The EHSCP Community Falls Prevention and Management Pathways have been developed for use by a wide range of health and care professionals across the system. The Pathways have beendesigned to support early identification and the management of individuals at risk of harm from falls. Using a consistent and structured approach to categorising risk enables equitable access to effective, person-centred support and care.
The guidance is divided into three sections:
1. Framework and Toolkit: This uses a model of risk stratification for falls based on a population health approach, which can be used by a variety of health and care professionals. This tool enables people to be identified and categorised by risk of harm. Following this screening, people are categorised into falls risk levels:
- Level 0 – very low risk
- Level 1 – low risk
- Level 2 – moderate risk
- Level 3 – high risk
Please see under the Referral Management section for how Clinical Frailty Scoring (CFS) can be used for falls risk stratification.
2. Falls Care Bundles: Once an individual’s level of risk has been identified they can be referred to the appropriate Falls Care Bundle/s which ensure that people receive a consistent level of support. In this section information on various resources and interventions are grouped under the different levels of Falls Risk. They include links to information on Health and Wellbeing, Physical Activity and Exercise and Environmental supports
3. Knowledge and Skills Framework: Provides an outline of the knowledge, skills, and learning required by teams and individuals to deliver the pathway consistently.
KOR & JB – 23-7-26
GPs can use Clinical Frailty (CFS) based stratification to determine a person’s risk of falling and experiencing harm due to a fall and easily identify what information to sign-post patients to and routes of referral.
Referral advice based on CFS / Falls Risk
CFS 0-1 (Level 0: Very Low Risk)
- Sign post patient to I Live in Edinburgh – Falls Support – see section “Care Pathway for Falls Level 0 (Very Low Risk) Signposting to Public Health Information”
CFS 2-5 (Level 1 & 2: Low – Moderate Risk of Avoidable Harm)
- Referral to Edinburgh Leasure “LEVEL 2 – Balanced Life” using their online Active Communities Balanced Life Referral Form. Please ensure that the patient has consented to the referral and being contacted by Edinburgh Leasure, who will contact patients directly regarding their referral.
- Sign post patient to I Live in Edinburgh – Falls Support – see section “Care Pathway for Level 1 (Low Risk of Avoidable Harm) – Falls Care Bundle 1” and/or section “Care Pathway for Level 2 (Moderate of Avoidable Harm) – Falls Care Bundle 2”
CFS 6+ (Level 3: High Immediate Risk of Harm)
- Refer the patient for a Multifactorial Falls Assessment (MFA), to Edinburgh Hub Services by calling Social Care Direct on the clinician-only falls telephone numbers 0131 200 2338 / 4262.
- (Practitioners outwith the GP setting who have access to TRAK can Request for Service for Edinburgh Falls Assessment and Rehabilitation Referrals, via TRAK using a Request for Service)
Information re other services outwith The Community Falls Prevention and Management pathway
Assistance to Get Up Off the Floor
For patients who are uninjured but stuck on the floor, then on this page you can find the Edinburgh Fallen Uninjured Person Pathway. This service is provided by the Assistive Technology Enabled Care (ATEC 24) monitoring and response team on behalf of the Edinburgh Health and Social Care Partnership.
Risk of Admission
If the patient is at imminent risk of hospital admission due to falls within the next 4 hours follow the Urgent Therapy and Social Care pathway by checking the referral criteria. Call the Flow Centre 8:30am to 2pm on 0300 013 4000 option 1 and 4, or Social Care Direct on 0131 200 2324 outwith these times
Care Home Residents
The Community Falls Prevention and Management pathway is not applicable in Care Homes. If you are working with a care home resident who has had recent falls, worsening or increasing falls, or is at risk of falls, referrals to services that can support the resident with a range of falls risk factors can be made by the care home, the GP, or a range of professionals. to the services here: https://services.nhslothian.scot/CareHomes/Pages/default.asp
MOE Assessment/Day Hospital For patients who would benefit from combined medical, nursing and rehabilitation assessments to reduce their falls risk this can be arranged through referral MOE. In some areas this is to Day Hospital, in other areas this is to MOE for triage as to most appropriate input. See guidance under the relevant MOE services.
Information for patients is available here: I Live in Edinburgh – Falls Support
Knowledge and Skills Framework – Community Falls Prevention and Management Pathways
The EHSCP Falls Prevention Knowledge and Skills Framework provides an outline of the knowledge, skills, and learning required by teams and individuals to deliver the pathway consistently. It is structured across three cumulative levels, with each level building on the learning from the previous one. As learners progress, they are encouraged to continue using earlier resources to deepen their understanding.
