Stage Two: Identifying individuals at risk of falls and/or fragility fractures
Description (adapted from Up and About)
At this stage:
- A person at risk of falls and fragility fractures is identified and this triggers appropriate intervention, or referral for appropriate intervention.
- A person is identified either (a) when they report a fall, or present with a fall or an injury or functional decline due to a fall, or (b) opportunistically when someone providing care or support asks about falls.
- There is potential for third sector organisations to support this process as they may be in regular contact with a person at risk who is not know to the statutory services.
- Opportunistic case identification links with both anticipatory care and the 'shared assessment' process.
- A level 1 'conversation' aims to identify a person at risk of falling; it is not intended to determine all contributory factors or specific interventions required.
Level 1 Conversation
A simple initial risk identification process which aims to identify people who have fallen/are at risk of falling and may benefit from further assessment and intervention. See Appendix 2 'The falls and fracture assessment continuum' for further information.
Level 2 Screen
A multifactorial falls risk screening process which aims to (a) identify risk factors for falling and for sustaining a fragility fracture, and (b) guide tailored intervention.
See Appendix 2 'The falls and fracture assessment continuum' for further information.
The focus for the minimum standard is ensuring any older person who reports a fall, or an injury, loss of function or increased care needs due to a fall, has the opportunity to access further assessment and support if it is necessary. Older adults who fall once are two to three times more likely to fall again within a year7.
Structuring and standardising the initial risk identification basic process may help improve service provider's implementation of guideline recommendations. The use of a limited number of simple questions, requiring a yes/no answer, may also simplify documentation. Any positive answer to the questions (Have you had two or more falls in the past year? Did you have a blackout or find yourself on the floor for no apparent reason? Have you experienced any difficulties carrying out your usual activities since you fell? Do you ever lose your balance or feel unsteady on your feet?) suggests the person screened is in a high-risk group that warrants further evaluation6.
In care homes for older people, the recommended practice is for care home staff to carry out a level 2 screen routinely on all residents8. In this case, a level 1 conversation is duplication and therefore not required.
For the evidence base for actions, see references seven and nine.
Actions to achieve the minimum standard for 2014/16
Health and social care services have a level 1 conversation with an older person who reports a fall or an injury or functional decline caused by a fall.
- Initial risk identification i.e. a level 1 conversation aims to identify individuals who have fallen/are at risk of falling and may benefit from intervention to prevent further falls and restore/retain function following a fall.
- A level 1 conversation is a simple process, which can be facilitated by the use of a tool or an algorithm. To meet the minimum standard, a level 1 conversation identifies people who have experienced:
- two or more falls in the previous 12 months.
- loss of consciousness/blackouts/dizziness at the time of the fall/s or an unexplained fall (found themselves on the floor for no apparent reason).
- difficulties with walking or balance.
- a change in their ability or confidence to carry out their usual day to day activities following the fall/s.
- A level 1 tool or algorithm (Figure 2) links the responses to falls questions to clear guidance for the 'screener' on what steps to take next.
Everyone identified at risk of further falls through a level 1 conversation is offered intervention to identify and address possible contributory factors, i.e. at least a level 2 screen.
- As part of the conversation, the 'screener' explains to the individual the reason why the intervention is indicated, what this will involve, such as a home visit or clinic attendance, and ensures consent has been given to share information and refer for further assessment.
- There are local referral pathways to services providing level 2 screen, and agreed referral protocols.
- For people not referred for further intervention, and those who decline further intervention, up-to-date information is offered on the prevention of falls and the prevention of harm from falls (as described in Action 1.1). People declining further intervention are offered details of the appropriate service to contact should they decide at a later date they would like to receive support.
Figure 2: Example of level 1 conversation pro forma
As a level 1 conversation is a relatively simple process, many services and organisations, including third sector organisations have the potential to contribute. Although falls prevention should be 'everybody's business', this creates potential for duplication and confusion. It is essential all stakeholders work in partnership to deliver a joined up, co-ordinated and integrated pathway.
The Framework in action
A level 1 conversation tool is being used by a range of services in Grampian including Emergency Departments, community alarm services, sheltered housing, day care and the Scottish Ambulance Service. Use of the tool has dramatically increased the number of people being asked about falls and improved the access to a level 2 screen - via an acknowledged pathway - and on to evidence-based services.
The tool includes six questions:
- Have you fallen recently?
- Can you remember how many falls you have had in the past year?
- Did you break any bones when you fell?
- Did you have a blackout or find yourself on the floor for no apparent reason?
- Are you able to do everything that you have done previously?
- Do you ever lose your balance or feel unsteady on your feet?
Further assessment is offered to people with two or more falls in the last year and a positive response to any of the questions.
The Integrated Community Support Team (ICST) in East Kilbride and the Community Alarm Social Work Service in North Lanarkshire are currently testing a level 1 conversation tool.
The tool asks six questions:
- Have you fallen more than once in the last six months?
- Do you have unsteadiness on your feet or have difficulties with your walking and balance (or has the screener observed any unsteadiness)?
- Did you experience a blackout or any dizziness when you fell?
- Have you experienced any difficulties carrying out your usual activities since you fell?
- Are you worried about falling again?
- Were you able to get up from the floor after you fell?
People identified as 'at risk' i.e. a positive response to any of the six questions, are asked for their consent to be placed on a falls register, which aims to improve co‑ordination of care. A leaflet is provided giving them information about the register and support services available in Lanarkshire. level 2 screening is delivered by the person who initiated the level 1 conversation if it is within their scope to do so. Alternatively, the referral is forwarded to the falls register team who arrange the relevant service (including District Nursing, Occupational Therapy, the Community and Assessment and Rehabilitation Service, the ICST or social work) to carry out level 2 screening.
Forth Valley is also developing a falls register for health and social care to help with pathway co-ordination and avoid duplication of level 1 conversations and level 2 screens.
More information and contact details for the examples provided can be found on the Falls and Bone Health Community at: http://www.knowledge.scot.nhs.uk/fallsandbonehealth/the-national-falls-programme.aspx
Clinical practice guideline: Prevention of Falls in Older Persons. Produced by the American Geriatrics Society, British Geriatrics Society in 2010. Access at:
Clinical Guideline 161. Falls: The assessment and prevention of falls in older people. Produced by the National Institute for Health and Care Excellence in 2013. Access at: http://www.nice.org.uk/CG161
Managing Falls and Fractures in Care Homes for Older People. Produced by the Care Inspectorate and NHSScotland in 2011. Access at:
Email: Susan Malcolm