Algorithm for Fall Risk Assessment & Interventions
Patient completes Stay Independent brochure
Screen for falls and/or fall risk
Patient answers YES to any key question:
NO to
all key
questions
Evaluate gait, strength & balance
Timed Up & Go (recommended)
30 Second Chair Stand (optional)
4 Stage Balance Test (optional)
No gait,
strength
or balance
problems*
Gait, strength or balance problem
2 falls
1 fall
Injury
No injury
HIGH RISK
Individualized fall
interventions
Educate patient
Vitamin D +/- calcium
Refer to PT to enhance
functional mobility & improve
strength & balance
Manage & monitor
hypotension
Modify medications
Address foot problems
Optimize vision
Optimize home safety
Follow up with HIGH RISK
patient within 30 days
R
eview care plan
A
ssess & encourage fall risk
reduction behaviors
D
iscuss & address barriers
to adherence
Transition to maintenance
exercise program when
patient is ready
*For these patients, consider additional risk assessment (e.g., medication review, cognitive screen, syncope)
Centers for Disease
Control and Prevention
National Center for Injury
Prevention and Control
High Risk
Conduct multifactorial
risk assessment
Review Stay Independent
brochure
Falls history
Physical exam including:
- Postural dizziness/
postural hypotension
- Medication review
- Cognitive screen
- Feet & footwear
- Use of mobility aids
- Visual acuity check
0 falls
MODERATE RISK
Individualized fall
interventions
Educate patient
Review & modify medications
Vitamin D +/- calcium
Refer to PT to improve gait,
strength & balance
or
refer to a community fall
prevention program
Moderate Risk
YES to any key question
LOW RISK
Individualized fall
interventions
E
ducate patient
V
itamin D +/- calcium
R
efer for strength & balance
exercise (community exercise
or fall prevention program)
Low Risk
Fell in past year? If YES ask,
- How many times? and,
- Were you injured?
Feels unsteady when standing or walking?
Worries about falling?