S.Hrg.119-482

1[Senate Hearing 119-482]2[From the U.S. Government Publishing Office]34                                                   S. Hrg. 119-48256                      PREVENTING FALLS, PRESERVING7                       INDEPENDENCE: TECHNOLOGY,8                        COMMUNITY PROGRAMS, AND9                      INNOVATION IN SENIOR SAFETY10=======================================================================1112                                HEARING1314                               BEFORE THE1516                       SPECIAL COMMITTEE ON AGING1718                          UNITED STATES SENATE1920                    ONE HUNDRED NINETEENTH CONGRESS2122                             SECOND SESSION2324                               __________2526                             WASHINGTON, DC2728                               __________2930                              MAY 20, 20263132                               __________3334                           Serial No. 119-303536         Printed for the use of the Special Committee on Aging3738[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]3940        Available via the World Wide Web: http://www.govinfo.gov4142                             __________4344                U.S. GOVERNMENT PUBLISHING OFFICE4564-194 PDF             WASHINGTON : 202646=======================================================================4748                       SPECIAL COMMITTEE ON AGING4950                     RICK SCOTT, Florida, Chairman5152DAVE McCORMICK, Pennsylvania         KIRSTEN E. GILLIBRAND, New York53JIM JUSTICE, West Virginia           ELIZABETH WARREN, Massachusetts54TOMMY TUBERVILLE, Alabama            MARK KELLY, Arizona55RON JOHNSON, Wisconsin               RAPHAEL WARNOCK, Georgia56ASHLEY MOODY, Florida                ANDY KIM, New Jersey57JON HUSTED, Ohio                     ANGELA ALSOBROOKS, Maryland58                              ----------59                McKinley Lewis, Majority Staff Director60                Claire Descamps, Minority Staff Director6162                         C  O  N  T  E  N  T  S6364                              ----------6566                                                                   Page6768Opening Statement of Senator Rick Scott, Chairman................     169Opening Statement of Senator Kirsten E. Gillibrand, Ranking70  Member.........................................................     27172                           PANEL OF WITNESSES7374Christine Didion, MSW, Director of Programs, Area Agency on Aging75  Pasco-Pinellas, St. Petersburg, Florida........................     376Laura Mitchell, Co-Founder and CEO, GrandCare Systems, San77  Marcos, California.............................................     578Martha Petteys, Director of Grant Management and Health79  Strategies, Alliance of New York State YMCAs, Saratoga Springs,80  New York.......................................................     78182                                APPENDIX83                      Prepared Witness Statements8485Christine Didion, MSW, Director of Programs, Area Agency on Aging86  Pasco-Pinellas, St. Petersburg, Florida........................    2687Laura Mitchell, Co-Founder and CEO, GrandCare Systems, San88  Marcos, California.............................................    3589Martha Petteys, Director of Grant Management and Health90  Strategies, Alliance of New York State YMCAs, Saratoga Springs,91  New York.......................................................    399293                        Questions for the Record9495Christine Didion, MSW, Director of Programs, Area Agency on Aging96  Pasco-Pinellas, St. Petersburg, Florida........................    4597Martha Petteys, Director of Grant Management and Health98  Strategies, Alliance of New York State YMCAs, Saratoga Springs,99  New York.......................................................    48100101                       Statements for the Record102103Advancing Foot and Ankle Medicine and Surgery Statement..........    52104American Physical Therapy Association Statement..................    55105Alliance for Physical Therapy Quality and Innovation Statement...    59106Argentum Statement...............................................    62107North East Medical Services Statement............................    68108109                      PREVENTING FALLS, PRESERVING110                       INDEPENDENCE: TECHNOLOGY,111                        COMMUNITY PROGRAMS, AND112                      INNOVATION IN SENIOR SAFETY113114                              ----------115116                        Wednesday, May 20, 2026117118                                        U.S. Senate119                                 Special Committee on Aging120                                                    Washington, DC.121    The Committee met, pursuant to notice, at 3:32 p.m., Room122216, Hart Senate Office Building, Hon. Rick Scott, Chairman of123the Committee, presiding.124    Present: Senator Scott, Gillibrand, Kim.125    Also present: Senator King.126127                 OPENING STATEMENT OF SENATOR128                      RICK SCOTT, CHAIRMAN129130    The Chairman. The U.S. Senate Special Committee on Aging131will now come to order. Every year, more than 14 million older132Americans experience a fall. Many of them end up in emergency133rooms across our great country.134    Many seniors never recover and lose the independence they135spent a lifetime building. Falls are the leading cause of136injury, injury related hospitalization, and injury related137death for Americans over the age of 65. This isn't something we138should ever accept as an inevitable statistic.139    It is a crisis we need to resolve. The numbers behind this140crisis are staggering. Non-fatal medical spending related to141falls among older adults reached approximately $80 billion in1422020. With Medicare bearing the majority of that cost, and as143our population continues to age, that number will only rise144unless our country wakes up and addresses this issue head on.145    We are talking about tens of billions of dollars spent146treating injuries that in many cases were preventable. As bad147as those numbers are, it is about as much--it is much more than148the budget. Every single one of those cases is an individual.149    This is a grandfather in Florida who breaks his hip and150never returns to his home. It is about someone's grandmother151who falls alone and waits hours before anyone finds her. It is152about families who worry if they are getting the call every153time the phone rings.154    Falls don't just injure people physically, they take an155emotional toll, create fear, increase isolation, and cause a156loss of confidence that accelerates decline. Once a senior157stops moving, stops going out, and stops engaging with their158community, the consequences begin to compound.159    That is because none of us were put on this earth to sit160alone and stare out the window. We need family, we need161friends, hobbies, purpose. Those things are what make life162worth living. The good news is that nobody has to just accept163this fate. There are solutions on the rise across the country.164    Our incredible Area Agencies on Aging are on the front165lines, delivering programs at work, strength and balance166training, home safety assessments, and medication reviews that167identify high risk drug combinations before they cause a fall,168are just a glimpse of what these organizations can do.169    These are all proven interventions that save lives and help170keep overall costs down. I am thankful for the work of the171Administration for Community Living and the role the whole172agency plays in supporting and scaling these efforts through a173nationwide network of state and local partners.174    The work the ACL and the AAAs do together is exactly the175kind of federal investment that pays for itself many times176over. That is why I am proud to be leading the reauthorization177the Older Americans Act with Ranking Member Gillibrand,178Chairman Cassidy, and Ranking Member Sanders.179    Alongside these OAA programs, technology is opening new180doors we have never had before. Remote monitoring systems, fall181detection sensors, predictive analytics, and smart home182platforms are changing what is possible in fall prevention and183emergency response. When a senior falls and no one is home,184every minute matters.185    Technology is cutting response times, reducing long-term186complications, and giving families everywhere peace of mind.187Let me be direct, the Older American Act is a foundational law188governing community-based services for older Americans, and it189is far past time Congress actually reauthorizes it.190    This hearing is an opportunity to continue building the191record, documenting what is working, and identifying where gaps192exist given the lapse in OAA reauthorization. I want to thank193our witnesses for taking the time to be here and for the work194they do every day on behalf of older Americans and now I would195like to recognize Ranking Member Gillibrand for her opening196statement.197198                 OPENING STATEMENT OF SENATOR199             KIRSTEN E. GILLIBRAND, RANKING MEMBER200201    Senator Gillibrand. Thank you, Mr. Chairman. I Appreciate202all our witnesses. Every year an estimated one in four adults203will fall, which can result in injury, hospitalization, and204even death.205    Today's hearing explores the role technology and innovation206can play in senior safety. For example, smartphone apps can207assess an older adult's fall risk. In-home sensors can alert208caregivers when a loved one falls. Wearable devices can even209cushion the blow of a fall.210    Before today's hearing, I worked with Senators King and Kim211to ask the Government Accountability Office, the GAO, to report212on new technologies that provide promise in helping our older213adults and people with disabilities live safely and214independently. We also asked GAO to examine the challenges215older adults face with adopting such new technologies.216    We know these challenges are real. For example, technology217is expensive. AI can be biased. Communities can lack high speed218internet access. There is promise in technology, but its219promise does have limits. This means we cannot stop investing220in programs that have a proven track record of working.221    This includes federal fall prevention programs authorized222by the Older Americans Act, delivered through the223Administration of Community Living, as well as the programs224afforded by CDC and HUD. Finally, we need to remember how much225technology and innovation is built upon federally funded226research.227    I look forward to hearing more about the opportunity that228this emerging technology plays in keeping our seniors safe, as229well as the role of our current successful falls prevention230program. I would just personally say, I have watched how falls231affected my own family members when my grandmother, my great-232grandmother fell and broke her hip, which is the story every233time, it took a lot of work, effort, using the walker.234    Using the walker, sometimes you don't graduate from the235walker because you never have that confidence again. Another236one of my friends in her 90's, she recently fell and kept her237indoors for two months until she was fully recovered and could238be back on the sidewalks where they are uneven and where her239eyesight is just not strong enough to catch those uneven240surfaces.241    When my mother-in-law fell, she had such a serious shoulder242injury, it took three surgeries to fix it. I personally know243the tragedies and complexities that arise because of falls, and244they are life changing. Sometimes your loved one does not245regain their capability that they had before the fall.246    Sometimes the psychological impact of the fall restricts247their movement, restricts their ambition, restricts their248willingness to travel or explore. It reduces the size of their249world. It changes their confidence level. It can affect them250emotionally, physically, and psychologically.251    Personally, I know how urgent and important this is, so I252am very eager to hear your solutions.253    The Chairman. Thank you, Ranking Member. Now, for our first254witness, I would like to introduce Christine Didion from my255home State of Florida. She is the Director of Programs at the256Area Agency on Aging, Pasco Pinellas in St. Petersburg,257Florida.258    She has dedicated her career to connecting older adults in259our communities with the services and support they need to stay260safe, healthy, and independent at home. Thank you for being261here today, and please begin your testimony.262263          STATEMENT OF CHRISTINE DIDION, MSW, DIRECTOR264265               OF PROGRAMS, AREA AGENCY ON AGING266267            PASCO-PINELLAS, ST. PETERSBURG, FLORIDA268269    Ms. Didion. Thank you. Chairman Scott, Ranking Member270Gillibrand, and distinguished members of this Committee, thank271you for the opportunity to speak before you today.272    I am honored to represent my colleagues, our partners, and273the work we do at the Area Agency on Aging of Pasco Pinellas in274St. Petersburg, Florida. It is a distinct privilege to advocate275on behalf of the thousands of seniors and caregivers we serve276and to speak on this vital topic that impacts one in four277Americans aged 65 and older each year.278    If I were to ask you what your plans are for your golden279years, most of us are not making plans to limit our activities280because we will have a fear of falling, or worse, making plans281on how we are going to care for ourselves after experiencing a282fall that results in a serious injury.283    Unfortunately, the stark reality of falls and the284reverberating impacts suggest that maybe we should be making285these plans. More than 14 million older adults report286experiencing a fault each year, and falls remain the leading287cause of fatal and non-fatal injuries among older adults.288    Eighty billion in healthcare costs were estimated to be289spent in 2020 on the treatment of non-fatal injuries from a290fall among older adults, with an estimated 71 percent of those291costs paid for by Medicare or Medicaid. That cost is expected292to rise to $101 billion by 2030. Even if an older adult never293experiences a fall, the fear of falling still exists for a294majority of those over the age of 65.295    A fear of falling can lead to an avoidance of physical296activities, functional limitations, and increases in social297isolation. This can all compound to reduce an older adult's298quality of life and impact their ability to live well and299independently.300    Through the Older Americans Act, or OAA, older adults and301communities are not powerless against the growing impacts of302falls and the fear of falling. For more than 50 years, the OAA303has represented the national commitment to assisting older304adults to age at home and is the cornerstone of the Nation's305non-Medicaid home and community-based services system.306    Each year, through the OAA, more than 14 million older307Americans receive supportive services from the nationwide Aging308Network, which consists of State Units on Aging, Area Agencies309on Aging, Title VI Native American Aging Programs, and310thousands of local service providers.311    The OAA provides a wide array of home and community-based312services that address the social determinants of health and313supports evidence based falls prevention programs and safety314technology.315    The Area Agency on Aging of Pasco-Pinellas, with OAA funds316that are contracted through the Florida Department of Elder317Affairs, has forged over 61 public-private partnerships to318provide the evidence-based falls prevention programs of A319Matter of Balance, bingocize, and Enhance Fitness to over 753320older adults over the last year.321    Because of our partnerships with residential communities,322our local hospital systems, local YMCA branch, senior centers,323and libraries, we are meeting older adults where they are in324the community and equipping them with more than just a few tips325on how to reduce falls.326    These programs are proven to empower older adults to reduce327their fear of falling, increase their coordination and balance,328engage in strength training or other physical activity, and329build environmental awareness.330    These outcomes prevent falls from happening, and these331prevented falls yield an estimated savings of over $1 billion332in health care costs. While the work to prevent falls will333continue, we must also work to reduce the long lie, or the time334an older adult remains on the floor after a fall.335    OAA funding can provide wearable emergency alert response336and fall detection technology that allows for 24/7 monitoring337and emergency assistance at the detection of a fall or the338press of a button. In West Central Florida, over a quarter of339older adults live alone and are often far away from family.340    Beyond dispatching emergency services, this technology341keeps remote families informed in real time. A recent342activation in our area allowed a daughter to coordinate343directly with paramedics and provide vital medical history344after her mother, who lives alone, had fallen.345    This technology has been able to transform potentially346fatal isolation into a connected, responsive network that347supports the independence of older adults. Falls do not have to348be an inevitable part of aging. They can be a preventable349health event using existing and proven interventions.350    The reauthorization and adequate funding of the Older351Americans Act gives Congress the opportunity to ensure that the352more than 600 Area Agencies on Aging that serve every area of353the United States can continue to provide evidence-based falls354prevention programs and safety technology that is cost-355effective and community focused.356    Not only will this reduce the risk of falls, but it will357increase the overall wellness of older adults to live well358where they choose to and alleviate fall related injury costs on359an already strained health care system.360    I thank Chairman Scott, Ranking Member Gillibrand, and the361members of this Committee for their leadership and support of a362reauthorized Older Americans Act to continue to help older363adults live well. Thank you.364    The Chairman. Thank you for your testimony. Next, I would365like to introduce Laura Mitchell, Co-Founder and CEO of366GrandCare Systems based in San Marcos, California.367    She is a nationally recognized leader in aging technology368and remote monitoring, and GrandCare has been at the forefront369of aging technology platforms that help older adults and their370caregivers manage health, safety, and communication from home.371    Thank you for being here. It is a long way. Please begin372your testimony.373374            STATEMENT OF LAURA MITCHELL, CO-FOUNDER375376                  AND CEO, GRANDCARE SYSTEMS,377378                     SAN MARCOS, CALIFORNIA379380    Ms. Mitchell. Thanks. Hi, my name is Laura Mitchell. I am381the CEO of GrandCare Systems, an assistive technology that382empowers independence using touch screens for communication and383integrated activity and telehealth sensors. It is truly an384honor to be with you here today.385    I would like to start my testimony with a true story about386Jean, one of our GrandCare clients from Florida. At the age of38775, Jean experienced her first petit-mal seizure. Her daughter388didn't know until four critical hours later when she found her389mom confused and disoriented.390    Doctors advised assisted living as her only option, but391Jean wanted to stay home, and instead, she began to use392GrandCare. Using simple motion sensors, the system tracked her393daily patterns and could alert her daughter if something seemed394off, like wandering or inactivity. It also tracked her blood395pressure and reminded her when to take her medications.396    Jean stayed in her home for another four years until397something shifted. She became agitated. She wasn't sleeping,398and she showed signs of sundowners. Now, typically, that might399lead to additional medications and maybe even a diagnosis that400could alter Jean's life but Jean's daughter, Carol, had data.401Using GrandCare's motion reports, she was able to pinpoint402exactly when Jean's behavior changed.403    She brought that information to the doctor, and together404they saw that this change aligned perfectly when Jean's blood405pressure medication changed. They switched the medication, the406symptoms disappeared.407    Think about that for just a minute. Without this408technology, Jean could have been treated for the wrong409condition, medicated unnecessarily, or even prematurely forced410into a higher level of care. Instead, she remained home for an411additional two years.412    Due to the power of proactive, data driven care, Jean413stayed in her own home beyond the initial diagnosis for over414six years, saving her family over $180,000. When people think415about falls, we picture, help, I have fallen and I can't get416up, a commercial that actually aired almost 40 years ago.417    While falls are absolutely serious, they are not the root418problem, they are merely a symptom. Studies have shown that419falls can be caused by things like medication noncompliance,420dehydration, or other underlying health issues. By the time a421fall occurs, we are already in crisis mode, and the outcomes,422like we said, can be devastating.423    We have to ask ourselves, why are we still waiting for the424fall? Why should technology activate only after something goes425wrong? The good news is today we have technology tools to shift426from reactive to proactive, predictive, and preventative care.427Imagine a simple tablet in the home, something accessible and428empowering.429    It reminds mom to take her medications, to drink more430water, to take her blood pressure reading. Meanwhile,431unobtrusive smart home sensors are working quietly. They can432recognize when something seems amiss, like the kitchen hasn't433been accessed at mealtime, medications weren't taken, or if434mom's vitals are out of threshold.435    Only then, only when true support is actually needed, will436it notify a designated caregiver. This isn't about437surveillance, it is about independence. It is connection to438family and giving older adults the confidence and security to439live where they want, while ensuring someone is there whenever440needed.441    Access to this type of technology isn't a luxury. It is a442moral obligation deserved, regardless of age or cognitive443function. Through simple video chat, messaging, and even brain444games, individuals can stay engaged and mentally acute.445Technology doesn't isolate, it connects. Beyond the improved446happiness, health, and safety outcomes that technology447provides, it also saves a lot of money.448    The cost of this technology compares to a mere 15 days in449the average assisted living community, 15 days. Now, not every450person has the option to stay home, but if technology can451support one person to delay additional care, they can save452roughly $50,000 a year but it is not only saving money. It is453about preserving dad's dignity, securing independence for mom.454It is about adult children having peace of mind.455    It is about taking care of our parents and our loved ones456when they need us the most. Now we are at a turning point. Our457nation is in an aging crisis exacerbated by staffing shortages458and high health care. We cannot solve tomorrow's challenges459with yesterday's tools.460    Let's move beyond crisis management and turn to proactive461and person-centered technology. It is time to reimagine aging462in America, not as a loss of independence, but as an463opportunity for personal growth, purpose, and the ability for464our greatest generation to live life on their own terms. Thank465you.466    The Chairman. Thank you, Ms. Mitchell. Next, I would like467to introduce Martha Petteys. She is the Director of Grant468Management and Health Strategies for the Alliance of New York469State YMCAs.470    She oversees statewide implementation and scaling of471evidence-based chronic disease prevention programs to reduce472fall risk and lower long term health care costs for seniors.473Thank you for being here. Please begin your testimony.474475            STATEMENT OF MARTHA PETTEYS, DIRECTOR OF476477            GRANT MANAGEMENT AND HEALTH STRATEGIES,478479               ALLIANCE OF NEW YORK STATE YMCAS,480481                   SARATOGA SPRINGS, NEW YORK482483    Ms. Petteys. Chairman Scott, Ranking Member Gillibrand, and484distinguished members of the Committee, thank you for inviting485me to testify on this important topic. I am here on behalf of486the 35 YMCA associations and over 140 branches and program487sites across the State of New York.488    In my role as Director of Grant Management and Health489Strategies at the Alliance of Newark State YMCAs, I support Ys490with healthy aging initiatives, community partnerships, and491evidence-based programs that strengthen health and well-being492across the lifespan. For 175 years, YMCAs have been dedicated493to strengthening communities through youth development, healthy494living, and social responsibility.495    As the largest provider of after school programming in New496York State, YMCA's also support communities through early497childhood education, food access, housing, and lifesaving swim498instruction. This broad community presence allows Ys to support499older adults through programs that promote healthy aging,500independence, and well-being.501    As this Committee examines the role of technology,502community programs, and innovation in senior safety, the Ys'503experience delivering both in-person and statewide virtual504falls prevention programs demonstrates that technology can be a505powerful tool to expand access for older adults facing506barriers, such as transportation, mobility, or isolation.507    At the same time, we have learned technology is most508effective when paired with trusted, community-based509relationships and local support. Falls remain the leading cause510of injury and accident related deaths for adults over the age511of 65. According to the CDC, one in four adults reports falling512every year.513    Falls are devastating for individuals and families and are514a major driver of long-term health costs but now for the good515news. Falls are not a normal part of aging. They are516preventable and proven, evidence-based falls prevention517programs like those offered every day at YMCAs are changing518stories for people like Marianne.519    Fear of falling kept Marianne isolated in her New York City520department, afraid to venture outside onto busy city streets521with her walker but Marianne took a virtual, a matter of522balance, class. She learned strategies to reduce falls risk in523her home and exercises to improve her strength and balance.524    Through the virtual class, she also found encouragement,525connection, and confidence. The Alliance of New York State526YMCAs is currently managing an Administration for Community527Living Grant awarded to the New York State YMCA Foundation to528support a statewide falls prevention initiative. The initiative529both complements and expands the YMCA's broader healthy aging530work.531    Through technology and ACL funding support, Ys have reached532more older adults than would have been possible through533traditional in-person programming alone, particularly in rural,534underserved, and home bound communities. In just two years,535more than 1,000 people have participated in falls prevention536programs through this initiative.537    In addition to falls prevention programming, YMCAs have538long partnered with federal, state, and local health539organizations to deliver evidence-based programs that support540chronic disease prevention, arthritis management, cancer541survivorship, diabetes prevention, and healthy aging.542    We urge Congress to support the highest level of funding543possible for the CDC so Ys can continue to deliver these544supportive programs and to preserve funding for the ACL so545community-based healthy aging and falls prevention programs546like the New York State Initiative can continue. Every dollar547invested in community-based organizations like the YMCA create548lasting impact and strengthens the health of communities.549    Federal investment in prevention helps older adults remain550independent, connected, and healthier longer. They are551investments in dignity, healthier communities, and changing552stories for people like Marianne. New York State YMCAs look553forward to continuing this critical work in communities across554the state.555    Thank you again for the opportunity to testify, and for the556work of this Committee on behalf of older adults.557    The Chairman. I thank each of you for your testimony. I558think we are going to turn it over to Senator King. Welcome to559the Aging Committee.560    Senator King. Mr. Chairman, thank you very much. I561appreciate your accommodating me. I am sort of halfway between562a witness and a Senator today. I am not a normal member of this563Committee, but this is an issue I have taken a deep interest564in.565    As the Chairman and all of us know, one of the principal566problems facing our society today is the high cost of health567care, and prevention is the low-hanging fruit to combat the568high cost of health care. The cheapest health intervention is569the one that doesn't have to happen.570    That is why I think this hearing is so important, because571as you have testified, falls are a tremendously important and572significant and dangerous part of the aging process, but they573can be prevented. I have done my own falls prevention work by574selling my Harley a couple of years ago, which was a very hard575decision, but I had an attack of prudence.576    My second thought is, an old friend of mine once said, the577secret to a long life is to always use the banister and that is578something that I follow all the time and that sounds funny, but579it is really true and how many times have we gone down the580steps with our hand on the banister and one foot sort of slips,581and if you don't have that banister, you are in trouble.582    The steps behind the U.S. Senate where they always take the583pictures are a death trap. They are granite and there is no584banisters, so I have a couple of suggestions along this line.585One is this, this is an $11 bathmat. I am the Johnny Appleseed586of bathmats.587    Whenever I go to see somebody, and they don't have one of588these in their shower, I buy one and send it to them. Now, here589is the proposal, though. Why doesn't CMS send one of this to590every Medicare recipient in the country?591    I did the back of the envelope calculation. It would pay592for itself in about nine months. This is $11. I suspect if CMS593bought them by the millions, they could get a deal, and it594would have a noticeable effect on the number of falls. A very595simple idea.596    Along with that is, and I have some legislation along this597line, allow CMS to spend money on prevention, things like grab598bars and bathmats. Right now, Medicare will pay for a broken599hip, but they won't pay for a grab bar in your shower. That is600just insane.601    I think, Mr. Chairman, that is one of the things we need to602do, is authorize Medicare to get much more active in the603prevention area and to provide things like this. I mean, I am604not kidding. Send out 20 or 30 million of these and you will605see the $100 million cost of falls fall significantly.606    I am proposing that we should have an office in HHS607dedicated to falls prevention, and one in the Veterans608Administration. The initial Medicare home visit should include609an analysis of the house in terms of fall risks. Medicaid, as I610mentioned, should cover--or Medicare, rather--should cover611equipment like grab bars, bathmats, and others. There should be612a tax credit, I believe, for home improvements that prevent613these kinds of injuries.614    Again, this would be a tax credit that paid for itself615because of the savings to Medicare and Medicaid that are616occasioned by treatment of falls and finally, Mr. Chair, I617suggest right now that the Congressional Budget Office--when we618legislate things, the Congressional Budget Office estimates619costs, but they are not allowed under their rules to estimate620projected savings.621    I believe we should instruct the Congressional Budget622Office to look at the savings as well as the cost of these623kinds of preventive measures, so you all have nodded. Could you624all say, yes, Senator King, you have some good ideas here, just625for the record but this is--I am very passionate about this626because all of us have experienced falls.627    My sister had a bad fall just about a year ago and they--if628she would have had a bathmat, she wouldn't have had that fall629in the shower and a disproportionate number of these falls630occur in the bathroom.631    That is why something like this - I think makes sense. Mr.632Chairman, I deeply appreciate you allowing me to come and633testify today, and hope that I look forward to working with the634Committee on some of these legislative proposals that I think635can really make a significant difference. I appreciate it.636Thank you.637    The Chairman. That is a good idea. You know, if you were in638business, you would clearly do it, right? Because you could639save money, and everybody is better off. Like, why we don't do640this in Government doesn't make any sense.641    Senator King. The return on investment is infinite.642    The Chairman. Right.643    Senator King. Thank you.644    The Chairman. Yes. It makes people's lives better, too, on645top of that. Senator Kim.646    Senator Kim. Thank you, Chairman and thank you Senator King647for those thoughts there. I mean, I think it is absolutely648critical and important for us to be thinking so much more about649the preventative space.650    You know, I have shared a lot in this Committee, as well as651more broadly in the Senate, about how my, you know, my father652was diagnosed with Alzheimer's last year, but what I don't talk653as much about is what initially caused this crisis that we are654with him is that he fell.655    He is somebody that broke his femur and was originally sent656to the hospital that way and it was that kind of change in657location, and the surgery, and the medication involved that658very much spurred his cognitive decline as well and we are kind659of in this doom loop right now as a family because he cannot660walk but he cannot remember that he cannot work, and constantly661stands up and falls, and constantly stands up, falls, goes back662to the hospital.663    We have now, you know, have sensors within his room to let664us know when he is trying to stand up. We have sensors that let665us know if he is on the ground, so this technology is something666that I am using in my father's room right now while I am here667to try to help make sure that we are understanding of his fall668risk, as well as be able to quickly remedy.669    I have an app that lets me know, you know, whether or not670any of these sensors have been triggered, so you know, I just671share that with you because like I feel it and see it in my own672way and, you know, I am interested in trying to figure this out673more deeply, so you know, Ms. Didion, if you don't mind, I674would like to just start with you.675    You know, can you share how access to fall prevention676technology could have an impact on a family's considerations,677whether that they are weighing, you know, long-term care678facility or care at home, and what is the better option? You679know, how is this technology now being utilized to help people680make those types of decisions?681    Ms. Didion. Absolutely and thank you, Senator Kim, for682sharing that story about your father. Because you are right,683technology can really make a difference for a senior or an684older adult being able to remain in their own home.685    We know that a vast majority of older adults want to remain686in their own home, or want to remain with family, living with687family, or are living with a memory condition or other chronic688condition that otherwise they wouldn't be able to live alone689without that support of a caregiver or family and technology690can only leverage the time, effort, and care that a caregiver691or family can provide to a senior or leverage that additional692independence for a senior to live on their own.693    Like I mentioned, in West Central Florida, a quarter of694older adults live alone, and we often see in Florida that they695are not living anywhere near their family. Their family lives696up North, in my colleague's State of New York, or all over.697That is the great thing about emergency alert response698technology is a family, or caregiver, or whoever does not have699to live in the same home.700    They don't have to live on the same street. They could live701in a different state. Like I mentioned in my testimony, the702daughter who got the call about her mom who had fallen, she703actually lived in a completely different state. She lived on a704different coast, in California actually, but she was able to be705connected right away.706    Not only are emergency services able to be contacted, but707caregivers or other loved ones can be contacted too and can708really set up that step process so that maybe emergency709services don't need to be called, maybe just a caregiver who710does happen to live by just needs to come over and check on711that person, so you may be eliminating a trip to the emergency712room after all, even with that emergency technology.713    Senator Kim. Yes. I find that it just allows me to operate714without this constant anxiety of wondering whether he is okay715at any given moment, having to check in and that kind of vein.716    It just gives that reassurance that I think, you know,717allows for caregivers when they are away to have that respite718that they absolutely need in addition to just, you know,719hopefully, you know, proceeding in other ways.720    Ms. Mitchell, I wanted to turn to you because I think what721I find interesting here is that there is a lot of potential722here, the potential dual applications that this technology can723be used for with both older adults as well as with people with724disabilities.725    I just feel like, as we are thinking through how to be able726to harness this, you know, that is something that we can727potentially buildupon but I wanted to kind of get your thoughts728about that potential there.729    Ms. Mitchell. Well, thank you so much. Yes, I think that730individuals living with intellectual and developmental731disabilities have a pretty high fall risk as well. I think it732is in the 25 to 33 percent for adults 65 plus. It is about 35733to 40 percent in adults living with intellectual and734developmental disabilities but then when we are talking about735adults with intellectual and developmental disability that are73665 plus, it goes up to the highest risk of 45 to 70 percent.737    The good news is people with intellectual and developmental738disabilities are living longer than ever and that is great, but739we do have some added fall risks because of balance issues and740gait issues.741    I think that technology can play a pivotal role in not only742supporting that individual to proactively sort of prevent the743fall with, you know, reminders, drink more water, take your744blood pressure medication, you know, whatever medications they745are taking, but also take your vitals reading, so there is lots746of different ways that we can determine before a fall occurs.747    Of course, there is accessibility things. We have got the748bathmat, we have got banisters, and I definitely agree with749that but then, you know, how do we prevent the fall? Then if a750fall does occur, it is critical that we know right away, so751maybe we are detecting excessive motion in the bathroom.752    Maybe we are detecting that, hey, this person didn't get up753and get out of bed, or we are detecting that that person didn't754access the fridge at mealtime. All of these different755checkpoints that are just sort of notifying us that something756may be wrong.757    Senator Kim. I am going to go right away and get a bathmat758for my own--oh yes, yes, okay. Well, I am making progress here759on this----760    [Laughter.]761    Ms. Mitchell. Should bring one for everyone.762    Senator Kim. My wife can no longer say that I don't get any763benefit out of this job but the last thing I will just say here764is, the question now is - how do we scale this? You know, how765do we try to actually proliferate this in a meaningful way?766Because, you know, like I will be honest, it was hard for me to767explain and convince my dad that these sensors are okay, or768even for me.769    I didn't even know about this. I needed someone to tell me770about this. I am busy with my life, and I don't always have the771latest understanding of where the technology is and as Senator772King was mentioning, you know, I think Government can play a773big role in trying to scale this, so it is not just sort of a774case by case type of situation.775    I guess I just wanted to ask you, Ms. Mitchell, as I close776out here, just what is the role of the Federal Government? What777should we be considering about not only in terms of knowing778about this technology, but how we might be able to play a role779to be able to proliferate this and get this in the hands of780many more people that could very well benefit from it?781    Ms. Mitchell. Yes, so I think reimbursements and waivers782play a pivotal role. There seem to be a little bit more783reimbursements going on, on the Medicaid side of things for784individuals with intellectual and developmental disabilities,785more so than Medicare. I think that is really too bad because I786think the Government should actually proactively support this787type of technology.788    It is clearly less expensive than the cost of hands on789caregiving, and we are at such a need for hands on caregiving790that individuals that actually don't need it 24/7, we are791wasting an individual that may be, you know, staying overnight792and watching Netflix or sleeping while this person is also793sleeping and instead, that individual could be delegated to794somewhere where that person--where somebody actually really795needs that 24/7 hands on support.796    I think that if Government put some money toward this type797of proactive technology, it would not only save, you know,798everybody money, the cost of health care. If someone is799healthier, it is going to save money. If someone is happier, it800is going to save more money. If someone has less isolated, they801are at a much less risk for falls and all sorts of other bad802outcomes.803    When you mentioned your father maybe not being willing to804try out this type of technology, I think there are some ways805that we can get around that, so that is why we have the806technology that helps connect individuals.807    For the story I told you about with Jean, she was the one808who contacted us in 2005 and asked for us to do the technology809in her home and asked if we would please call her daughter810Carol and convince her that she could do it.811    The reason was, as she said, I need Carol to live her own812life. She is calling me constantly and I want her to live her813own life. She also wanted to stay independent at home. She was814a swimmer. She grew orchids in her kitchen. She was not ready815for assisted living.816    It was that need for independence and the desire for her817daughter to be notified if something was wrong, but having that818independence where she wasn't going to have her daughter be819contacting her every minute of the day just to check in.820    There was some technology that was playing that role, and821it allowed her daughter to actually spend that time with her822mom and being her daughter. Not being her caregiver but being823her daughter because she knew what was happening in the home824and she didn't have to spend time talking about it.825    Senator Kim. Yes. Thank you for sharing that. Chairman, I826yield back.827    The Chairman. Thank you, Senator. Senator King, Senator828Kim, thank you both. Senator Justice.829    Senator Justice. Thank you, Mr. Chairman and thank all of830you all for being here. You know, it was a big time honor for831me to introduce this bill and be a part of that and everything832in every way. I have got a confession to make.833    You know, there is three ways in the world you can make a834friend. You can ask a favor, make a confession, or tell a835secret. Now, think about that and carry that with you in your836life. Make a confession, ask a favor, tell a secret. Well, I am837going to make a confession and tell a secret right now.838    First of all, you know, folks that some way grow older, we839don't really believe that we are older for a long time, you840know and all of a sudden, I still think I am 25 years old and I841have climbed every mountain, I have followed every bird dog in842the world all over kingdom come. I have loved to hunt and fish843and play golf and do everything in the world.844    I am kind of broke up now because I was too slow to get out845of the way and I got hit a lot. You know, but with all that846being said, let me just tell you just this. This past847basketball season, I am the girls' high school basketball coach848at Greenbrier High School. A public school, big school, and849everything, and my team just happened to be really rolling850along.851    All of a sudden, we are in the quarterfinals of the state852tournament, and we win and now we are going to the final four,853and if I could fast forward, we finished, we won it, we won the854whole state championship and we ended up 27-0 on the season, so855they are a pretty good team.856    In fact, they are an incredible team, to tell you the857truth, and great, great kids but after the quarterfinal game,858you know, you go into this room where all the media is there,859all the cameras and everything, and they tell us, then you go860up on a platform and you are sitting there with probably three861of your players and everything that they want to interview, and862they want talk to you too.863    I am sitting there and everything, and they tell us that864when we go in the room, watch all these wires now right here865and everything because just maybe you could fall or trip over866that and everything and so, I get through all the wires. I am867on the stage. Everything is all good--all good in the world.868You remember, I don't think I am 75 years old and at that time,869really, I was still 74 years old.870    The next thing I come off that stage, and the next I know I871am flying through the air, and I am going just like this, and I872have face planted right on the floor. I dislocated my shoulder,873and I hit right on a knee that has had so many surgeries it is874unbelievable and it was a really, really bad day, you know.875    I can tell you just this, that since that time now, I am876three times more disabled than I was right before that877happened. Now, I need two knee replacements, and I need a hip878replacement and all that and I have got to get all that done,879and I hope to goodness after that happens that things will be880better.881    Let me tell you, not long ago there was a group of physical882therapists that I met with, and they told me about this883incredible, incredible idea. You know, SAFE Act. I thought,884well, what in the world is SAFE Act? You know, we went through885all the different stuff, and then, lo and behold, all of a886sudden, they said something that at the time maybe didn't mean887near as much to me as it means today.888    That is a way to improve potential balance and a way to889avoid falls. Because we all know that as we age, $80 billion a890year--are you kidding me? You know, I just came out of the Ag891Committee meeting, and really and truly we are scrambling892around trying to figure out how we could have x number of893dollars because our foreign community is upside down and we are894hurting like you can't imagine.895    With all that being said, $80 billion attributed to falls896in this country? This is our opportunity, and this is our897moment--our moment is right now--to do something that really898and truly a lot of us as we grew a little bit older, we never899really would have believed that it would be us but as I was900flying through the air, believe me be, I knew it was us and I901was the us.902    I commend you in every way. I really only have one903question, and basically it is just this, that--you know, and904maybe this is to Ms. Didion and that would be just, in your905work, how many people show up after they have had a fall,906versus how many show up trying to prevent a fall?907    Ms. Didion. That is a great question, Senator. It actually908is a mix that we see, just anecdotally. Under our evidence-909based falls prevention programs that we offer anywhere, we910actually get a lot of people who come because they said their911friend took the class, one of our classes, whether it is A912Matter of Balance, bingocize, or Enhance Fitness, their friend913took the class, said they had a great time.914    They can't believe they actually had fun talking about915falls for eight weeks and their friends suggested it, they have916never had a fall, but they just thought it might be a fun thing917to do and then of course on the flip side, we do have those918people that do come to us after they have experienced the fall,919they have broken a limb or experienced a serious injury, and920they don't want it to happen again.921    Either, or we don't care how you came to the Area Agency on922Aging to take an evidence-based falls prevention class or923access any of the support services that the Older Americans Act924can provide to keep a senior in their home. We just want to925keep a senior in their home as safe as possible.926    Senator Justice. I commend you. Keep doing the great work,927and we have got to get this across the finish line because this928is really, really, really important. Maybe it took, you know,929hard-headedness for me to believe, but I believe, I will930promise you that. Thank you so much. Thank you, Mr. Chairman.931    The Chairman. Thank you, Senator.932    [Technical problems]--sorry. Polypharmacy is one of the933most overlooked fall risk factors we have. How often have you934seen older adults come into your programs who are on drug935combinations that nobody has flagged as dangerous, and do the936AAAs have the resources and clinical support to address that937systematically?938    Ms. Didion. Yes, absolutely. That is a great question. We939do see that a lot and as you said, one of the biggest fall940risks, or risk for causing a fall, is living with a chronic941condition and being on multiple different medications that can942have side effects like dizziness or confusion that can increase943the chance for a fall. We do you see that lot with older adults944that we serve.945    That is the great thing about, especially, A Matter of946Balance class that can be offered with funding from the Older947Americans Act, because we can address or empower an older adult948to advocate for themselves or learn how to advocate with their949family to talk to their doctor about their different950medications or different treatment options for their chronic951conditions.952    Because the other great thing about the Older Americans Act953is we don't just offer evidence-based classes for falls954prevention. We are able to offer evidence-based classes that955address chronic conditions like living with diabetes, chronic956pain, or just general chronic conditions and teaching older957adults how to self-manage those and that includes looking at958their medications and asking the right questions with their959doctor about what kind of medications they are on.960    Then on the other side, again on the Older Americans Act,961it is really looking at that holistically of how we can prevent962falls, and the Old Americans Act really allows Area Agencies on963Aging, and State Units on Aging, and those local service964providers to do that because we can address other factors and965chronic conditions that can help prevent falls like meals, and966again, those emergency alert response technology systems.967    The Chairman. Thank you. Ms. Mitchell, you have been968building aging technology for quite a while, which means you969have watched a lot of promising products fail to scale or fail970to reach the people who need them most.971    What is the single biggest structural barrier preventing972fall prevention technology from achieving widespread adoption973among older adults, and is it a funding problem, a974reimbursement problem, or something else entirely?975    Ms. Mitchell. Yes, thank you. I think there is a couple976things. First, I think funding is definitely a problem. I would977say the biggest problem, though, might be internet connectivity978and that sounds crazy, because internet has been around since979the 90's but it is especially access to this type of980telehealth, or telemedicine, or activity of daily living981monitoring technologies.982    You need internet for it to function and particularly in983remote areas, it is great for them to have internet984connectivity, which is where it is the hardest to get internet,985so I think it is a twofold funding for this type of technology,986also funding for internet connectivity, and, you know, sort of987turning that into more of a utility versus a nice to have,988because it is really a need to have.989    And then also really about awareness, letting individuals990know that this is a--this is a technology that works. There is991a return on investment. It is proven. It is not new, so I mean,992the 40 year ago, help, I have fallen, and I can't get up, a lot993of changes have been made since then and that is a great piece994to have, that complementary piece of crisis management but for995the proactive, preventative technology is really where we are996going to save the money.997    The Chairman. You know, what is frustrating is the Federal998Government has spent a fortune to do broadband, but it doesn't999pay to connect the home, it just pays to lay the fiber and so,1000fortunately now with satellite technology, we don't have to1001rely on that but don't worry, we are still spending the money.1002    Ms. Petteys, the YMCA's evidence-based fall prevention1003programs have strong outcome data behind them. What does the1004research actually show in terms of fall rate reduction, and why1005hasn't evidence been sufficient to drive the kind of federal1006investment and reimbursement these programs have earned?1007    You know what doesn't make sense to me is Medicare1008Advantage, because you don't have to worry about a federal law.1009It is like, are the Medicare Advantage players doing this?1010Because they have an economic interest in doing it. It is1011just----1012    Ms. Petteys. Unfortunately, no. Yes, I would love to talk1013to you about the return on investment and exactly this point.1014We talked already about one in four older adults will1015experience a fall every year. Of those falls, more than half1016will result in a trip to the hospital, so if we could talk1017about what that means in money terms, the average ER visit for1018a fall is over $1,000.1019    The average inpatient trip for a fall is over $18,000. The1020cost for an individual to take a virtual, a matter of balance1021program, $250, so according to a recent study by the National1022Council on Aging, individuals who took evidence-based falls1023prevention programs saw a 52 percent reduction in the number of1024falls, so that is a $250 investment in prevention that can help1025an older adult stay independent, connected, and out of the1026hospital.1027    The Chairman. Let me ask you a question, if you--would you1028take the financial risk? If I went to Mehmet Oz, who is running1029CMS, and said, you know, Medicare, you pay for this program, or1030Medicaid, whatever, and then if it doesn't save that amount of1031money, you have to give the money back. Would you guys all do1032that?1033    Ms. Petteys. Yes, the Y----1034    The Chairman. You take that financial risk, right? It1035doesn't make sense. As a business guy, I would do that in a1036heartbeat, right, to save the money. I mean, it is not just to1037save the money. You change people's lives, right. Okay. If you1038have a--if any of you want to do that, and you give me1039something, I will take it to CMS.1040    I mean, just try for whatever you are responsible for.1041Because they have all--you know, they have all the data, right.1042They know exactly--they know what they have been spending, so1043you could do a program. They know exactly what they are1044spending on this. We have to file for Medicare, it is pretty1045specific, so you know exactly that is. You know, what this1046costs, so, you know, just take a portion of the savings, so1047Okay.1048    All right, Ms. Didion, Area Agencies on Aging receive a mix1049of federal, state, and local funding, and they operate within a1050significant amount of federal regulatory and reporting1051overhead_I bet, I bet you love all that.1052    How much of your staff's time and your organization's1053resources go toward compliance and paperwork rather than1054actually serving seniors, and what federal requirements could1055be eliminated or streamlined without reducing outcomes? Just so1056you know, when I was Governor of Florida, first I was a1057business guy. You know what you got--as a business person, you1058would get frustrated with? Government and crazy, stupid1059Government regulations. I am sure that never happens to you,1060right?1061    Ms. Didion. Oh, no, not at all. No, and I do have to brag1062about our Area Agency on Aging. The great thing about the Older1063Americans Act and setting up that aging infrastructure or1064network is that there is a constant feedback loop of1065monitoring, and fiscal responsibility, and programmatic1066responsibility.1067    To an extent, having that regulation and having that follow1068through is very important because that is how we know that1069things are doing what they are supposed to be doing and that it1070is working for seniors.1071    We have gone 17 years, my particular Area Agency on Aging1072has gone 17 years with the--from the Florida Department of1073Elder Affairs not having a finding, so we are all too familiar1074with being in compliance, following those regulations, and when1075we are monitored by our State Unit on Aging.1076    All that to say, you know, especially on the evidence-based1077side, it is actually very important that we do follow that1078regulation, again, for those specific evidence-based programs,1079because that is how we know that those programs are working.1080Like my colleague said, those evidence-based falls prevention1081programs result in a 52 percent reduction in falls.1082    In addition to that, there is a 58 percent reduction in1083falls that result in serious injury and we don't necessarily1084have to keep tracking that after every Matter of Balance class1085because that evidence-based programming tells us that that is1086what that programming does for us.1087    The Chairman. Have you ever gone to a Medicare Advantage1088program and just ask them? Because they should pay you. I mean,1089if you can prove this, they should pay you and you should take1090a cut of the savings. Because you--it sounds like you got--each1091of every one of you can defend it, right?1092    You should go to the Medicare Advantages because they don't1093have to worry about what CMS does, just ask them and go with1094the proposal of whatever--you know, a cut of the savings. They1095pay for your programs, and then you get a cut of the saving. If1096they don't--if they--it doesn't make any sense if they wouldn't1097do it.1098    Ms. Didion. If I can add, you know, it is certainly1099important that there should be private investment in falls1100prevention, Medicare Advantage plans, private insurance1101companies. There definitely should be that private-public1102partnership.1103    We do want to make sure that we are reaching all of those1104seniors and older adults, including the ones that just have1105straight Medicare, they don't have access or are able to afford1106those Medicare Advantage plans or other private insurance1107options. That is why those public-private partnerships are so1108important, and like you said, there should be that investment1109on the private side.1110    The Chairman. You know, you should be able to make a1111profit. If you can save them that much money, you should make a1112profit off the Medicare Advantage that you can do the others.1113On top of that, if you give me the information, I will see if I1114can get CMS to do a pilot with you that would help, you know,1115make it happen across the country.1116    Florida has been a leader in state level innovation on1117elder services. To what extent do Federal OAA requirements and1118funding conditions constrain Florida's ability to design1119programs that fit its population, and would you support giving1120states more flexibility in how they use OAA dollars, even if it1121meant less federal prescription over how programs are run? I1122will just ask you--same----what do you think?1123    Ms. Didion. Thank you. Yes, we would enjoy any kind of1124flexibility to be able to use funding to support seniors. The1125main issue is that the funding is just inadequate across the1126board. It doesn't matter if we are shifting funding between1127Title III-B supportive services to Title III-D preventive1128services, or from both buckets to Title III-C nutrition1129services.1130    In our area--excuse me, in our planning and service area,1131we have over 7,000 seniors waiting for at least one kind or one1132type of Older Americans Act service because we just don't have1133the funding to serve the need in our communities.1134    Yes, while flexibility is always welcome, we really have to1135pivot and know what seniors need and where they need it the1136most to be able to help them and again, that Older Americans1137Act really helps that holistic approach to preventing falls. It1138is not just that Title III-D evidence-based programming.1139    The Chairman. What I found when I became Governor of1140Florida, is a lot of the regulation, is all put in because1141somebody did the wrong thing and took advantage of the program,1142and everybody else pays for it. Then the consumer, whoever, the1143senior in this case, gets less, right.1144    Ms. Mitchell, predictive analytics are increasingly being1145discussed as a way to identify fall risks before fall happens.1146How mature is that capability today in real-world deployment,1147and what would it take for that kind of tool to move from a1148premium product to something an Area Agency on Aging could1149integrate into its program?1150    Ms. Mitchell. Right. I think that is, you know, what we are1151always going toward is being able to predict versus being able1152to just, you know, assess based on what has already happened.1153    At GrandCare we like to call our data that we receive,1154let's call it little data, right, so we are taking a GrandCare1155System, and we are monitoring, or we are managing somebody's1156chronic conditions. We are saying, okay, so if Jim has1157congestive heart failure, I want to know if Jim gains five1158pounds in two days because that is indicative of a problem, and1159I am going to set up a clinical visit before that turns into a1160hospital admission.1161    Obviously that kind of--that is sort of predictive, that1162type of thing, or I want to know if somebody is having a1163seizure, so I want to detect if there is wandering motion that1164occurs. I want to be notified so that I can go in and intervene1165before something else occurs, so you know, that type of stuff1166exists already today.1167    Some of the AI and predictive analytics, I think in my mind1168it is, hey, so I want to know if Jean gets out of bed every day1169at this time, for weeks and weeks and week, what happens if a1170month later, now she is getting out of the bed at this, or what1171happens if she used to get out of bed every night--you know, we1172are pretty habitual creatures--so what happens if she gets out1173of bed every night, you know, at 2:00 a.m. in the morning to1174use the restroom, well, now she is using the restroom three or1175four times.1176    That could be a UTI, that could be sundowners, that could a1177lot of things, so being able to assess that information and1178comparing information from something that this person used to1179do or something that they are doing later is super helpful.1180    What if my mom used to win at Solitaire all the time and1181suddenly now on the system she is losing? You know, like all of1182those types of things--or it used to take her this long to play1183the memory game and now it is taking her this long, so being1184able to assess that kind of information--all of that1185information exists right now.1186    We can take a look and see how many times they are playing1187games, which videos they are watching, how much they are video1188chatting with family and friends. Like all of that is just1189untapped and ready to be either put into, you know, delegated1190into a greater analytics system so that somebody can create1191algorithms and determine, hey, we have determined that this1192person who is about to have a stroke, here is their motion1193patterns.1194    Here was their blood pressure. Here are the amount of times1195that they use the restroom. All of that kind of information1196would be very, very exciting for us to know in order to predict1197events, but also prevent them.1198    The Chairman. It makes sense. Ms. Mitchell, a lot of1199seniors and their families are enthusiastic about technology in1200the abstract, but are resistant to it in practice, often1201because of privacy concerns or the perception that monitoring1202feels intrusive. How does GrandCare approach that tension, and1203what have you learned about designing systems that actually--1204that people actually use and keep using?1205    Ms. Mitchell. Yes, I think that that is a great question,1206you know. I often feel like older adults aren't scared of1207technology. I mean, this is a population that went from1208walking--to potentially walking to flying in their lifetime and1209so it is not technology. They use technology every day. They1210watch TV. I mean all sorts of different technologies.1211    They have got fancy cars, and fly, and do all the things1212that we are all utilizing technology. It all comes down to the1213interface, so are we providing them with something that they1214feel is accessible, usable, and friendly to what their needs1215are and what they want to do or are we forcing them to use a1216technology like, here is my tablet, go ahead and use this, and1217it may have been not designed specifically with them in mind.1218At GrandCare, we designed it initially in 2005 with the older1219adult in mind.1220    Now we also have individuals with intellectual and1221developmental disabilities that we also work together with, so1222we have designed for both populations and it really is designed1223so that an individual who can read or look at pictures or touch1224buttons can participate with. We have had folks that are in1225hospice that can't touch the touch screen at all.1226    And family members that live far away, like in hospices,1227you can't--you may not know necessarily how much time you have.1228If you are flying in from another state, you may say, okay,1229well, for the next, you know, six weeks, I am going to sort of1230be on edge and sort of wonder, but with a technology like this,1231I can video chat in with mom and dad.1232    She doesn't even need to be able to touch the touch screen.1233If I am designated, I can drop in on that touch screen and then1234talk, and communicate, and connect at end of life, so it is1235really giving those advantages over the disadvantages. It is1236really about somebody feeling more secure and of course, you1237know, we don't have any sort of access to remotely monitoring1238or assessing that ourselves.1239    We provide it for the family members to be able to assess1240the tools and set up rules. They are not sitting there pouring1241over the motion graphs. That would be very boring to look at1242motion graphs, but instead we are just saying, if this happens,1243you know, if there is excessive motion in the bathroom in the1244middle of the night for more than 45 minutes, I want to be1245notified and in that case, I might be able to sort of support1246somebody. If somebody is sick, did a fall occur? It is just an1247outlier that occurred.1248    The idea is not monitoring. The idea is about providing1249independence and letting individuals be connected to family and1250friends wherever they want to live.1251    The Chairman. Ms. Petteys, YMCAs sit in communities across1252the country, including in rural and underserved areas where1253Area Agencies on Aging may have limited reach. How are you1254thinking about the YMCA network as a delivery infrastructure1255for fall prevention, and where does that partnership with the1256AAAs work well and where are the gaps?1257    Ms. Petteys. Thank you. Yes, we are--across New York State,1258we have over 140 different locations across the state, and we1259do work with our Area Offices of Aging in many of those1260locations and we see the use of technology really to expand1261that reach that we have to fill in those gaps, as you say, to1262meet those individuals wherever they are at.1263    For our evidence-based falls prevention programs, we are1264not only offering them at YMCA facilities across the state, but1265we are also bringing those programs into other community1266settings, like senior centers, like libraries, or my favorite,1267we have a program happening at an Old Joanne's Fabric in a mall1268in upstate New York, so we are bringing those program where the1269people are at.1270    Then technology, like I said, is allowing us to fill in1271those gaps to reach those individuals who have various1272barriers, say mobility, transportation, or maybe they are1273caregivers themselves, so they are at home.1274    We are always about connecting with partners throughout the1275region because we know that we cannot do this work alone, so we1276are absolutely open to partnerships with the AOAs and others.1277    The Chairman. Well, first of all, I want to thank each of1278you for what you do every day. If there is any way I can help1279you in working with CMS, or any of the Medicare Advantage, or1280anything else, if you just let me know.1281    Thanks everybody for being here today and participating.1282What we have heard today reinforces something I came into this1283hearing already believing: falls are not an inevitable part of1284aging. They are a preventable crisis, and we have the tools,1285the programs, and knowledge to do something about it. I look1286forward to continuing to work with members across the aisle and1287down the dais.1288    If any Senators have additional questions for the witnesses1289or statements to be added, the hearing record will be open1290until next Wednesday at 5:00 p.m. Thank each of you for being1291here.1292    [Whereupon, at 4:37 p.m., the hearing was adjourned.]1293=======================================================================12941295                                APPENDIX12961297=======================================================================12981299                      Prepared Witness Statements13001301=======================================================================1302[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]13031304=======================================================================13051306                        Questions for the Record13071308=======================================================================13091310                 U.S. Senate Special Committee on Aging13111312 "Caught in the Middle: Supporting Families in the Sandwich Generation"13131314                              May 13, 202613151316                        Questions for the Record13171318                            Christine Didion13191320                  Ranking Member Kirsten E. Gillibrand13211322    Question:13231324    You stated that 80 percent of falls-related injuries are1325paid for by Medicare and Medicaid in your testimony. You also1326stated that a notable amount of falls treatment is paid for by1327families - families who are already coping with inflation and1328increased prices on everything from gas to groceries.1329    Considering the huge impact that Medicare and Medicaid1330funding has on falls treatment and prevention, can you talk1331about the impact on individuals and their families if federal1332funding for these programs were jeopardized?13331334    Response:13351336    The Centers for Disease Control and Prevention estimates1337that $80 billion in healthcare costs were spent in 2020 on the1338treatment of non-fatal injuries from a fall among Older Adults1339and that cost is expected to rise to $101 billion by 2030. 71%1340of those costs were estimated to be paid by Medicare or1341Medicaid.1342    The impact of falls reverberates far beyond just the1343physical effects; falls touch every aspect of an Older Adult's1344life including their wallets. Even with healthcare costs1345covered by Medicare and Medicaid historically, there remains1346out-of-pocket expenses that an Older Adult and, potentially1347their family or Caregiver, are responsible for. For an Older1348Adult or Caregiver that is already stretching every dollar to1349buy groceries, pay their utility bill, or purchase fuel for1350their car, a single fall can instantly plunge a family into a1351financial crisis situation. Any reductions in Medicare or1352Medicaid coverage will only escalate these existing issues.1353    We also must remember that Medicare does not pay for any1354type of long-term care assistance for Older Adults, whether1355that is in-home long-term support or in an institutional1356setting. If a senior experiences an injury from a fall that1357necessitates the need for long-term supportive and healthcare1358services, and they cannot afford it on their own or access1359long-term supports through Medicaid, it increases the chances1360that a loved one will now need to step into an unpaid caregiver1361role, often having to leave the workforce to care for the Older1362Adult.1363    Ultimately, any jeopardization of Medicare and Medicaid1364funding puts more pressure on the nationwide Aging Network and1365Area Agencies on Aging (AAA). AAAs, with level-funding, will1366have to stretch Older Americans Act funding even further to1367provide home-and-community-based services to Older Adults with1368high levels of needs that may have otherwise been able to1369receive supportive services through Medicaid Waiver programs.1370Restricting access to long-term care and supportive services1371drives up out-of-pocket costs, forces Older Adults to rely on1372unpaid family caregivers, or gives Older Adults no choice but1373to enter institutionalized care settings, ultimately increasing1374Medicaid spending and driving more families into economic1375crisis situations.13761377                        Senator Elizabeth Warren13781379    Question:13801381    Untreated hearing loss and balance issues are associated1382with a significantly higher risk of falls for older adults. How1383do Area Agencies on Aging integrate treatment for hearing loss1384and balance issues into their falls prevention efforts?13851386    Response:13871388    There are many factors that can contribute to or increase1389the risk of an Older Adult experiencing a fall. Untreated1390hearing loss not only triples the risk of a fall but can1391isolate a senior, reduce their environmental awareness, and can1392cause or increase balance instability. Area Agencies on Aging1393(AAA) must address falls prevention holistically and through1394the Older Americans Act (OAA), AAAs are able to provide a wide1395array of home-and-community-based services that address the1396social determinants of health that keep Older Adults living in1397their own homes and communities.1398    Evidence-based falls prevention programs, like A Matter of1399Balance, help participants understand the many factors that can1400contribute to a fall and include comprehensive health1401checklists into its curriculum. Participants learn and become1402empowered to take steps to act on their health, including1403understanding what hearing loss is and what balance issues may1404look like. Other Evidence-based falls prevention programs, like1405Bingocize and Enhance Fitness, focus on and implement balance1406exercise, functional movements, and strength training.1407    Evidence-based falls prevention programs, funded by the1408OAA, simply work. In a study by the National Council on Aging,1409evidence-based falls prevention programs contributed to a 52%1410reduction in the number of falls, a 56% reduction in falls that1411caused an injury, and programs that incorporated balance and1412strength training components reduced fall rates by 42%.1413    AAAs don't stop at just evidence-based programs to connect1414Older Adults with solutions to falls prevention; the wide array1415of programs and services, funded by the OAA, can contribute to1416a decrease in falls. Congregate and home-delivered meals help1417seniors access socialization and important nutrition that can1418lessen the impact of chronic conditions; adult day care1419services can provide supervision for an Older Adult and respite1420for a family caregiver; home modification can address1421environmental concerns and provide falls prevention tools like1422ramps and grab bars; emergency alert and falls detection1423technology decrease the chance of an Older Adult remaining on1424the floor after a fall occurs; and, information and referral1425services can link Older Adults to important community1426resources, like free hearing screenings. The reauthorization1427and adequate funding of the Older Americans Act gives Congress1428the opportunity to ensure that the national aging network can1429continue to provide holistic services that help to prevent1430falls in a cost-effective and community-focused way.14311432    Question:14331434    A recent study found that hearing loss intervention slowed1435the loss of thinking and memory abilities for older adults at1436increased risk of cognitive decline by 48% over three years.1437Since individuals experiencing cognitive impairment are also at1438greater risk of falls, how should Congress better leverage1439resources in the Older Americans Act to connect older adults1440with evidence-based hearing loss interventions?14411442    Response:14431444    The reauthorization, modernization, and adequate funding of1445the Older Americans Act gives Congress the opportunity to1446ensure that the national aging network, and the 600 Area1447Agencies on Aging (AAAs), can continue to providelistic1448services that help to prevent falls in a cost-effective and1449community-focused way.1450    Expanding and modernizing the available services that the1451Older Americans Act (OAA) allows for AAAs to deploy in1452communities can leverage greater returns on investment.1453Expanding definitions of Title IIID Health and Wellness1454Programs should include evidence-based sensory health1455interventions, like hearing health education and auditory1456screenings and interventions. Expansion of Title IIIB1457supportive services should modernize services and provide1458flexibility for AAAs to identify and address unmet needs in1459their communities, such as providing assistive devices that1460enhance mobility options and aid when balance concerns exist,1461and assistive sensory devices like talk-to-text telephones and1462over-the-counter hearing aids.1463    Most importantly, federal funding for the OAA must keep up1464with demand for the vast array of home-and-community-based1465services that are proven measures to prevent falls. Each year,1466through the OAA, more than 14 million Older Americans receive1467critical support from the nationwide Aging Network; however,1468the current funding level has not kept up with the growing1469number of adults turning 60 in the United States. In fact, per1470capita OAA funding over the last ten years has decreased by 3%.1471This has resulted in waitlists for services and Older Adults1472having to seek costly institutional care because they cannot1473access adequate community-based support services that will keep1474them in their own home. Increased funding of all Titles of the1475Older Americans Act will provide more Older Adults with1476evidence-based falls prevention programs, safety technology,1477home modifications, nutrition, and expanded, modern services to1478support Older Adults in living where they choose to.14791480    Question:14811482    Under Medicare Part B, seniors cannot seek preventive1483hearing and balance care from an audiologist without first1484obtaining a physician order and cannot receive treatment1485services provided by audiologists. In your view, would updating1486the Medicare statute to eliminate these barriers to preventive1487hearing and balance care support overall falls prevention1488efforts?14891490    Response:14911492    Any removed barriers for Older Adults to access preventive1493health measures is a critical step forward in falls prevention.1494The current path requires an Older Adult to schedule and travel1495to a primary care physician just to get a referral to an1496audiologist. For Older Adults with limited incomes or1497transportation access concerns, this lengthy process may make1498them skip this type of care entirely. The untreated hearing or1499balance issues then go unnoticed until it causes a fall1500resulting in an injury or death.1501    Allowing audiologists to provide both preventive care and1502direct treatment services under Medicare Part B would support1503the critical work the national Aging Network engages in. First,1504it will help to catch the risk earlier. If an Older Adult is1505able to walk directly into an audiologist's office at the first1506sign of dizziness or hearing concerns, they will be able to1507receive treatment immediately, thus decreasing the risk of an1508injurious fall. Second, it strengthens the community safety1509net. Area Agencies on Aging (AAA) rely on public-private1510partnerships, especially in the healthcare system, to reach1511Older Adults. If barriers are removed for Older Adults to1512easily access audiologists who can refer Older Adults directly1513into evidence-based programs, like a Matter of Balance, and1514vice versa, it will further strengthen the falls prevention1515safety net.15161517    Question:15181519    Research shows that consistent hearing aid use is1520associated with lower prevalence of falls. How can Congress1521better incorporate hearing and balance care into national falls1522prevention strategies?15231524    Response:15251526    The reauthorization, modernization, and adequate funding of1527the Older Americans Act gives Congress the opportunity to1528ensure that the national aging network, and the 600 Area1529Agencies on Aging (AAAs), can continue to provide holistic1530services that help to prevent falls in a cost-effective and1531community-focused way.1532    Expanding and modernizing the available services that the1533Older Americans Act (OAA) allows for AAAs to deploy in1534communities can leverage greater returns on investment.1535Expanding definitions of Title IIID Health and Wellness1536Programs should include evidence-based sensory health1537interventions, like hearing health education and auditory1538screenings and interventions. Expansion of Title IIIB1539supportive services should modernize services and provide1540flexibility for AAAs to identify and address unmet needs in1541their communities, such as providing assistive devices that1542enhance mobility options, like walkers, canes, and lift chairs,1543and assistive sensory devices like talk-to-text telephones and1544over-the-counter hearing aids.1545    Most importantly, federal funding for the OAA must keep up1546with demand for the vast array of home-and-community-based1547services that are proven measures to prevent falls. Each year,1548through the OAA, more than 14 million Older Americans receive1549critical support from the nationwide Aging Network; however,1550the current funding level has not kept up with the growing1551number of adults turning 60 in the United States. In fact, per1552capita OAA funding over the last ten years has decreased by 3%.1553This has resulted in waitlists for services and Older Adults1554having to seek costly institutional care because they cannot1555access adequate community-based support services that will keep1556them in their own home. Increased funding of all Titles of the1557Older Americans Act will provide more Older Adults with1558evidence-based falls prevention programs, safety technology,1559home modifications, nutrition, and expanded, modern services to1560support Older Adults in living where they choose to.15611562                 U.S. Senate Special Committee on Aging15631564 "Caught in the Middle: Supporting Families in the Sandwich Generation"15651566                              May 13, 202615671568                        Questions for the Record15691570                             Martha Petteys15711572                  Ranking Member Kirsten E. Gillibrand15731574    Question:15751576    Your organization received funding from the Administration1577for Community Living to carry out programs related to three1578different evidence-based methods of falls prevention. They1579include A Matter of Balance, offered both in person and1580virtually; EnhanceFitness; and Moving for Better Balance.1581    Can you discuss the benefits of utilizing different types1582of falls prevention services and what the drawbacks would be if1583you were limited to only providing one?15841585    Response:15861587    With thousands of locations nationwide, YMCAs provide an1588established infrastructure to deliver evidence-based programs1589at scale, particularly in communities where other providers may1590be limited. YMCAs are also uniquely positioned as trusted1591community-based providers to meet older adults where they are.1592Effective falls prevention is not a one-size-fits-all approach1593but considers the unique needs of an individual, including1594level of mobility, health, and confidence.1595    Programs such as A Matter of Balance, EnhanceFitness, and1596Moving for Better Balance each serve a purpose. Offering1597multiple evidence-based interventions allows YMCAs to match1598participants to the appropriate level and type of program.1599Internally, different types of programs allow providers to1600scale reach across the community.1601    If providers were limited to only one program model, many1602older adults could be excluded due to fit or access, limiting1603the overall public health impact of falls prevention efforts.1604Delivering multiple programs maximizes capacity and1605effectiveness, ensuring access to the right intervention at the1606proper time.16071608    Question:16091610    Funding for research equips older Americans with the1611knowledge and confidence to avoid falls. For example, the1612National Institute on Aging helped to develop and test a1613program called "A Matter of Balance" to empower older Americans1614with techniques to reduce the incidence of falling. Remarkably,1615participants reported significant improvements after just 61616weeks of engaging with the program.1617    New York State YMCAs utilize "A Matter of Balance." Can you1618speak to the direct connection between support for federally1619funded research and incidence of falls? What happens to these1620vital community networks when federal funding is disrupted1621through inadequate funding or staffing?16221623    Response:16241625    Federal funding has been essential to develop and validate1626evidence-based falls prevention programs that community-based1627organizations like YMCAs rely on. These programs are cost-1628effective and produce strong outcomes - including reduced risk,1629improved mobility, and increased confidence among participants1630after short periods.1631    When federal funding is disrupted, program implementation1632is affected. Reduced technical assistance and training can slow1633expansion, particularly in underserved areas.1634    During the pandemic, for example, program delivery and1635accessibility were disrupted. Simultaneously rates of isolation1636and need for programming to reduce falls when individuals were1637homebound rose. This period served as a case study,1638underscoring how fragile systems can be when implementation1639support is reduced.1640    Ultimately, programs rely on federal investments. When the1641pipeline from the federal to the community level is disrupted,1642fewer older adults would be able to access programs that keep1643them healthy and independent.16441645    Question:16461647    How have ACL grants enabled the YMCA's falls prevention1648work to reach more members of the community?16491650    Response:16511652    The ACL grant has been integral in expanding the reach and1653sustainability of YMCA falls prevention programming across the1654state. In particular, ACL grant funding has enabled the1655development and expansion of a statewide virtual program,1656significantly increasing access for older adults in rural and1657underserved communities. This virtual delivery model has acted1658as a "doorway" into other YMCA programs and has connected1659individuals to additional in-person services and social1660supports.1661    Without federal investment, YMCAs face limitations in their1662ability to scale programs and maintain staff.16631664    Question:16651666    How could more seniors benefit if Congress were to scale1667investments into these types of preventative public health1668initiatives?16691670    Response:16711672    Scaling federal investment in evidence-based falls1673prevention programs would significantly expand access for older1674adults while also generating long-term savings and return on1675investment in public health systems.1676    As we have mentioned, falls are the leading cause of fatal1677and non-fatal injuries among older adults, according to the1678CDC. Among older adults who fall, over half receive care in a1679hospital; the estimated annual average cost per inpatient visit1680for falls injuries is $18,658 and $1,112 per emergency1681department visit. (https://www.sciencedirect.com/science/1682article/abs/pii/S0020138323009166).1683    According to a July 2025 study by the National Council on1684Aging, participants in evidence-based falls prevention programs1685experienced a 52% reduction in the number of times they fell, a168656% reduction in the number of falls that caused injury and an168718% reduction in emergency room visits due to falls. (https://1688www.ncoa.org/article/return-on-investment-of-evidence-based-1689falls-prevention-programs/).1690    The cost of sending an individual through one of our eight-1691session virtual A Matter of Balance programs is approximately1692$250. While falls cannot be eliminated entirely, evidence1693suggests that investments in proven falls prevention programs1694can reduce fall risk, improve confidence and independence, and1695help avoid costly injuries and health care utilization. Even1696small investments in prevention have the potential to generate1697meaningful benefits for older adults, caregivers, and the1698broader health care system. Falls prevention represents a1699proactive investment that reduces reliance on costly1700emergencies and acute care services. Furthermore, scaled1701investments continue to keep programs stable and sustained.1702    Community-based organizations like YMCAs are consistently1703operating at or near capacity and are unable to meet demand1704without support. Scaled investment would allow providers to1705expand programming, reach new areas, and serve more1706participants overall. Together, these outcomes demonstrate that1707falls prevention is not only a health intervention, but a1708system-level strategy to reduce strain on the health care1709system.17101711    Question:17121713    We have heard that older adults can be reluctant to1714participate in some falls prevention programs that involve1715exercise. This can be especially true if the older adult has1716been physically inactive for years. We also hear about how1717loneliness and social isolation can be significant problems for1718America's older adults.1719    Can you discuss the role of social connection in convincing1720people to participate in falls prevention programs and regular1721exercise? Do many falls prevention programs essentially tackle1722two significant problems for America's seniors at the same1723time?17241725    Response:17261727    Social connection is a critical, and often under-1728recognized, component of effective falls prevention1729programming. Many older adults are initially hesitant to1730participate in exercise-based programming due to fear, lack of1731confidence, and previous periods of inactivity. However, group-1732based community programs like those offered by YMCAs address1733both physical and social needs simultaneously.1734    Research shows that social isolation is associated with1735higher risks of depression, reduced physical activity, and1736increased fall risk. Positive social connections improve1737motivation, reduce stress, and increase engagement in healthy1738behaviors, all of which contribute to lower fall risk and1739improved overall well-being.1740    According to a recent report from the US Surgeon General,1741loneliness, isolation, and lack of connection in our country is1742an alarming public health crisis. Lacking connection increases1743the risk for premature death by up to 60%, comparable to1744smoking daily (https://aging.ny.gov/combating-social-1745isolation).1746    The CDC estimates that loneliness costs the US economy an1747estimated $406 billion a year, in addition to $6.7 billion a1748year in Medicare costs for socially isolated adults.1749    In this way, falls prevention programs effectively address1750two major health challenges at once - physical risk of injury1751and social isolation. The combination of movement and1752connection is what makes these programs especially powerful and1753effective in supporting healthy aging.17541755                        Senator Raphael Warnock17561757    Question:17581759    Since 2014, the Administration for Community Living (ACL)1760at the Department of Health and Human Services has provided1761federal grants to community-based organizations and government1762agencies that implement evidence-based falls prevention1763programs, including the Atlanta Regional Commission in Georgia.1764However, the Trump administration cut the workforce at the1765Administration for Community Living by nearly half on April 1,17662025, and has proposed to dissolve the agency.1767    How will cuts to ACL's workforce affect their efforts to1768reduce the risk of falls among older Americans in states like1769Georgia?17701771    Response:17721773    The Administration for Community Living plays a central1774role in supporting the development, implementation, and scaling1775of evidence-based falls prevention programs nationwide. Any1776significant reduction in staffing or capacity within ACL could1777slow technical assistance and limit coordination with states.1778    This would have downstream impacts on local organizations1779that rely on guidance and funding to implement programs1780effectively, particularly in states with emerging or under-1781resourced infrastructure. These programs rely on trained1782instructors and community-based staff to deliver them1783effectively; disruptions in funding directly affect workforce1784capacity and program quality. In practical terms, reduced1785federal support could slow the expansion of falls prevention1786services at a time when demand continues to grow.17871788    Question:17891790    In 2024, nearly 74,000 Georgians aged 65 and older visited1791the emergency room for a fall-related injury, and 844 died as a1792result of their fall. The Centers for Disease Control and1793Prevention's (CDC) National Center for Injury Prevention and1794Control (NCIPC) has played a vital role in leading public1795health research on falls among older adults and in developing1796clinical toolkits to help health professionals treat1797individuals with fall-related injuries. However, the Trump1798administration eliminated nearly one-third of its workforce on1799April 1, 2025, including the entire workforce that focused on1800older adult falls.1801    How can Congress continue investments in medical research1802and clinical practices to improve treatments for older1803Americans with fall-related injuries, given massive layoffs at1804NCIPC?18051806    Response:18071808    The Centers for Disease Control and Prevention's National1809Center for Injury Prevention and Control has played a critical1810role in advancing research, surveillance, and clinical guidance1811related to older adult falls. This work has helped translate1812evidence into practical tools for healthcare providers and1813community organizations.1814    Reductions in workforce capacity within this area could1815slow the development and dissemination of updated clinical1816guidance, limiting data collection and analysis, and weakening1817national coordination on falls prevention strategies.1818    Congress can continue to strengthen outcomes for older1819adults by maintaining and expanding investments in both medical1820research and community-based prevention. Sustained federal1821support ensures that evidence-based interventions continue to1822be developed, rigorously evaluated, and implemented1823effectively, and that health care providers have the knowledge1824and tools to reduce falls-related injuries. Continued and1825sustained federal investment will be critical to maintaining1826momentum and meeting growing demand as the population ages.1827=======================================================================18281829                       Statements for the Record18301831=======================================================================1832[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]18331834                              [all]