Removing home hazards for older adults living in affordable housing: A stepped-wedge cluster-randomized trial

Falls are the leading cause of injury, disability, premature institutionalization, and injury-related mortality among older adults. Home hazard removal can effectively reduce falls in this population but is not implemented as standard practice. This study translated an evidence-based home hazard removal program (HARP) for delivery in low-income senior apartments to test whether the intervention would work in the "real world."

From May 1, 2019 to December 31, 2020, a stepped-wedge cluster-randomized trial was used to implement the evidence-based HARP among residents with high fall risk in 11 low-income senior apartment buildings. Five clusters of buildings were randomly assigned an intervention allocation sequence. Three-level negative-binomial models (repeated measures nested within individuals, individuals nested within buildings) were used to compare fall rates between treatment and control conditions (excluding a crossover period), controlling for demographic characteristics, fall risk, and time period.

Among 656 residents, 548 agreed to screening, 435 were eligible (high fall risk), and 291 agreed to participate and received HARP. Participants were, on average, 72 years, 67% female, and 76% Black. Approximately 95.4% of fall prevention strategies and modifications implemented were still used 3 months later. The fall rate (per 1000 participant-days) was 4.87 during the control period and 4.31 during the posttreatment period. After adjusting for covariates and secular trend, there was no significant difference in fall rate (incidence rate ratio [IRR] 0.97, 95% CI 0.66-1.42). After excluding data collected during a hiatus in the intervention due to COVID-19, the reduction in fall rate was not significant (IRR 0.93, 95% CI 0.62-1.40).

Although HARP did not significantly reduce the rate of falls, this pragmatic study showed that the program was feasible to deliver in low-income senior housing and was acceptable among residents. There was effective collaboration between researchers and community agency staff.