In one recent online learning session, fall prevention expert Patricia Quigley outlined the problem with the practice of universally prescribing non-slip socks for fall-risk residents.
“So, we want you to stop this universal application of non-skid socks. There should be criteria for the use of non-skid socks, they should not be just put on everybody. […] Especially people who can't feel their feet, people with peripheral neuropathy, or people who have a shuffling gait, Parkinson's patients. [...] You're actually increasing their risk hazard."1 – Dr Patricia Quigley
In addition to this, the Framingham foot study2 found that there was an association between older adults who had foot pain and those who reportedly fell in the last year. As a matter of fact, the study found that there was a 62% increased risk of recurrent falls for those who experienced foot pain. In this case, those residents with foot deformities or atypical foot postures such as plantar (flat foot) or bunions may have an increased risk of falling due to their ill-fitting standard footwear and the prevalence of foot pain as a result. So, if this is the case, what is the best practice for fall-prevention footwear?
Expert in fall prevention, Dr Patricia Quigley and Director of Rehabilitation, Karen Kaminski-Ciancio propose an exemplary fall prevention footwear program that challenges the use of non-slip socks as a blanket risk mitigation measure and positions the benefits of individualized shoes in fall management for both ambulatory and non-ambulatory residents.
Now we've established that slipper-socks with non-slip soles may not be the universal fall prevention intervention we once thought and are not suitable for everyone in a long-term care setting, how would you go about implementing a custom footwear program for your residents and what would the cost implications be for the residents and for the facility? Karen Kaminski-Ciancio shares how she did it in her skilled nursing facility in Westfield, New York.
Before you can implement a shoe clinic or footwear program, you'll need to find a vendor that can make custom shoes or inserts and is able to work out the billing with Medicare and Medicaid on behalf of the resident.
Karen Kaminski-Ciancio explains the role of the Skilled Nursing Facility and the shoe vendor.
"We have a vendor that we work with very closely that does terrific work. And what we do is we send them our residents’ face sheets, that include the insurance and any qualifying diagnoses. Because quite frankly, they do all the billing. They, check authorization. So that is not part of what we do here at all, which makes this process very easy."1 – Karen Kaminski-Ciancio
Just as you'd need to assess for the appropriate use of non-slip socks for residents, it's up to your therapists and the interdisciplinary team to decide which of your patients may most benefit from individualized footwear to support their foot health, mitigate risks and ultimately prevent falls.
"When we decide that someone would benefit from getting shoes, what we do is the therapists as well as the nurse managers on the units, make a list of the residents that we feel would benefit from these."1 - Karen Kaminski-Ciancio
When it's been determined that the resident will benefit from a custom pair of shoes and confirmation from CMS has been obtained by the vendor you can hold a shoe clinic where they'll be assessed for proper footwear.
"So, when they come to our facility, essentially, what we do is we get all of our residents, and we bring them down to our physical therapy clinic. And the fitters do an assessment of the residents barefoot when they push it into a box of soft foam. That conforms to the exact shape of their foot, which allows them to get a custom mold for the inserts.
"So what happens is, our shoe vendors take all these boxes with them, and they do their work. They order the shoes, they come back, and the shoes either have a custom-molded insert or a heat-molded insert."1
One of the benefits of custom shoes in this footwear program is that the shoe fitter will be able to take into account the individual resident's diagnosis as well as consider health conditions and factors like edema and together with clinical and therapy staff can present the resident with some options for shoes with custom inserts that would most benefit that person.
Karen advises that another key feature of the program is that the resident has some space to exercise a personal preference in the shoe style. She says the residents are "able to choose the color and sometimes have some input into the style."1
With resident preference, foot size, foot width, foot shape, foot deformities (such as plantar fasciitis or bunions), gait, medical conditions and fall prevention needs all assessed and taken into account, individualized shoes can perhaps be considered to be the best shoes for elderly to prevent falls and for improving quality of life in general. These shoes have been developed for ease of resident donning and doffing including adjustable straps rather than shoe laces or hook eye fastenings which can exacerbate a risk of falls.
Of course, an initial assessment that the shoe does fit and is comfortable for the resident is done by the vendor but it's then up to therapy and nurses to monitor the success of the custom shoe in day-to-day life.
"When all those shoes have been ordered and the inserts are done, they all come back to us on one day. The vendor returns to us, and we kind of do a repeat of what happened that first day. So, the residents are brought down to our department again. The shoe fitters, just kind of grossly assess to make sure that the shoe is correct for them. So, in other words, the size is correct, and it's fairly comfortable when the resident places their foot in the shoe for the first time, and then they leave.
"They leave the shoes with us. And then what we do over the course of a period of weeks is our physical therapists evaluate the residents, put them on program. As part of the program, what we do is to make sure that the resident isn't having any skin issues. They're not having any pain."1 - Karen Kaminski-Ciancio
Karen advises, "This program can be repeated, twice a year as insurance generally allows the residents to receive two pairs of shoes a year. So, the shoe clinic comes back to us approximately every six months."
This means that these shoes are suitable for everyday wear and you don't have to worry about wearing them out and replacing them at cost.
In long-term care settings, it's a common practice to use non-slip socks to prevent falls, but experts like Dr Patricia Quigley argue that these medical slipper socks may not be suitable for all residents. Instead, an individualized approach to fall prevention through the use of properly fitted shoes and using individual assessments for the prescription of fall prevention slipper socks may be more beneficial.
Studies2,3 show that ill-fitting shoes increases the risk of falls and impairs mobility, while appropriate footwear improves balance, decreases the fear of falling and enhances functional performance. Fall prevention programs should therefore assess each resident’s specific needs, considering foot health, deformities, and any underlying medical conditions to achieve the best outcomes in terms of fall prevention.
If a footwear program like this interests you, you'll love our on-demand learning session with our two experts, Dr Patricia Quigley and Karen Kaminski-Ciancio. You can watch the whole session right now to learn how this exemplary program was successfully implemented in a New York skilled nursing and rehab facility.
Watch An Exemplar: A Unique and Innovative Interdisciplinary Footwear Program on the Accora website now.
PhD, MPH, APRN, CRRN, FAAN, FAANP, FARN
Dr Patricia Quigley is a Nurse Consultant and Nurse Scientist. She is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation, and her contributions to patient safety, nursing and rehabilitation are evident at a national level – with emphasis on clinical practice innovations designed to promote elders’ independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers.
PT, Director of Rehabilitation
An expert Physical Therapist and Director of Rehabilitation Services, at Absolut Care Westfield, practicing for over 30 years. She practices in a Skilled Nursing Facility Clinic with both long-term care and subacute rehab residents.
Karen has responsibility for clinical, administrative, education and program evaluation of rehabilitation programs to ensure the highest quality of care for residents in need of interdisciplinary rehabilitation programs. Her professional focuses include maximizing residents’ safety, function, independence and autonomy with their families and caregivers.
"If a resident is diabetic, the billing is submitted through Medicare or the Medicare managed care programs because they will cover it with that diagnosis. If the resident is not diabetic, the vendor then bills the primary insurance such as, the Medicare products. They'll get a denial, and then they bill Medicaid as their secondary insurance, which then covers the cost of the shoe.
I will tell you that there are some residents that do not qualify for insurance coverage but this is very infrequent."1 - Karen Kaminski-Ciancio
While the shoes we've discussed in this article aren't specifically marketed as fall-prevention shoes, we do know that any shoes that are stable, comfortable and well-fitting will reduce fall risks because of the balance issues and risks associated with ill-fitting shoes and also with foot pain. Custom-fit shoes are therefore naturally likely to reduce instances of fall events for fall-risk residents if their shoes are individualized to their specific needs and reducing pain in the feet.1
When in doubt regarding options for elderly footwear, consider:
Are they comfortable shoes?
Are they flat shoes?
Do they have adjustable straps?
Are they the correct shoe size?
Do they allow for wide feet or any other atypical foot postures the resident has?
Are they made of breathable material to prevent foot fungal infections?
Does the resident feel stable and balanced?
If the answer to any of these is "no" you may want to assess different senior footwear options based on the individual needs of that individual.
“So, as you know, some of the residents in your facility are not ambulatory. And so oftentimes, they get missed when it comes to shoes. And that's something that we really try to rectify because, you know, we all put shoes on our feet when we leave our homes. And, you know, especially when the resident gets out of bed, they might have cold feet. They might have, a high risk for skin breakdown or, significant medical problems that we would be really concerned about if that resident hit their foot on something while they were being pushed in their chair.
“So, it really is a lovely thing to be able to offer, to give someone back some normalcy that is not ambulatory. […] And what I love is [this program is] not just for people who are walking. It's even for people who are just in the wheelchair, you know, just to protect their feet while they're in the wheelchair. I can't tell you how many people end up with foot injuries because their feet aren't protected getting in and out of a wheelchair."1 - Karen Kaminski-Ciancio
1 - https://us.accora.care/webinars/an-exemplar-a-unique-and-innovative-interdisciplinary-footwear-program
2 - Maden T, Bayramlar K, Maden C, Yakut Y. Investigating the effects of appropriate fitting footwear on functional performance level, balance, and fear of falls in older adults: A comparative-observational study. Geri Nurs 2021;42(2):331-335
3 - Awale, A., Hagedorn, T.J., Dufour, A.B., et al. (2017). Foot function, foot pain, and falls in older adults: the Framingham foot study. Gerontology, 63(4):318–24.
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