At the time of each Comprehensive Assessment (initial and every 6 months), PHN screens for fall risk.  At that time, clients who screened positive should be provided with a fall prevention intervention.  Interventions may include: medication review/reconciliation, physical therapy, home modification, DME, patient education, caregiver training and education, blind services, medical workup to determine treatable etiology.  We have only counted clients here who had an interval reassessment during Q3 (6, 12, 18 etc. month RA).  These clients have been screened and PHN has had time to implement a fall prevention strategy.

Clients, caregivers, healthcare providers (PCPs and PTs), Healthy Homes, Alameda Alliance for Health (DME), medical suppliers, community-based organizations that provide fall prevention training.

Clients enrolled in OA/HR may have overlapping factors that compound fall risk.  PHNs screen all clients for fall risk at initial assessment and 6 month interval reassessment.  However, at any point in the case, PHN intervenes if a fall risk is assessed.  PHNs have to be creative and skilled at identifying specific and combined risk factors.  PHN must customize their fall prevention interventions to address each client's specific need.  Many times this involves only mitigation of risk.  Often high risk clients living in the community are unable to eliminate risk-taking behaviors or risky environments.  Much is out of their control.  We start with a harm reduction approach and implement whatever strategies are possible and acceptable to client.  We have found that our population of vulnerable clients with complex care needs are almost always unable to take advantage of community fall prevention interventions such as classes and clinics.  The interventions that the PHNs offer are much more individualized and occur within a client's home.

Continue through FY 22-23 before evaluating progress and merit of this measure and success in improving fall risk.