NFPA Journal

In November 2019, about four months before COVID sent most of the United States into lockdown, a diverse group of professionals gathered in a conference room at NFPA headquarters outside of Boston to discuss a different kind of health emergency: the growing threat of fire and accidental falls among adults 65 and older.

Almost all of those seated around the conference table—including firefighters, elder care providers, occupational therapists, researchers, and public safety educators—were veterans of NFPA’s Remembering When™ initiative, an educational program aimed at helping older adults reduce their risk of experiencing a fire or fall. Collectively, the assembled educators had spent thousands of hours delivering the program’s safety messages, presenting to senior groups, handing out materials, and visiting residences to check for things like working smoke alarms and to point out and correct dangerous tripping hazards.

And yet, by nearly every metric, both falls and fires among seniors are worse now than they were a decade ago.

“I am happy to share my statistics, but I don’t think it’s going to tell the story you are hoping for,” said Dori Krahn, of the Saskatoon Fire Department in Saskatchewan, Canada, one of the Remembering When users I contacted to get a sense of whether the program has helped reduce falls. “What we’ve found in our community is that falls just keep going up, usually by about 150 per year.”

RELATED: NFPA’s new Steps to Safety program addresses the role of prescription meds in falls and fires

That seems to be the case in nearly every municipality that tracks such statistics. Another commonality is that local fire and EMS departments, which comprise the bulk of Remembering When’s educators, are feeling the strain. According to the National Fire Incident Reporting System (NFIRS) and NFPA survey data, “lift assist” or “invalid assist” calls increased 35 percent from 2014 to 2017. Lift-assist calls now outnumber structure fire calls by a good margin at both rural and urban departments. 

When Ashby Anderson, a sergeant at the Louisville Fire Department’s fire prevention and fire education bureau, ran her department’s stats, even she seemed surprised to learn that 10 percent of all the department’s runs last year were to aid people who had fallen. “And we aren’t even the first department called in these incidents,” she said. “Louisville Metro EMS is dispatched first, and they will only call us if they need assistance because a person is wedged, or too heavy to lift, or they need some special tools. So, our data only gives you just a tiny piece of the problem. It’s very big.”

In Farmington Hills, Michigan, a town of just over 10,000 people, the local fire department responded to 428 falls in 2021, up 22 percent from the previous year, according to prevention officer Stanley Barnes. In Saskatoon, a city of a quarter million, the fire department lifted 1,285 people in 2021, a nearly 12 percent jump over 2020 and more than double the number of lifts the department handled in 2013. Nearly 50 residents in Saskatoon called the department at least five times for lift assists last year, and some frequent fallers called the department nearly 20 times, Krahn told me.

While the rise in fires has been less dramatic than that of falls, the problem is no less concerning to safety professionals. Forty years ago, people 65 and older made up 18 percent of the total fire deaths in the US; by 2018, that age group comprised 36 percent of all fire deaths, according to NFPA statistics. All told, older adults are now twice as likely as the general population to experience a fatal fire.

With those daunting numbers as a backdrop, Krahn, Anderson, and about 20 others at the 2019 workshop set to work brainstorming strategies to reverse the trends. They agreed that a significant shakeup and expansion of the Remembering When program was needed. “We knew that reach and scale needed to be first and foremost in the new strategy,” said Andrea Vastis, the director of public education at NFPA. “About 10,000 people turn 65 every day in the United States—we needed a way to get this program into the hands of a lot more people.”

After months of work, and with the help of a $500,000 Assistance to Firefighters Grant from FEMA, the group settled on a more modern approach with new digital assets, a new online training module, and a new name—Steps to Safety™: Prevent Fire and Falls at Home. The reimagined program, set to launch this summer, will continue to utilize the group presentations and home visits that characterized Remembering When, while bolstering the effort with a much more robust digital presence to reach the target audience—“more images, more social media offerings, more videos, more things that reflect their community and how people consume information,” Vastis said. Steps to Safety will still use its predecessor’s core messages on falls and fires, and it will add an important new focus on the potential impact of prescription drugs on falls and fires (see “Medication Focus”).  

The changes are designed to more effectively reach a demographic that is growing while also undergoing rapid change, Vastis said. “The older adult of today is not like the older adult of 20 years ago, and the older adult 20 years from now will have a very different experience as well,” she added, speaking to me over a computer screen. “The person who’s 50 years old right now probably lives on their phone, which is why we need to digitize our assets and the way we deliver the messages. That’s the way we need to reach tomorrow’s older adult.”

Scaling up

The first version of Remembering When was launched in 1999, and the program was revised into its current form in 2013. However, despite best efforts, death rates from falls among seniors in the United States have increased by about 30 percent since 2009, according to the US Centers for Disease Control (CDC). More than 3 million older adults are now treated annually in US emergency rooms from accidental falls, the CDC says, resulting in about $50 billion in inpatient and outpatient hospital costs. The total number of falls among older adults, most of which are not captured by hospital or fire data, is closer to 36 million per year, resulting in 8 million injuries; by 2030, there will be a staggering 52 million falls each year, the CDC predicts.

One of the explanations for these developments is that the population of older adults in the US has surged in recent decades, a trend that is expected to accelerate. Since 2009, the number of people age 65 and over has risen 36 percent, to 54 million people, far outpacing the 3 percent population gain of all other age groups over that span, according to US Census data. By 2040, there are expected to be nearly 81 million older adults, and they will make up more than 21 percent of the population, compared to about 16 percent today. Similar trends are also happening in Canada.



Cultural factors are also contributing to the fall problem, experts say. “People all across North America are staying in their homes longer—they aren’t moving to assisted living until they are well into their 80s, whereas 20 years ago that was happening in their 70s,” Krahn told me. “There is this cultural mindset shift to independence and it’s a good thing—but the unintended consequences include more falls and more lifts.”

More older adults are also living alone. According to a 2019 report by the Harvard Joint Center for Housing Studies, 42 percent of households headed by someone 65 or older contained only one person, and 57 percent of households headed by someone 80 or older had only one person. If the trend continues, by 2038 there will be more than 10 million single-person households in the US with someone 80 or older.

These large-scale demographic trends have been emerging for a while and have the attention of the public safety community. Even before the pandemic sent much of the world into isolation, there was consensus among educators that Remembering When needed to be more dynamic and more digital. For more than a decade, the program’s content and approach had changed little. At its core are two key activities: an in-person presentation to a group of seniors centered around fall and fire prevention messages, and a home visit where an educator walks through asking questions and pointing out changes that would help reduce the resident’s risk of a fall or fire.

While those efforts have helped countless seniors avoid injury in communities across the US and Canada, they are time consuming and not particularly scalable, especially considering the size of the problem. To make matters worse, Vastis said, “both approaches are very much pre-COVID constructs,” and further, they are out of step with the digital direction that the world, including many seniors, is moving.

To better align Steps to Safety with how people live and communicate, a library of digital resources is being created to supplement traditional outreach methods, which will allow fire departments and others to continuously push out messages to seniors through online platforms and social media. In lieu of attending a group presentation, which has been impossible during COVID, older adults can watch them at home and on their phones. A portion of the new videos will feature seniors talking directly to their peers about their own struggles with falls and how they were able to make simple changes around their homes that made a difference. The idea is to help seniors overcome the stigma and embarrassment many feel about admitting they are aging and that they may need more help—a significant hurdle to making safety changes, public educators told me.

“So many people will just say, ‘I’m not that old—this is not happening to me,’” Krahn said. “And when they do fall, they are too embarrassed to talk about it. They think, ‘well, that’s not going to happen again.’ When it does happen again, they rationalize it by telling themselves ‘that wasn’t really a fall, I just slipped getting out of bed.’ People are really good at redefining things to fit their mindset.”

Better and more efficient ways to reach seniors, however, is just one part of the plan to improve the reach of Steps to Safety. The other is to vastly increase the number of people trained in delivering its safety messaging. The number of educators implementing Remembering When was always relatively small, especially considering the millions of vulnerable seniors out there. Between 2013 and 2017, NFPA trained a total of about 400 people on how to administer the program and conduct “train the trainer” events in their communities; all of those training sessions were in-person events.





Members of the Saskatoon Fire Department in Saskatchewan, Canada, lifted nearly 1,300 fallen residents in 2021. After a lift, firefighters take patient’s vitals and offer them educational materials. The department also gives group presentations to seniors about fall and fire prevention as part of its Remembering When program. Courtesy of the Saskatoon Fire Department

The Steps to Safety training, which will be rolled out in the next few months, takes a different, more scalable approach. NFPA is using about $200,000 of the FEMA grant money to build a series of free online training modules that will educate users on Steps to Safety’s core fire and fall messaging. One module will even simulate three separate home visits, allowing attendees to interact with a virtual resident, spot potential hazards, and make decisions on how to proceed. The training will also help participants create an action plan for how to best administer the program in their community and incorporate it into a Community Risk Reduction plan.

As with the videos targeting seniors, the aim of the new digitized training approach is to attract a much wider audience of fire departments and other organizations, especially those that had not previously offered fall and fire prevention programs for seniors. “In Kentucky, 76 percent of our fire service is volunteer and most of those departments don’t have the funding or the personnel to do a lot of these in-person trainings,” said Anderson, of the Louisville Fire Department. “To be able to make this training accessible to everyone is going to be a game changer. It will get more fire departments familiar with the program and get more of these safety messages into their communities.”

Eventually, the online training portal and its ancillary features will also help communities collect and share the data from their outreach efforts, which could help yield better insights about what’s working and what isn’t. Information like that would be vital, safety advocates say, not only for departments but also for NFPA as it strives to keep Steps to Safety materials responsive to the shifting needs of fire departments and seniors in the community.

“We have departments that are doing a great job of collecting the data and documenting their results, and what we’d really like to do is help them do a better job of it,” Vastis said. “If we could collect that data on a large scale and analyze it, that will help inform the next iterations of the program and enable us to continue to push out updates to the departments.”

Beyond the stats

While no one is under illusions that Steps to Safety will solve what has proven to be a massive societal problem, educators understand that prevention programs will play a vital role as the population ages and seniors increasingly spend their later years alone in their homes. If they could prevent even a fraction of the falls and fires that are expected in decades to come, many thousands of lives could be saved. On top of that, emergency agencies may be saved from being crushed under the weight of demand.

Despite current trends, none of the educators I spoke with felt discouraged and they certainly don’t shy away from the challenge. Every day they see firsthand the impact of the work.

In Saskatoon, where the fire department lifts an average of more than three people a day, Krahn told me that statistics don’t begin to tell the whole story. She rattled off story after story about frequent elderly fallers who ceased calling for lift-assists as soon as firefighters flipped a mattress, or added handrails to a bathtub, or changed some detail like a loose rug or wayward cord. She spoke about her monthly meetings with the local health authority officials, and brainstorming sessions with doctors and partner organizations—efforts that have helped individual seniors go from falling almost weekly, to living happy and healthy lives.

The story is the same in Louisville. Anderson said that her fire department’s fire prevention bureau began delivering meals twice weekly to seniors after the local Meals on Wheels program lost nearly all its volunteers due to COVID. Even though the pandemic cancelled all of Louisville’s Remembering When group presentations, these frequent visits to deliver meals helped fire prevention officials build relationships and trust with the city’s most vulnerable seniors. This not only allowed officials to keep better tabs on the residents’ needs,  but it also put them in a better position to help residents make substantive changes in their homes to improve safety.

One can only imagine how many more lift-assist calls and serious injuries from falls would have happened in Louisville and Saskatoon if it weren’t for these efforts.

Other positives from the program were more unexpected and even harder to quantify, Krahn told me. Perhaps most interestingly, even as lift calls continue to rise, morale at the Saskatoon Fire Department has improved dramatically since it started its Remembering When efforts in 2017, she said. The program offered the weary responders hope.

“Firefighters now regularly come up to me at the station to thank me and tell me they are going on fewer lift-assist calls—even though they’re not, I never tell them differently,” Krahn told me with a bemused smile. “Before we started this program, the firefighters would be so frustrated by the fact that they were lifting somebody over and over again and there was nothing they could do about it. Now, there is a mechanism in place to improve these residents’ lives. Firefighters are good people who are motivated by helping others. They just need the tools to do it.”