline value because aiming to reduce the rate is too ambitious. 

Fall rate data for Lake County was provided by the Lake County Sheriffs communication director. 911 emergency calls were tracked for call responses for falls and evaluation of the quantitative data was compiled by the Program Manager at LCGHD. Data from June 2016 to June 2017 reported 2,870 falls in Lake County averaging about 239 falls each month. The Matter of Balance (MOB) addresses the portion of the CDC Winnable Battles 2010-2015 under nutrition, physical activity, and obesity and is an evidence-based program that utilizes the best evidence for fall prevention to the individual patient.  The MOB program is an integration of clinical expertise, patient values, and the best research evidence into the decision-making process for patient care. Lake County seniors as observed an increase in fall rates over the years. Lake County is particularly vulnerable to high rate of falls due to weather conditions causing hazardous environmental conditions.

What target population is affected by problem (please include relevant demographics)

The target population is predominantly those aged 65 and older but will additionally impact caregivers, families and the community that would otherwise have to care for an individual who falls. Lake County's total population is 228,614 with a senior population of 51,488 persons aged 60 years and older (22.4%), plus 5,300 of them are 85 years and older (2.3%) (U.S. Census 2010). Within 15 years, it is estimated that the 60+ population will increase to 70,781 with 8,204 being over the age of 85. Also by 2030, the 60+ group's population share is projected to grow to 33.9 percent, outnumbering youth under 20 years old (Lake County Senior Report, 2015). The growth of the younger age cohort, 60-74 years, is projected to stabilize by 2020. By 2030, one of three residents of Lake County will be 60 years and older, with most of the growth after 2020 in the cohort 75 years and older (Lake County Senior Report, 2015). In 2010, it was estimated that 3,428 person's aged 60+ and 1,339 persons 85+ had a severe physical and/or cognitive disability. This means they met the nursing home level of care which made them functionally eligible for a Medicaid-funded nursing facility or home and community-based services. The numbers are expected to increase to 5,649 for 60+ and to 2,236 for 85+ by 2030. Twenty-five percent of these persons are expected to have incomes below 200 percent of the poverty threshold (Lake County Senior Report, 2015). An aging population in Lake County not only translates into needs for more services for older persons, but also can impact the financial structure of the county and its communities, specifically from potential decreases in sales and local income tax revenue (Lake County Senior Report, 2015). People are living longer and falls have become a major threat to the health and independence of older adults. Many older adults have a fear of falling which often leads to limiting activities, which can result in physical weakness, making the risk of falling even greater (http://www.lakecountyohio.gov/Portals/4/SeniorReport/Lake%20County%20Report%20-%20FINAL%2010-16-2015.pdf).

What is the target population size?

The target population is Lake County's seniors aged 55 and older of which 51,488 persons are 60 years and older (22.4%) (U.S. Census 2010). Within 15 years, it is estimated that the 60+ population will number 70,781. Also, by 2030, the 60+ group's population share is projected to grow to 33.9 percent, outnumbering youth under 20 years old. (Lake County Senior Report, 2015). The growth of the younger age cohort, 60-74 years is projected to stabilize by 2020. By 2030, one of three residents of Lake County will be 60 years and older, with most of the growth after 2020 in the cohort 75 years and older (Lake County Senior Report, 2015).

What percentage did you reach?

To date, nine full classes with a total of 95 participants have completed the full course in Fairport Harbor, Willowick and Mentor Senior Centers. Fairport Harbor participated in four full courses with a total of 45 participants. The class sizes are limited to only ten to twelve participants for fidelity of delivering the MOB model program. In addition, the reach extends much farther due to many of the participants reaching out to their family and friends by discussing the knowledge they have learned from the class and encouraging their peers to become physically active.

What has been done in the past to address the problem?

There has been a growing need to bring a fall prevention program to the Lake County community but resources have been in short supply. Fairhill Partners was able to conduct a couple of MOB classes over the years in Lake County but their limitations included being short-staffed and limited funding for the number of classes that could be held in Lake County. Fairhill Partners reached out to the LCGHD, Lake County MRC, RSVP and the Lake County Commissioners for volunteer interest. It was decided that to have the greatest impact in the community, a collaborative effort was put forth,  with recruiting fliers sent to senior centers and senior living apartment complexes. The response was overwhelming from interested community members who wanted to be trained in the MOB program. Since the program would be operated under the auspice of the Lake County MRC and RSVP it was made a requirement that all community members being trained would be required to join the MRC and/or RSVP for efficiency of communication and liability protection.  

Why is the current/proposed practice better?

The MOB program has been around since 1995 and is a program that is operated under grant funding for Fairhill Partners to conduct. What makes this program better is the utilization of Medical Reserve Corps and RSVP volunteers who are active at their senior community centers. The volunteers are integrated into the senior center making it conducive to conduct the MOB classes and they want to contribute to improve the health of those they spend time with. The community knows and trusts each other and this makes for an ideal group that is more inclined to participated and commit to the program.

Is current practice innovative? How so/explain?

The utilization of MRC and RSVP volunteers who are active at their senior centers is an innovative practice to bring the MOB program to the centers to help save money and to bring a much needed service to the community.  The MOB program consists of eight two-hour sessions occurring twice a week for four weeks. The recruitment of additional MRC/RSVP volunteers will help to increase the capacity to serve older persons at the senior centers. New MOB coaches have been recruited by veteran coaches and through the MOB program. Senior centers are part of a complex, community-based service network that has been developed during the past several decades. In Lake County, they have played a strong role in providing opportunities for health and wellness through fitness classes and other activities. These services support the optimal outcome of services for older adults, to delay the onset of chronic illnesses and other events that prevent them from prematurely not being able to provide for their own daily living needs. 

Is it new to the field of public health

The MOB program is fairly new to public health including expanding the program in a way that recruits community, MRC and RSVP volunteers to be actively engaged in their own community senior centers. This has also shown to be an ideal recruitment activity to bring additional MRC and/or RSVP volunteers to register.

Is it a creative use of existing tool or practice:

Expanding the lay leader model for MOB coaches to those who are involved at their senior center community was a creative use of resources to increase volunteerism with the MRC and/or RSVP and the senior centers. Due to greater interest in Lake County, the train the trainer courses were provided by Fairhill partners at a location that was convenient for the new coaches, making the training more accessible.

What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO's Toolbox etc.)

Information from Healthy People 2020 was evaluated in which the goal for injury prevention specifically is addressed in IVP-23.2 prevent an increase in fall-related deaths among adults aged 65 years and older. The original program, A Matter of Balance: Managing Concerns About Falls, was developed and evaluated by the Royal Center for Enhancement of Late-Life Function at Boston University, with a grant from the National Institute on Aging. Under the original model, a healthcare professional - frequently a nurse or physical therapist - delivered the program.

In October 2003, MaineHealth's Partnership for Healthy Aging, Southern Maine Agency on Aging, Maine Medical Center's Geriatric Center and the University of Southern Maine received grant funding from the Administration on Aging to translate A Matter of Balance into a program that uses volunteer lay leaders instead of healthcare professionals to deliver the Matter of Balance class. Because the Matter of Balance Lay Leader Model uses volunteer lay leaders instead of healthcare professionals, it reduces the cost to deliver the program. Therefore, it can be offered more frequently, reaching a significantly higher number of older adults. 

The Matter of Balance Volunteer Lay Leader Model has proven to be as effective as the original program. Significant improvements for participants were found regarding their levels of falls efficacy, falls management, falls control, exercise and social limitations with regard to concerns about falling.

Is the current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)

The MOB program is recognized as an evidence-based program represented by the Evidence Based Leadership Council (EBLC). The mission of the EBLC is to increase delivery of evidence-based programs that improve the health and wellbeing of diverse populations. MOB is a program that utilizes the best evidence for fall prevention to the individual patient. The program is an integration of clinical expertise, patient values, and the best research evidence into the decision-making process for patient care. The CDC's Morbidity and Mortality Weekly Report (MMWR) includes a report describing the epidemiology of falls among older adults, and how health care providers can use CDC's STEAD (Stopping Elderly Accidents, Deaths, and Injuries) initiative to reduce preventable falls. The Agency for Healthcare Research and Quality (AHRQ) provides recommendations for population, intervention, comparators, outcome (PICO) for fall related injuries. PICO 6 strongly recommends risk stratification with targeted, comprehensive risk-reduction strategies tailored to high risk groups. A mix of strategies has shown to decrease the risk of fall-related injuries among the elderly. The U.S. Preventive Services Task Force (USPSTF) recommends a multifactorial intervention to prevent falls to adults age 65 years or older.

There was a need in the community to provide the MOB program and it was through the collaboration of LCGHD, Lake County MRC, Lake County RSVP, Lake County Commissioners, and Fairhill Partners that made this program a reality. LCGHD was actively involved in the recruitment, training and implementation of the Matter of Balance program in the community. Further involvement has expanded to include the senior center directors and community members.

The first goal was to recruit and train individuals to become a coach in the MOB program. The second goal is to implement the MOB program at five Lake County senior centers twice a year by the end of 2019. The objectives are 1.) Recruit Medical Reserve Corps (MRC), Retired Senior Volunteer Program (RSPV), and community volunteers to be trained as MOB coaches; 2.) Register recruited individuals as new MRC and/or RSVP volunteers; 3.) Conduct a train the trainer course for the volunteers through Fairhill Partners; 4.) Work with at least two participating Lake County Senior Centers to facilitate the MOB program.

Steps taken to implement the MOB training and program involved activity by a number of community stakeholders. In person meetings and email correspondence with the community partners began in May of 2017. Over the course of two months, information was sent out to the Lake County MRC and RSVP volunteers for those who would be interested in the training. Additionally, a flier was sent by the Lake County Commissioners to the senior centers to recruit volunteers who would be interested in coaching the program. LCGHD was the point of contact in organizing the volunteers and explaining the process for involvement. It was explained that volunteers would be required to register as an MRC and/or RSVP volunteer to ensure communication channels and liability protection were covered to deliver the MOB program to the community. New volunteers either registered before or during the MOB training. In-kind costs for the MOB training of volunteers was conducted by master trainers from Fairhill Partners. Fairhill Partners conducted the two-day training in Lake County for those who were interested on August 25 - 26, 2017.  LCGHD provided the food for the two-day training at a cost of about $100 for two master trainers and eleven volunteers. Additional in-kind support from Fairhill Partners included all necessary training materials, as well as all coach participant books for the MOB program.

The next steps were to begin contacting the target population at senior centers to bring the MOB class to their communities. Integral to the process was the newly recruited volunteers who are active in the community senior centers. They met with the directors and set up class dates and times for participants to register. The utilization of the new MRC/RSVP volunteers within their community has shown to be a key component to the delivery of the MOB classes in a timely fashion.

In-kind support for the MOB program includes: Fairhill Partners, which supply the paperwork, materials and handbooks for the participants. LCGHD provided the flip charts, markers and pens for the MOB classes. A requirement of each MOB class is providing a light snack and drink to the participants. In-kind support came from both the senior center directors and volunteers who have provided these light snacks to the participants.

The MOB class consists of eight two-hour sessions conducted twice per week for four weeks. The first MOB class was held in October 2017 at Willowick Senior Center, one month after training had been completed. Additional MOB classes have been completed at Fairport Harbor Senior Center in September 2017, November 2017, March 2018 and June 2018, Mary Rose Estates in January 2018 and at Mentor Senior Center in April and September 2018.

Start-up costs came from grant funding through the National Association of County and City Health Officials for $7,500.00 which covered the costs of supplies, printing, mileage, and a stipend to offset additional costs for the MOB coaches. The program has generated great support from our senior center directors wanting to expand the MOB program and they have requested the Lake County Commissioners office to fund the program expansion. Over the past six months, Lake County General Health District worked to propose funding to cover the cost for an employee to oversee the expansion of the MOB program in Lake County. Lake County Commissioners voted and passed the funding proposal for $30,000 of which, Lake County General Health District will receive $20,000 and Fairhill Partners to receive $10,000.  

The objectives are: 1.) Recruit Medical Reserve Corps (MRC), Retired Senior Volunteer Program (RSPV), and community volunteers to be trained as MOB coaches; 2.) Register recruited individuals as new MRC and/or RSVP volunteers; 3.) Conduct a train the trainer course for the volunteers through Fairhill Partners; 4.) Work with at least two participating Lake County Senior Centers to facilitate the MOB program.

Collection and evaluation of short-term quantitative data from volunteers was conducted by the Program Manager at LCGHD. Evaluation of the participant data was collected by the volunteers and the Health Educator at the LCGHD with evaluation data compiled by Fairhill Partners and placed into a national data base.

Short-term outcome evaluation data shows recruitment of MOB coaches has increased the MRC and RSVP volunteer base. The recruitment phase brought in twelve new MRC volunteers (7% increase of Lake County MRC volunteers) of which six also registered with RSVP. A total of fifteen MRC took part in a two-day train the trainer course. Many of the new volunteers were recruited from senior centers in Lake County making an ideal situation to integrate the MOB program at their centers.

Data collected from the MOB participants include; demographics, pre- and post-surveys, session and participant level attendance, class information, class implementation site and master trainer organization data, and coach information. A total of 95 seniors have participated in the MOB program with ten at Willowick Senior Center in October 2017, eight at Willoughby Mary Rose Estates, sixty-one at Fairport Harbor Senior Center, and sixteen at Mentor Senior Center.  Pre and post survey data showed that all participants had a dramatic increase in knowledge concerning fall prevention.

Fall rate data was provided by the Lake County Sheriff's Communication Director on the number of 911 emergency calls for a fall that caused an injury. Evaluation of the quantitative data was compiled by the Program Manager at LCGHD. Data from June 2016 to June 2017 reported 2,870 falls in Lake County averaging about 239 falls each month. Recent data reported by the Lake County Sheriff's Communication Director calculated between the dates of June 1, 2018 to November 5, 2018, the number of falls causing injury in Lake County was 1,033, averaging about 207 falls each month, showing overall 13% decrease in falls.

Participants were encouraged to pass along the information they had learned to others in their social groups. Thus, the decrease in falls is possibly associated with the fact that many seniors who took the MOB program have passed this knowledge onto their friends and family.

Valuable lessons were learned by implementing a program of this nature by building partnerships to receive the optimal outcome of educating the older adults in the community and building a strong volunteer-base within Lake County.  Collaboration of partners is beneficial due to contributions of expertise, knowledge and ability to offer a wide array of supportive services to provide a multi-faceted approach to program implementation. Recruiting volunteers within the target population is a benefit to any program implementation as many volunteers are already vested in their local community and want to contribute to positive health benefits. It is also recommended that when there are two new coaches teaching their first MOB program, that a third coach who is knowledgeable in the MOB program, mentor the new coaches by providing direction and instruction for optimal delivery of the program.

There are a number of reasons that this program is highly sustainable in the community. First is the commitment by Fairhill Partners to train volunteers, provide training materials and participant handbooks at no cost to the community. Second is the short-term costs for the two-day training requirement for volunteers is minimal. Third is the involvement of the volunteer to be actively involved in their community senior centers, which will enable the MOB coach to deliver the program at the optimal day and time for themselves and the participants. Fourth is the need within the community and the support from senior center directors to offer the MOB program on a regular basis, with a minimal cost to the senior centers to provide the training room and snacks. Lastly, the Lake County Commissioners has realized the need for the MOB program in the community and have provided start-up funding through the senior levy to support the expansion of the MOB program.

A cost/benefit analysis' demonstrates the cost-effectiveness of training lay volunteers at very little cost to deliver the MOB program. Once a volunteer is trained and continues to teach the MOB program twice a year they will maintain their certification which limits the cost that could be spent on re-training.

The economic evaluation compares the original MOB implementation which used trained coaches who were either a nurse or physical therapist to the utilization of a lay person to implement the program. This is a huge economic savings by having community volunteers deliver the program. Fairhill Partners places a cost for a nurse or physical therapist to conduct a workshop with two coaches for 8 weeks at about $3,000.00. The cost savings of training lay volunteers to administer the MOB program versus a paid nurse can be roughly quantified as a savings of $1,200 per a MOB program

The budget impact analysis of adopting the MOB program at the local level is the cost associated with Fairhill Partners to provide the master trainers, training material, and program participant handbooks. The cost for the two trainers for two days is approximately $800 for time and travel and additional $40 for the instruction manual for each volunteer coach. The first round of volunteer training totaled $1,300 which includes; two trainers, ten new MOB coaches, instructional supplies, and food. The cost of training ten new lay volunteers is about approximately equal to the cost of training two medical personnel.

A class size averages about ten participants, thus a long-term economic outcome can be quantified that for each fall prevention by a participant translates to a saving of $5,000 to $30,000 depending on the severity of the fall.   

The health impact assessment shows that the implementation of the MOB program using the lay model of volunteer engagement capitalizes on a cost savings with an opportunity to improve the health and well-being of the aging community.

Senior centers are part of a complex, community-based service network that has been developed during the past several decades. In Lake County, senior centers have played a strong role in providing opportunities for health and wellness through fitness classes and other activities, These services support the optimal outcome of services for older adults, to delay the onset of chronic illnesses, injuries, and other events that prevent them from prematurely not being able to provide for their own daily living needs. Since most senior centers receive funding through grants and tax subsidies for food they are able to provide snacks to the participants. 

The sustainability of the program was developed over the past year. The Lake County General Health District worked with the Lake County Senior Services Coordinator to develop a proposal for the Lake County Commissioners to continue and expand this program in Lake County through the senior levy. The Senior Center Directors were supportive of the MOB classes and have communicated the need to the Lake County Commissioners.  In November 2018 the Lake County Commissioners voted to approve the funds to support continuation and expansion of the Matter of Balance in Lake County through the senior levy funding for $30,000 to support an Associate Health Educator, costs for Fairhill to conduct coach trainings, and for needed materials for the Matter of Balance program. With the success of the program the Lake County Commissioners are committed to setting aside funds every year for the ongoing support of the Matter of Balance program.

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