Falls Prevention at Home: The Daily Support Role

The clinical heart of falls prevention lies with physiotherapy, as does the assessment, the strength and balance prescription, the mobility aid, the referrals, and every physiotherapist working with older people and neurological conditions is familiar with the gap between the clinical heart and the outcome.

Falls do not occur in clinics. They occur during the usual household hours, without anyone else being present, at the third step with the washing basket, at the bedside in the dark, at the appointed hour of the clinical program, and only through what happens during those moments. Staff are there in the moments, so the support worker is the most underutilized tool in the falls prevention toolkit: there in the moments, having the routines the program relies on, able to see the environment and the decline that quarterly reviews can't.

The four daily-support contributions

Holding the program. The strength and balance work that actually prevents falls is a dosage intervention; the delivery of the intervention is the supported program, the one page sheet, the completion reports; the first article of this series addresses that. The adherence question is the outcome question in falls prevention, and the worker is the adherence technology.

Managing the moments. The physio evaluates this person's risk moments, the night route, the shower, the stairs, the external step, and the worker's brief translates into practice: being present at the identified moments, the lighting being on before the walking has started, the aid being at the bedside, not across the room, the stairs being clearly marked when walking up and down, the external step being managed during the walking. It is not about spying on someone, in this instance it is about choreography in a house, and when the brief is written respectfully, it is a difference that participants feel.

Maintaining integrity in the environment. Home hazards come back: the mat rolls back in, the cord moves, the clutter goes back on, the new pair of slippers is more of a hassle. The worker is given the physio's list of environmental points to check and the report goes along with him/her.

Reporting the drift. The majority of the falls have warning signs in the weeks leading up to them: furniture touching, slower stands, new hesitation at thresholds, near-misses that are not recorded. The worker's watch-list is part of this library's standard genre, it's a set of three to four observables that activate a review trigger whenever they appear as precursors, and a physio who reads "steadying on furniture this week, two near-misses at the back step" has been given the window of opportunity for intervention that the fall, itself, would alert.

The brief, and the balance it must strike

The tension this puts in the falls brief is one that the physio must work out deliberately: over protection is a falls risk, doing for is a deconditioning, hovering is a lack of confidence, and the world shrinks until deconditioning completes the job. The shorthand of this library's language of grading says both sides: the worker helps, and the person does it, because it is the help that is the intervention, and the line that governs everything: we're not stopping him from moving, we're protecting his activity. It works where it is written, but not where it is only implied, which is the whole argument for writing it.

How this plays out in practice

Imagine that woman was given a physio program, a new four wheel walker and she was now being supported every morning, five days a week, something that had never been offered to her before. The briefed version collates this article, it finishes the programme four mornings in five, it choreographs the bathroom route and it stages the light and the aid at night, while the watch-list runs live. In May the worker's report mentions furniture touching, and a decreased and slower stand; the physio reviews during the week, adjusts the program, checks the aid height and flags the GP for the medication review which discovers the cause. No one component does it; the winter passes without a fall. The system did, and all the components went through the person there at 6:40am.

Next steps

When your next patient is a fall-risk patient on support, jot down the four-part "brief" on the program page, the "risk moments", the "environmental checklist", and the "watch-list", including the protection-versus-prevention line. One page, and the toolkit's missing instrument is playing.