Table 1.

Lessons learned, with examples, from the State-driven Fall-Prevention Project from New York (NY), Colorado (CO), and Oregon (OR) Departments of Health (DOH).

Learned lesson	Description	Example
Dedicated staff time from DOH is required for relationship building	Substantial time is required to nurture and redefine (in some instances) pre-existing partnerships to the point where they are vested in implementing and sustaining change	Each DOH had established relationships with health-care systems through advisory boards and planning groups. Additional time required before partners valued and were ready to engage in practice change After committing to change, additional time was required to support/assist partners to complete implementation responsibilities.
Potential stakeholders have different goals and initiatives	Understanding market drivers for each stakeholder is an effective adoption and implementation strategy	All three states Provided tailored technical assistance to each partner Specifically addressed program alignment with business goals
Roles and responsibilities must be clearly defined	Effective fall risk management requires communication and collaboration between multiple partners Partners do not understand the parameters of their role. Gaps may exist in their management program	A large academic medical center adopted STEADI Planned to refer to evidence-based programs in the community Did not realize they needed to create a system to make those referrals happen
The DOH plays a role as a connector	The DOH can connect established and engaged partners with new partners by showcasing efforts of each	OR convened a “Health Systems Partner” meeting attended by five health-care systems, State Unit on Aging, AAA, DOH, and DHS Champions presented their STEADI model Key stakeholders presented their role in primary care fall risk management Many stakeholders had never met Many did not value partnering to manage fall risk Most health-care partners were unaware of DHS resources available to their patients The meeting resulted in A stronger connection and greater motivation to improve referrals among all players
Begin with early adopters or those in a high state of readiness	Highly motivated stakeholders due to market drivers or incentives or penalties are more willing to invest time and resources into effective partnerships	OR and CO Level -1 Trauma Centers are mandated to provide community injury prevention education Stepping on is one of the few evidence-based injury prevention programs target older adults The Level 1 Trauma Centers motivated to adopt and implement Stepping on In CO, the AAA were motivated to partner with the trauma centers for client referrals
		OR The rate of falls in a health system in Portland was putting it at risk of losing its Medicare 5-star rating. The health system was motivated to implement fall risk management solutions The DOH was able to connect the system with resources for health-care providers and community programs The system offers STEADI, the Otago Exercise Program, and refers to Tai Chi The Oregon Geriatric Education Center (OGEC) had identified falls and dementia as two priority areas They were willing to take on STEADI dissemination It aligned with research priorities OR is a Comprehensive Primary Care Initiative (CPCi) market OHSU Internal Medicine needed to meet CPCi quality standards OHSU was an early adopter of STEADI A large health-care system was not ready to implement a new fall-prevention program They had developed a fall risk management program It was not evidence-based DOH worked with them for over 3 years without success to implement evidence-based programs and/or refer system
Any new processes needs to fit within the clinical culture	Evidence-based practices to improve fall risk management will only be successful if the implementation process is simple fully integrated into the culture	NY developed a clinically-specific referral process Physicians were given a referral sheet with program contact information The referral sheet was provided to the patient OR aligned EBHP programs with the concept of a “specialist.” It is common for patients to receive referrals to a specialist Physicians and health-care organizations have specialty referral systems in place The EBHP program became a “specialist” Integrate referrals to EBHP into electronic medical records Salem Primary Care Clinic implemented a system which directly refers patients to physical therapists to implement the Otago Exercise Program
Celebrate successes, regardless of the size	Promote and publicize the accomplishments achieved by partners	NY made a video disseminated nationally about the success of STEADI implementation in one practice (https://youtu.be/XxDr4V06KaU)
		CO presented Level 1 Trauma Centers with a “Program of Excellence” award to publicly acknowledge accomplishments and reward efforts
Provide meaningful data to partners	Identify important drivers that influence your partners likelihood to change (i.e., cost, patient satisfaction)	CO Infographic of stepping on outcomes data More trauma centers have adopted the program
	Make sure data collected and analyzed is in alignment with drivers	NY Systematic evaluation of program processes and outcomes from physician practices implementing STEADI Clinic and provider-level STEADI reports to OHSU demonstrate improvements in claims billing and provider uptake
Identify innovative funding sources	Seeking out new and alternative partners can provide new referral and funding sources	OR – Tai Chi as a Medicare Part C Silver and Fit and Silver Sneakers FLEX now cover Tai Chi programs at the YMCA Similar options are being expanded in Silver Sneakers programs nationwide. CO – promoted to the Area Agencies on Aging EBHPs eligible for Older Americans Act Title IIID dollars
Plan for program sustainability from the beginning	Often grant-funded projects focus on number of programs started. This project focused maintaining and growing programs after funding	NY and OR Partners required to create sustainability plans Embed the EBHP into systems Promote systems change CO Focused on partners embedding the programs within stakeholder organizations Established a policy they would not provide subsidies for agencies or organizations to implement programs Offered mini-grants to cover start-up costs and facilitated instructor training The two major hospital systems hold the Stepping On licenses, cover all the costs of program implementation, and independently run the programs in their facilities
Leverage the infrastructure and lessons learned to pursue new fall-prevention funding opportunities	Build upon the strong foundation to continue to expand program reach	CO was awarded a grant by the Administration for Community Living to expand its falls prevention programing statewide
		NY was awarded a grant by ACL to develop new partnerships with Level 1 Trauma Centers to deliver EBHP across the state
		NY received additional state funds to implement fall risk management
		OHSU was awarded a grant to develop the STEADI toolkit for EHR dissemination with a national EHR company

DOH, Departments of Health; DHS, Department of Human Services; AAA, Area Agencies on Aging; STEADI, Stopping Elderly Accidents, Deaths, and Injuries Tool; NY, New York; OR, Oregon; CO, Colorado; EHR, Electronic Health Record; OHSU, Oregon Health Sciences University; ACL, Administration for Community Living; EBHP, Evidence-Based Health Promotion Programs.