Please see explanations under the 2 previous measures – # clients who were screened for falls and # clients who screened positive.  OA/HR works with vulnerable clients with complex care needs.  Many of them face daunting behavioral health challenges, functional impairments, and have inadequate access to caregiving support.  They are doing the best they can to live as safely as possible in their homes and communities, but in order to do so they take a number of risks. PHN works to implement targeted interventions to reduce this risk then support the client with motivational interviewing and harm reduction strategies to support acceptance of interventions and progress toward goals.  In FY 22-23 the percentage of clients who screened positive for falls who received a fall prevention intervention has consistently exceeded our 75% goal. 

Community-based fall prevention partners, DME suppliers (ReCARES), MCPs, mental health providers, home health providers, housing advocates, caregivers, healthcare professionals, and clients themselves.

PHNs must provide individualized assessment and care planning.  Their fall prevention strategies must specifically address each client's particular problem, barriers, and goals.  Furthermore, clients and caregivers and PHNs must prioritize according to the client's hierarchy of needs.  If the fall risk is an immediate safety hazard, then the PHN works to address it right away.  But, if there are more urgent and immediate needs/priorities, the PHN works with the client and caregiver on addressing various goals, only one of which is fall prevention.  A fall risk may be a matter of degree and if the degree is low and other needs are much more urgent, implementing fall prevention occurs as a client is ready and willing.  It is a part of the care plan but may not necessarily be the #1 goal.

In terms of data collection, we have found this to be a somewhat difficult data point.  The total number of clients that we assess for initial or reassessment is relatively low in a 3 month period.  This is because our caseload is necessarily low due to the high intensity and complex care needs of our client population.

FY 22-23:  We will continue to review our data collection plan and efficacy of interventions; then reevaluate at the conclusion of the FY.