geriatrics

Article
Implementation of a Multicomponent Otago-Based Virtual Fall
Reduction, Education, and Exercise Program (MOVing FREEly)
in Older Veterans
Katherine C. Ritchey 1,2, * , Amanda Olney 3 , Sunny Chen 1 , Erica Martinez 1 , Michelle R. Paulsen 1 ,
Jennifer Tunoa 1 and James S. Powers 4,5

1 Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System,
1660 S. Columbian Way, Seattle, WA 98108, USA; sunny.chen@va.gov (S.C.); erica.martinez@va.gov (E.M.);
michelle.paulsen@va.gov (M.R.P.); jennifer.tunoa@va.gov (J.T.)
2 Division of Geriatrics and Gerontology, Department of Medicine, University of Washington School of
Medicine, 325 9th Ave, Seattle, WA 98104, USA
3 Rehabilitation Care Services, VA Puget Sound Health Care System, 1660 S. Columbian Way,
Seattle, WA 98108, USA; amanda.olney@va.gov
4 Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Health Care System,
1310 24th Avenue South Nashville, Nashville, TN 37212, USA; james.powers@va.gov
5 Division of Geriatrics, Vanderbilt School of Medicine, 2147 Belcourt Ave., Suite 100, Nashville, TN 37212, USA
* Correspondence: katherine.ritchey2@va.gov

Abstract: Purpose: The COVID-19 pandemic limited access to community fall prevention programs,
thus establishing the need for virtual interventions. Herein, we describe the feasibility, effectiveness,
and acceptability of a virtual, multicomponent fall prevention program (MOVing FREEly). Methods:
A team of clinical falls prevention experts developed a six-week multicomponent fall prevention
exercise and education class for older community-dwelling adults at risk of falling. Feasibility was
measured through class attendance; effectiveness was measured through changes in performance
measures, self-report of falling risk, and concern about falling; acceptability was assessed through
questionnaires completed immediately upon program completion and at a three-month follow up.
Citation: Ritchey, K.C.; Olney, A.; Results: A total of 32 patients participated in the MOVing FREEly program. Attendance for education
Chen, S.; Martinez, E.; Paulsen, M.R.; and exercise classes on average was greater than 80% with little attrition. Patient reported reduced
Tunoa, J.; Powers, J.S. concern of falling, improvement in the falls efficacy scale—international (FES-I) short form, and had
Implementation of a Multicomponent
statistically significant improvement in 30 s sit-to-stand and single-leg balance tests. The program
Otago-Based Virtual Fall Reduction,
was well received by participants, saving them significant time and costs of travel. Conclusions: A
Education, and Exercise Program
virtual, multicomponent fall prevention program is feasible and acceptable and effective as reducing
(MOVing FREEly) in Older Veterans.
falling risk. Future studies can explore the ability of this program to reduce falling incident and injury.
Geriatrics 2023, 8, 115. https://
doi.org/10.3390/geriatrics8060115
Keywords: fall prevention; telerehabilitation; veteran affairs; quality improvement
Academic Editor: Ralf Lobmann

Received: 25 September 2023

Revised: 31 October 2023
Accepted: 22 November 2023 1. Introduction
Published: 28 November 2023 Falls are common among veteran older adults, and result in serious consequences [1].
They are the leading cause of fatal and nonfatal injury in older adults and precipitate
functional decline, psychological stress, and loss of independence [2]. One in three persons
over the age of 65 and one in two over the age of 80 will fall each year [3]. Falls continue
Copyright: © 2023 by the authors.
to be the leading cause of injury related morbidity and mortality [3]. Recent trends also
Licensee MDPI, Basel, Switzerland.
This article is an open access article
suggest that mortality from falls is highest for the oldest age groups (>75 years) and overall
distributed under the terms and
rates of death from falls continues to increase [4].
conditions of the Creative Commons
Falls have adverse effects on mobility, independence, and quality of life, but are
Attribution (CC BY) license (https:// largely preventable [5]. Multicomponent interventions deliver a standardized (i.e., non-
creativecommons.org/licenses/by/ individualized) combination of fall prevention interventions and are effective (e.g., ex-
4.0/). ercise focused on strength and balance; home safety hazard reduction; polypharmacy

Geriatrics 2023, 8, 115. https://doi.org/10.3390/geriatrics8060115 https://www.mdpi.com/journal/geriatrics

Geriatrics 2023, 8, 115 2 of 10

reduction) [1,6–8]. The Centers for Disease Control (CDC) “Stopping Elderly Accidents,
Deaths and Injuries” (STEADI) has endorsed several evidence-based multicomponent
fall prevention programs (e.g., Stepping On; Matter of Balance) in the hope of improving
community-based dissemination and engagement. The closure of many community centers
during the SARS-CoV-2 pandemic limited access to in-person programs, thus highlighting
the need to adapt fall prevention programs to virtual-based platforms.
Even before the pandemic, studies suggested that telerehabilitation (i.e., the delivery
of rehabilitation services via telehealth modalities) is feasible and efficacious. A systematic
review of nine studies which explored the concurrent validity and inter- and intra-rater
reliabilities concluded that several assessments (e.g., pain, swelling, range of motion, muscle
strength, balance gait, and functional assessment) were technically feasible and valid over
telerehabilitation modalities [9]. A corresponding systematic review and meta-analysis of
randomized physical therapy trials suggested that therapeutic interventions for physical
function decline and/or disability delivered over telerehabilitation performed as well as
usual care and produced similar long-term benefits [10]. Telerehabilitation is cost-effective,
may improve participation in rehabilitation programs, and offers additional benefits to
caregivers of persons recovering from a disabling health event such as a stroke [11–13].
The Veterans Health Affairs (VHA) system has been a leader in telemedicine de-
ployment, supporting end users (i.e., veterans), infrastructure (i.e., devices, internet, and
software) and staff (i.e., training and practice support and productivity/reimbursement)
in a wide variety of therapeutic areas, including telerehabilitation [14]. Telemedicine is an
accepted way to provide and receive care in VHA, and in many cases is a preferred modal-
ity due to transportation and other logistical challenges that rural veterans face [15–17].
Though there has been some success in converting other Veterans Affairs (VA) mobility
and exercise programs to virtual platforms, a virtual fall prevention group program has yet
to be piloted in VHA [18,19]. The goal of this project was to evaluate the feasibility and
acceptance of a novel VHA multicomponent and interdisciplinary virtual fall prevention
program, developed to increase awareness of fall risk factors, improve strength and balance,
and promote risk-reducing behaviors.

2. Materials and Methods

2.1. Setting and Participants
This quality improvement project was piloted at VA Puget Sound, located in Seattle,
Washington. This hospital is a large tertiary Veterans Health Administration (VHA) facility,
which serves a large, geographically diverse area ranging along the entire Puget Sound and
Western Cascade mountain range, has an inpatient hospital, skilled nursing facility and
outpatient clinics including primary care, subspecialty medicine and rehabilitative services.
The Seattle facility hosts a Geriatric Research, Education and Clinical Center (GRECC)
and Telerehabilitation Enterprise Wide Initiative (TREWI) hub, both of which are adept
at implementing novel telemedicine programs across a large, often rural, geographical
region [20].
Participants at risk of falling, as defined by one or more CDC STEADI key fall risk ques-
tions (https://www.cdc.gov/steadi/pdf/steadi-algorithm-508.pdf; accessed on 28 October
2023), were referred to the program from outpatient primary, geriatric, and rehabilitation
clinics [21]. A physical therapy assistant (PTA) screened participants for the following
exclusion considerations: in a wheelchair 50% of the or the day or more; requires moderate
to full assistance with transfers; evidence of significant cognitive impairment or dementia
through chart review or basic screen; not community-dwelling. A full description of the
class was offered, and patients were asked to accept or decline participation at that time.
Patients with various telemedicine barriers (e.g., lacked experience with the VA Virtual
Care (VVC) platform or telemedicine visits; did not own a device (i.e., tablet; computer)
with microphone and camera; or lacked Internet service provider) were offered training by
the PTA and/or ordered devices with Internet through a central VA distribution center.
Geriatrics 2023, 8, 115 3 of 10

From January 2022 to January 2023, 32 veterans were enrolled into MOVing FREEly
(a total of four class cohorts). Complete data were analyzed for 27 participants who were
older (mean age 75 years), mostly male (89.0%) and white (85.2%), and were at moderate or
high risk of falling based on a prior history of falls or self-report response to STEADI fall
risk questions (Table 1). Most (70%) had never had a VVC visit in the past. Average score
on the FES-I short form indicated a high level of concern for falling when completing ADLs
(14.67, SD +/− 5.0) 32. Seven participants (35%) reported a fall while participating in the
series but no injuries. There were no falls or injuries during any of the exercise sessions.

Table 1. Participant characteristics.

Sex, Male, n(%) 24 (89.0%)

Age, mean (SD, range) 75 (5.11, 64–85)
Race, white, n (%) 23 (85.2%)
Time to Seattle VA, minutes, median (SD) 80.2 min (±45.7)
Fallen within the last 12 mo, n (%) 25 (92.6%)
Fall that caused an injury, n (%) 8 (29.6%)
Fear of falling, n (%) 22 (81.5%)
Unsteady when walking, n (%) 23 (85.2%)
Use arms to stand up from a chair, n (%) 21 (77.8%)
Participant characteristics for study population for whom there was complete data (N = 27).

2.2. Program Design and Implementation

The MOVing FREEly (Multicomponent, Otago, Virtual, Fall Reduction, Education and
Exercise) program is a six-week multicomponent fall prevention education and exercise
class. An interdisciplinary team consisting of a geriatrician, pharmacist, occupational
and physical therapist (PT), all with a training in geriatrics and fall prevention, reviewed
evidence-based fall prevention interventions and programs and developed class curricu-
lum, presentation materials and participant education and exercise handbooks [22–24].
The elements of a successful group-based intervention (e.g., engaging participants in an
active manner which is less prescriptive and more contextual; using simple language and
developing trust; promote self-monitoring of behavioral change; and progression of content
by group leader(s), especially exercises) were incorporated into the class model [22] [23,25].
Other patient-related education materials were obtained from the CDC STEADI website
(Patient & Caregiver Resources|STEADI—Older Adult Fall Prevention|CDC Injury Center,
https://www.cdc.gov/steadi/patient.html, accessed 28 October 2023) [21,26].

2.3. Education Program

A weekly educational class focusing on different fall prevention topics met weekly
over a virtual platform (i.e., VVC) (Figure 1), and was facilitated by occupational or physical
therapist, physician, or pharmacist. Instruction included a standardized pres8entation
intermixed with small-group discussion, and participant handbooks mirrored weekly
content/topics, including activities for participants to re-enforce concepts learned during
the educational class. Participants also identified fall-risk behaviors (“risky behaviors”) at
the initial class and worked with group facilitators to reduce risk through specific behavioral
modifications. These self-identified goals were reviewed and reinforced at the beginning of
each class and recorded into the participant handbook. Homework related to the weekly
topic provided additional opportunities to reinforce class concepts between each class.
, x FOR PEER REVIEW 4 of 10

Geriatrics 2023,weekly
8, 115 topic provided additional opportunities to reinforce class concepts between each
4 of 10
class.

Figure 1. MOVing FREEly

Figure weekly
1. MOVing classweekly
FREEly structure.
class structure.

2.4. Exercise Program

2.4. Exercise Program
The exercise program was based on the CDC Otago Exercise Program (Otago_2023-
The exercise program was based on the CDC
Implementation-Guide-for-PT-1.pdf Otago
(unc.edu), Exercise Program (Otago_2023-
https://www.med.unc.edu/aging/cgwep/
wp-content/uploads/sites/865/2023/08/Otago_2023-Implementation-Guide-for-PT-1.pdf,
Implementation-Guide-for-PT-1.pdf (unc.edu), https://www.med.unc.edu/ag-
accessed 28 October 2023), which focuses on lower extremity strengthening and balance [21].
ing/cgwep/wp-content/uploads/sites/865/2023/08/Otago_2023-Implementation-Guide-
A PTA or PT conducted virtual exercise sessions once a week on an individual or group
for-PT-1.pdf, accessed 28 October
basis, separate from the2023), whichclass.
educational focuses on lower
At weeks extremity
three and strengthening
five, the physical therapist
and balance [21]. A PTAtheornumbers
increased PT conducted virtual
of repetitions exercise
or challenge sessions
(e.g., once
eyes closed witha balance
week on an in-if
exercises)
the participant was willing and could do so safely. Participants were encouraged
dividual or group basis, separate from the educational class. At weeks three and five, the to perform
exercises
physical therapist on their
increased own
the two to three
numbers times a week.or challenge (e.g., eyes closed with
of repetitions
balance exercises)
2.5. if the participant
Measurements was willing and could do so safely. Participants were
and Analysis
encouraged to perform exercises on their
Feasibility was defined own two tointhree
as participation times
the group, a week.
staff effort to sustain group and
ability of the group to reduce falling risk. Weekly exercise and education class attendance
2.5. Measurements as recorded in the electronic health record. Staff effort included administrative time by
and Analysis
facilitators or program assistants to review referrals to MOVing FREEly, enroll participants,
Feasibility connect
was defined as participation
participants in the group,
to the virtual platform staffongoing
and provide effort technical
to sustain group
support and
through-
ability of the group to reduce falling risk. Weekly exercise and education class
out the 6-week class. This was capture in the monthly MOVing FREEly operational meetingattendance
as recorded in notes
the electronic
and electronichealth
healthrecord. Staffapplicable.
record when effort included
Reductionadministrative
in falling risk was time by
measured
by change in performance and self-reported measures of falling
facilitators or program assistants to review referrals to MOVing FREEly, enroll partici- risk. The program PT
completed an initial virtual evaluation for all participants who opted into the program.
pants, connect participants to the virtual platform and provide ongoing technical support
Assessment incorporated subjective falling history and performance tests specific for falling
throughout the(e.g.,
6-week class. balance
four staged This wastest capture
(FSBT) and in30the monthly (STS))
s sit-to-stand MOVing FREEly
according to theopera-
CDC’s
tional meeting STEADI
notes and guideelectronic health record when applicable.
(STEADI-Assessment-30Sec-508.pdf (cdc.gov) and Reduction in falling
4-Stage_Balance_Test-
risk was measured print.pdf (cdc.gov);
by change inboth accessed onand
performance 28 October 2023) [27,28].
self-reported Performance
measures testsrisk.
of falling were
conducted over video platform with PT providing guidance and demonstration as needed.
The program PT completed an initial virtual evaluation for all participants who opted into
Other performance tests are more difficult to conduct over a virtual modality and were
the program. Assessment
omitted [18,29]. incorporated
Pre-class, postsubjective falling history
class and three-month and performance
post program questionnairestests
com-
specific for falling (e.g.,
pleted four stagedbybalance
independently test captured
participants (FSBT) and 30 sin
changes sit-to-stand
self-report of(STS)) accord-
gait, balance or
ing to the CDC’s STEADI guide (STEADI-Assessment-30Sec-508.pdf (cdc.gov) and 4-
Stage_Balance_Test-print.pdf (cdc.gov); both accessed on 28 October 2023) [27,28]. Perfor-
mance tests were conducted over video platform with PT providing guidance and demon-
stration as needed. Other performance tests are more difficult to conduct over a virtual
Geriatrics 2023, 8, 115 5 of 10

lower extremity impairments (adapted from CDC STEADI “Stay Independent” assessment),
concern for falling (e.g., falls efficacy scale—international (FES-I) short form and self-report
concern for falling) and demographic information [30–32]. Responses were either “yes” or
“no”. Paired-sample T-tests analyzed participant improvement in physical performance
measures of falling risk (e.g., 30 s STS, ability to hold a single leg test) and FES-I for patients
in which there was complete pre-/post-program data. Descriptive statistics were used to
examine self-report of improvement in falling risk.
Acceptance of this telemedicine fall prevention program was derived from the post-
program and three-month post program questionnaires, which asked participants about
their experience of participating in a virtual class, likelihood to recommend the class to
others, and steps taken to incorporate fall risk behaviors (e.g., home safety modifications
and changes to “risky behaviors”). We calculated travel time and mileage saved by receiving
the program at home vs. in person at the Seattle VA. This was calculated by estimating the
roundtrip travel mileage from participant home address (as found in electronic medical
record) to Seattle VA. This implementation study was determined a quality improvement
project by VA Puget Sound IRB, and patient consent was not obtained. Participation was
voluntary, participants were able to opt out of program evaluation surveys, and data were
de-identified prior to analysis.

3. Results
3.1. Feasibility of Program
Weekly attendance was higher for the educational (mean % attendance 89%; SD ± 0.05)
than exercise classes (mean % attendance 83%; SD ± 0.04). There was low attrition through-
out the six weeks for education and exercise classes, and group exercise classes had a higher
attendance than the individual sessions (Table 2). All participants were offered a “test
call” prior to their initial VVC visit. “Test calls” could take between 20 and 40 min, and
were conducted in the context of the PTA’s regular clinical practice. On average, 40% of
participants needed extra help at the start of each class to sign-on to the VVC visit, which
was provided by the PTA or medical support assistant. By the fourth class, all participants
were self-sufficient in their ability to navigate the VVC platform, which was a finding
consistent throughout all four cohorts. The proportion of participants needing support in
each cohort declined throughout the course of the study period. Table 3 summarizes the
operational experiences for the virtual multicomponent exercise and educational class.

Table 2. Attendance (%) for exercise and education class per week.

Week 1 2 3 4 5 6
Education 91 97 81 88 91 84
Exercise—overall 77 87 87 83 80 86
Exercise—group 100 100 100 83 75 83
Exercise—individual 61 78 78 83 83 89
Weekly attendance for educational session (n = 32), group exercise (n = 12), and individual exercise (n = 18) classes
by week for all study participants. Two participants were already enrolled in a community-based Otago exercise
class at the time of group participation; thus, total group exercise class enrollment was 30, not 32.
Geriatrics 2023, 8, 115 6 of 10

Table 3. Considerations for implementing a virtual fall prevention program.

Program Component Tips Rationale

• Review virtual skills, virtual platform features, • Builds confidence in technical skills and literacy
discuss virtual etiquette • Allows for technical support (logging on,
• Additional staff to support class facilitator troubleshooting audio/visual difficulties)
• Send virtual appointments via email rather than improves presentation timeliness, reduces delays
Logistical text message and consider reminder calls and enhances participation
considerations • Knowledge of local and/or health system virtual • Improves class attendance
clinic requirements, documentation and coding • Captures workload, provider productivity and
• Verify participant emergency contacts quality metrics to support program sustainability
and location • Establish methods to engage first responders in
the event of an emergency
• Clarifies class expectations; improve attendance
• Reduces scheduling “bottlenecks” (accessibility)
• Physical handbooks are easier to use than
digital copies
• Pre-class enrolment call • Determine “best-fit” for exercise class (group
• Enrollment on a “rolling” basis vs. individual)
Enrollment • Mail hardcopies of participant handbooks • Build rapport with individual; learn what
• Pre-class physical therapy evaluations matters to them and guide
person-centered discussions
• Identify individual impairments impacting safe
mobility, addressing any individual concerns (e.g.,
issuing assistive devices)
• Encourages participants to share experiences
openly and improves participation, respect
and engagement
• Define virtual space as a confidential space and • Builds commadore between participants and
limit external noises and distractions facilitates group learning
• Prompt discussion during sessions • Maintain eye-contact; ensure adequate
• Consider presenter/facilitator communication lightening; visualize face and upper torso; listen
Management and and virtual presence with intention; share information that is simple,
delivery of class • Review virtual exercise safety considerations concise and free of jargon; repeat questions
content • Group participants with similar functional levels before answering
for exercise groups and limit exercise groups • Identify methods for balance support—assistive
depending on providers’ comfort level and device, chair, counter, corner of wall; utilize a
participants’ safety (e.g., 4 participants/group) caregiver to provide support and monitor exercises
• Allows adequate visualization of participant
bodies while exercising to ensure safety and
accuracy of movements

All participants (100%) reported that the program helped to reduce their fear of falling,
and three quarters (76.9%) indicated the program helped them improve strength, balance,
or both, and had made home safety modifications (73.1%) (Table 4). At three months,
most (>95%) continued to share that the class reduced their concern about falling and
had increased confidence with falling risk reduction, and few (33%) had sustained a fall
(Table 4). Though most stated they felt comfortable talking to their primary provider about
medications that increase their risk of falling, less than half (44.6%) had implemented
medication changes at the three-month post-program follow up (Table 4). There was
statistically significant improvement in the 30 s STS (pre-program mean 7.8 reps (±4.5);
post-program mean 11.2 reps (±3.2); p-value = 0.000), ability to hold a single-leg stance
(pre-program mean 2.4 sec (±3.9); post-program mean 5.2 sec (±4.3); p-value = 0.000), and
FES-I short form scores (pre-program mean score 14.7 (±4.95); post-program mean score
12.5 (±3.56); p-value = 0.016) by the end of the program.
Geriatrics 2023, 8, 115 7 of 10

Table 4. Response to fall risk measures post program and at three-month follow up.

End of Program (N = 26) n (%) Three Month Follow Up (N = 21) n (%)

7
Fall during class 19 (73.1%) Fall since class ended
(33.3%)
20
Reduced your fear of falling 26 (100%) Reduced your fear of falling
(95.2%)
Continued confidence in falling 20
Improvement in strength, balance 20 (76.9%)
risk reduction (95.2%)
I feel more comfortable talking to HCP 10
23 (88.5%) Made medication changes
about medications (47.6%)
25 14
Plan to continue exercising Exercising at least weekly
(96.1%) (66.7%)
I have made changes to my home 19 19
Has continued to reduce risky behaviors
environment to reduce risk (73.1%) (90.5%)
Table represents responses to post-program questionnaires immediately at the end of the program and at three-
month follow up. Response categories were organized by common themes and represent the questions asked of
participants at each time point. health care provider (HCP).

3.2. Acceptability of Program

As for the acceptability of the program, all (100%) were “satisfied with the program”
and would “refer the program to another veteran”. Most (89%) veterans stated they
“preferred a virtual platform” as it was more convenient, reduced travel burden, and
increased accessibility, and would not have participated if the program was not virtual. On
average, patients saved a total of 72.4 miles and 80.2 min of round trips per person by not
traveling to the Seattle VA.

4. Discussion
MOVing FREEly is a feasible and acceptable program for delivering group-based,
evidence-based fall prevention education and exercise interventions. Participation in the
program was high and sustained, and resulted in an improvement in objective and sub-
jective measures of falling risk. A virtual platform was well accepted by participants, and
preferred due to time and travel savings, which were considerable. Our findings are com-
parable to other group-based fall prevention programs, and add to the evidence supporting
the efficacy of virtually based, group, educational programs for fall prevention [23,33,34].
Our adherence rates were similar (above 80%), with a similar improvement in performance
measures of falling [29].
Telerehabilitation is a reasonable modality through which to provide fall prevention
programs, but requires careful logistical planning and considerations. Observations from
prior studies of virtual balance or fall prevention programs suggests that even persons
who are cognitively impaired or new to virtual care are able to master the independent
use of this modality and become technologically independent [29]. However, this does
require considerable initial skill-based coaching and assistance by the study teams or
facilitators [29]. Similarly, we found that many participants required pre-program support
in learning the virtual platform and signing on to virtual classes, and standby assistance
during the class if technical problems were encountered. Once mastered, our participants
embraced the virtual component and preferred this to in-person options. Our observations
also highlighted the growing familiarity of older adults with technology and virtual health
care [35]. Though most were still “new” to the VVC platform throughout the course of
our study period, fewer participants needed additional assistance as time progressed,
suggesting a possible increase in technological literacy in our older adult population.
Our program is different from other telemedicine-based balance or fall prevention
exercise classes as it includes an education class facilitated by health care professionals and
operates as a group medical appointment. Thus, it required additional considerations, such
Geriatrics 2023, 8, 115 8 of 10

as electronic health record documentation and coding; clinic setup, referral management
and virtual appointment scheduling; and patient privacy and health emergency planning
(Table 3). Because veteran populations have a higher prevalence of frailty and multiple
chronic conditions, the delivery of wellness and educational programs by licensed providers
can allow for adaptability to meet unique health care needs and patient preferences [36].
Thus, the unique features of the VHA system support the ability of a multidisciplinary
team of licensed health care providers to deliver a virtual fall prevention exercise and
education class, and support development of technological skills of our patients (e.g.,
turn on/off device and volume; set up email account; download documents; connect to a
virtual platform).
There are several limitations to our program evaluation. The number of participants
was small (N = 32). Given that the intent was to determine the feasibility and acceptability
of implementation of a clinical demonstration program, the data reflect the initial evaluation
of this program, and were not designed to test the effectiveness at reducing the rate of
falling. Future randomized control trials are needed to determine if the incidence and rate
of falling are reduced in participants vs. non-participants. Secondly, the limited diversity
of our participant population and health care system may limit the generalizability to
Black, Indigenous, and People of Color (BiPOC) communities, transgender persons, and
cis-women. As our region diversifies and our program increases in enrolment, we are
hopeful to evaluate the experiences of those with diverse backgrounds and continue to
incorporate inclusive language into our education and exercise curriculums. Lastly, the
evaluation of this program and operational observations shared are limited to a single VA
facility with telemedicine experience and infrastructure. Future work will need to explore
and establish the feasibility, efficacy, and acceptability of this program at sites throughout
VHA and other non-VA health care systems.

5. Conclusions
The MOVing FREEly program is a feasible, virtual option for offering a multicompo-
nent fall prevention program, which reduces measures of falling risk and was well received
by veteran participants. By utilizing telemedicine, this program has the potential to expand
the access to traditional fall prevention interventions and better serve an increasingly aging
and frail veteran population. Future studies will need to examine if this program is feasible
throughout VHA and if the improvements in performance and self-reported measure of
falling risk observed in this study translate into reductions in future falls.

Author Contributions: Conceptualization, Methodology, Writing—Original Draft Preparation,

Writing—Editing, K.C.R., A.O. and J.S.P.; Data Curation, Formal Analysis, S.C. and E.M.; Project
Administration, K.C.R., A.O. and E.M.; Writing—Reviewing and Editing, S.C., M.R.P. and J.T.; Fund-
ing Acquisition, K.C.R. and J.S.P. All authors have read and agreed to the published version of
the manuscript.
Funding: Support for this program was provided by the Veterans Affairs Office of Geriatrics and
Extended Care, Veterans Integrated Service Network 20 and the Office of Rural health.
Institutional Review Board Statement: Ethical review and approval were waived for this study due
to the quality improvement intent of this program and study.
Informed Consent Statement: Patient consent was waived due to the quality improvement intent of
this program. Participation in the program and evaluation activities was voluntary and all data were
de-identified prior to analysis.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to the quality improvement nature of
this work.
Acknowledgments: The authors would like to thank the Rehabilitation care service and the Geriatric
Research, Education, Clinical Center at VA Puget Sound for administration support and collaboration,
making this program possible. We would additionally like to thank Elizabeth Phelan, who provided
Geriatrics 2023, 8, 115 9 of 10

manuscript review. We would also like to acknowledge Ruby Farinas, Jennifer Chen, Terri May, and
Benson Wong, who provided additional program development, support, and guidance.
Conflicts of Interest: The authors declare no conflict of interest.

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