The Missing Link in Falls Prevention: What Iowa and Oklahoma's Rural Pilots Got Right

Every occupational therapist I know can run a STEADI screen without thinking twice. Screen for fall risk. Assess gait and balance. Review medications. Flag home hazards. It is second nature by the time you have been in practice a few years.

But here is the question I ask in every CAPS class, and it is the one that actually matters: after you screen someone and flag them as high risk, where do they go next? Who picks up the thread your clinical visit started? What happens in the six months between that appointment and the fall you were trying to prevent?

In a lot of communities, especially rural ones, the honest answer is nowhere. Nobody built that bridge. That is the exact gap ASTHO, the Association of State and Territorial Health Officials, just spent three years working on with CDC, and their new report on rural falls prevention, published July 1, 2026, is worth the attention of every OT and community partner doing this work.

Rural Falls Are Not Just a Smaller Version of Urban Falls

Falls among adults 65 and older are already the leading cause of fatal and nonfatal injury in this country, and as the older adult population grows, that number is projected to climb. Rural older adults carry a heavier share of that burden. CDC data cited in ASTHO's report shows older adults living in rural areas report 25% more falls than their urban counterparts, and the reasons are structural, not incidental: greater distance to care, fewer public transportation options, and far fewer health promotion programs within reach.

That gap does not close with more screening alone. STEADI, CDC's Stopping Elderly Accidents, Deaths, and Injuries initiative, gives clinicians a coordinated way to screen for fall risk, assess modifiable factors, and intervene. It is a genuinely good clinical tool. But a screening result is only as useful as what happens after it, and in a rural community with no formal falls prevention coalition, no community care hub, and no clear referral pathway to a Tai Chi or Matter of Balance class, a high-risk flag can become a dead end.

What ASTHO's Report Actually Recommends

Since 2023, ASTHO has partnered with CDC to help states build exactly the connective tissue that closes that gap, what the report calls community-clinical linkages. The framework it lays out is straightforward: assess your current falls prevention landscape, identify where clinical and community efforts could actually connect, and build a plan to sustain that connection over time, not just launch it once and hope it holds.

Two states, Iowa and Oklahoma, spent a multi-year pilot learning community putting that framework into practice, and the specifics of what they built are the most useful part of this report.

Iowa Built the Connective Tissue Itself

Iowa's approach centers on the Iowa Community HUB, a community care hub that links a network of community-based organizations to the health care system through shared infrastructure. Instead of leaving referral to chance or a business card handed across an exam table, Iowa embedded STEADI workflows directly into partner clinics, including electronic referral orders built into the EHR that route a flagged patient straight to the HUB.

They trained a substantial number of clinicians on STEADI principles, expanded the Iowa Falls Prevention Coalition into a broader network of regional coalitions, and partnered with the University of Iowa Injury Prevention Research Center for real evaluation, using structured interviews and the Consolidated Framework for Implementation Research rather than guesswork. They even built a Best Practice Advisory system inside the EHR itself, so a fall risk reminder surfaces automatically for the clinician instead of depending on memory.

That is the whole point. The clinical tool and the community resource stopped being two separate systems a patient had to navigate alone.

Oklahoma Scaled It Through Practice Facilitation

Oklahoma took a different route to a similar destination. They partnered with the Oklahoma Health Care Authority, the state's Medicaid agency, and contracted practice facilitators whose job was to help primary care practices actually integrate STEADI into daily workflow, not just hear about it in a training.

The reach is worth sitting with: more than 288 providers touched by the effort, 146 of them educated specifically on STEADI, 126 actively screening patients for fall risk, 124 intervening on identified risk factors, 82 confirmed following up with those patients, and 69 who fully integrated STEADI into their practice workflow. That is a real adoption curve, not a one-time training that faded by the next quarter.

Oklahoma paired that clinical push with community-side expansion, training instructors in evidence-based programs and partnering with county health departments to bring Tai Chi and Matter of Balance classes into libraries, faith communities, and senior centers.

What This Means If You're the One Doing the Screening

If you are an OT, a community health worker, or anyone doing falls prevention work in a rural or underserved area, the lesson from both states is not "do more screening." It is "know what happens after the screening," and build that pathway deliberately instead of assuming it exists.

A few things worth taking directly from ASTHO's own recommendations: ask whether your area has anything resembling a community care hub or falls prevention coalition, and if it does not, consider who the natural convener would be. Learn the falls prevention billing codes that exist so screening is not unpaid extra work squeezed into an already full visit. If you have any influence over how community health worker roles are used in your organization, know that CHWs are one of the most effective bridges between a clinical flag and a home or community-based response, especially for environmental screenings a busy clinic visit cannot fully cover.

That last point is where my own work overlaps most directly with this report. STEADI and community exercise programs address the body: balance, strength, medication risk, confidence. They do not address the home itself, the loose stair tread, the tub with no grab bar, the doorway too narrow for a walker. Someone still has to walk through that house. In a rural area without a HUB like Iowa's, an OT or a CAPS-trained professional who understands both the clinical picture and the home environment is often the only person positioned to see the whole risk, not just half of it.

This is exactly the kind of practical, cross-disciplinary fluency CAPS certification training is built to give occupational therapists and the professionals who work alongside them: the ability to walk into a home, understand what a STEADI-flagged client actually needs environmentally, and know how to act on it instead of stopping at the referral. If your practice or your community is working through what a falls prevention pathway should look like where you are, I would be glad to talk it through.

And for the piece of this that lives inside the home itself, our earlier look at what the research says about home modifications and fall prevention is worth reading alongside this report.

Ready to earn your CAPS certification?  Fritzi Gros-Daillon — NAHB Master Instructor and 2019 Educator of the Year - teaches every course personally. Classes run live on Zoom, with May sessions now open for registration.

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