A falls early response service in Aotearoa New Zealand: a scoping review

In Aotearoa New Zealand, the ageing population is experiencing increasing health needs, leading to a rise in urgent and emergency care demands. Many individuals, especially older adults, call emergency services when they have fallen, which can strain ambulance resources.¹ Data from Hato Hone St John (HHSJ) suggests many callouts and presentations to hospitals are related to falls, imposing substantial economic and personal costs.² Research from other countries, including Australia, highlights the potential benefits of a falls early response service (FERS), especially for vulnerable populations.^3–6

In addition to an ambulance response, occupational therapists (OTs) also help with the community management of falls. They work across both physical and mental healthcare settings and are well placed to meet health and social care demands. OTs visit older adults at home to conduct cognitive, physical and occupational performance assessments. They recommend modifications and equipment to enhance safety, aiming to reduce falls and support independent living for as long as possible.⁷ An OT service could complement that of the paramedic, which assesses and treats people ascertaining their clinical condition and potential risk for deterioration, before making an informed decision about the best outcome for the person who has fallen.⁸ Paramedics complete advanced patient assessments⁹ and look for both intrinsic, extrinsic and situational causes of a fall.¹⁰ The aim of their assessment is to rule out sinister causes, and assess a person for further risk of falls, before determining if transport to hospital or referral to community health services is required.¹¹

It is proposed the integration of OTs into a FERS with paramedics could improve access to timely interventions and prevent hospital admissions. This joint response could benefit healthcare services and the person who has fallen. A further aim of a FERS is to reduce ambulance responses for low acuity calls to falls, emergency department attendance by those who have fallen and, ultimately, unnecessary hospital admissions.^1,12–16 A report produced in 2015 by The Royal College of Occupational Therapists (RCOT) suggested significant cost savings and reduced hospital bed occupancy for people who had fallen in the community when using collaborative OT and paramedic interventions.¹⁷

Despite the evident need and potential benefits, there is a lack of understanding about what a combined OT and paramedic FERS could achieve. This scoping review examined the evidence and effectiveness of a combined OT and paramedic FERS for adults living at home in the community. The review specifically focussed on:

• What services currently exist that combine both occupational therapy and paramedicine in a call-out response service?
• Does a FERS combining occupational therapy and paramedicine benefit the person and/or health outcomes?

It is hoped that this review may inform future research and healthcare pathways in Aotearoa New Zealand and help address falls-related experiences in the ageing population.

Methods

A systematic literature review was conducted using the Joanna Briggs Institute (JBI) Framework for scoping reviews. The search explored the extent and type of evidence available on a joint service between OT and paramedics responding to falls in the community. The inclusion criteria were expanded to include paramedic services combined with other professionals to discover what practices were being undertaken internationally. The search strategy reviewed Medline, CINAHL and Scopus databases. These databases were searched for English articles using the predetermined key terms such as (fall* OR slip* OR trip*) AND (“occupational therap*” OR “emergency medical technician” OR paramed* OR ambulance or pre-hospital OR prehospital OR EMS OR “emergency medical services” OR paramedic OR “medical service” OR EMT).

The date range was kept broad due to the relative novelty of this topic. A copy of the detailed search protocol is available on request from the authors. The primary outcomes investigated were reduced acute secondary healthcare utilisation, decreased extensive individual healthcare funding and improved longevity of living in place.

Results

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram in Figure 1 shows the process of literature searching and the inclusion and exclusion of sources for further appraisal. A total of 128 sources were assessed for eligibility after their full-text articles were retrieved. Of the 119 reports excluded, 29 were focussed on the wrong or a single discipline, 35 were purely fall prevention or intervention focussed and 55 were not relevant to the topic.

View Figure 1, Table 1.

There were notable challenges in identifying evidence that related to only occupational therapy and paramedicine. As such, criteria were broadened slightly to incorporate any literature that included the ambulance service, or transportation to emergency departments for elderly fallers, and any combination with other health professionals. In total, 14 sources were included for review, consisting of both qualitative and quantitative studies. The number of participants in the studies ranged from 23 to 35,000. Two studies included people aged over 60 years, two studies included people aged 65 years and above and the other five studies reported on people of all ages who had fallen. Because of the variance in the objectives, design and results of the selected sources, strong conclusions cannot be drawn through this scoping review.

Signposts suggesting the presence of grey literature were evident in many references in the articles. For example, the National Health Service (NHS) review suggested that integrating fall prevention practitioners with ambulance services could either prevent the need for hospital-based assessments or speed up the process.¹⁹ Grey literature was subsequently pursued to investigate this evidence. Table 1 below provides a synopsis of each of the sources included for review. The randomised control trial protocol by Mikolaizak et al.²⁰ has been excluded from the table, as has one of the RCOT²¹ pieces, as it is incomplete in its publication.

The articles that clearly combined occupational therapy and paramedicine were produced by Van Dam et al.,²² Charlton et al.²³ and Dean et al.¹⁹The selected articles offering the most valuable information allowed us to consider if occupational therapy is the best profession to enter this kind of service. Furthermore, most of the included articles offered services in different formats, e.g., post-ambulance assessment referral and joint visitation, or there were differences in the types of intervention provided. There is a paucity of Aotearoa New Zealand-focussed research investigating alternative approaches to reducing transportation to hospital for people who fall and do not have a clinical indication for review in the emergency department. Although there were fragments in each piece of evidence that would lend itself to aspects of our query, few sources had a singular focus on an occupational therapy and paramedicine combination. This is why we extended our reach to include the reports produced by the RCOT, as described above.^19,22,23

Discussion

Our primary interest was to investigate if a combined OT and paramedic FERS would be beneficial in addressing the increasing number of falls experienced by older adults living in the community, with the view of informing future research opportunities. The key themes present in the literature were:

• assessment and intervention
• care coordination and monitoring
• home and environmental safety
• patient education and support

Assessment and intervention

Comprehensive assessment by a multidisciplinary team with immediate intervention was seen to be an effective strategy, identified in seven of the sources. Charlton et al.²³ investigated the clinical effectiveness of an OT rapid response service and found it to be clinically effective when compared to a standard ambulance response. The OT assessment focussed on environmental, personal/intrinsic and behavioural/activity domains. A similar observation was made by Kanne et al.,²⁴ detailing that most falls risk factors identified can be addressed by an OT. These include alcohol use, cognition, equipment, home safety concerns, sleep hygiene and habit formation around activities of daily living. Notably only two of the 13 risk factors identified would be suitable for physiotherapy input (footwear, gait/balance), but these can also be assessed by an OT. Two of the reviewed studies adopted interventions combined with nurse practitioner or physiotherapy services.^20,24

A multispecialty approach to envisioning the future of acute medical care was discussed by Dean et al., who explored potential future scenarios within the NHS. The integration of fall practitioners with ambulance services emerged as a proactive strategy, potentially preventing hospitalisation and fostering efficient assessment. As an alternative to an interdisciplinary service (allied health/paramedic), the use of the Support and Assessment for Fall Emergency Referrals (SAFER) 2 protocol by paramedics addressed a gap in evidence for older fallers not requiring hospital care.¹¹ This study reflected a comprehensive paramedic-delivered evaluation model, which offered valuable insights into the impact and cost-effectiveness of falls prevention initiatives. Therefore, a new pathway may be introduced by ambulance services at modest costs without further harm and a reduction in further emergency calls.²⁵ It is worthwhile to note that for the NHS there was no clear evidence that it improved health outcomes or reductions in emergency department workload.²⁵

Similarly, the reports produced in collaboration with the RCOT^17,21,26 exploring the value of occupational therapy in the NHS collectively emphasised its role in addressing urgent care needs and reducing pressure on hospitals. For example, more than 75% of people were able to remain at home after a joint OT and paramedic assessment.²⁶ Currently, in Aotearoa New Zealand, access to community/home healthcare services is through general practitioner (GP) referral or self-referral. Community OT waitlists are prolonged in some centres (for a low priority referral) with wait times ranging from 3 to 7 months²⁷ and, anecdotally, up to 2 years in certain regions.²⁷ An older adult at risk of falls will generally only know their risk after a fall, resulting in a call to ambulance or a visit to hospital, or through a routine visit to their GP. This highlights the necessity of care coordination and monitoring.

Care coordination and monitoring

Studies by Van Dam et al.²² and Watson et al.²⁸ demonstrated that most people seen by OTs were able to stay home with better quality of life compared with those who were conveyed to hospital. These studies had different approaches in their service delivery (e.g., referral from other services for an OT to assess a person in their home and via telecare services respectively), but both resulted in participants feeling safer and more confident through the tailored and focussed care provided. Kanne et al.²⁴ and Logan et al.²⁹ emphasise the positive impact of tailored interventions in reducing falls and improving clinical outcomes. Additionally, the integration of rapid response services with telecare presents a promising model for enhancing safety and wellbeing among vulnerable clients.²⁷ The combined approach not only reduced ambulance requests but also allowed individuals to remain in their homes longer, alleviating the burden on healthcare resources. The effectiveness of some interventions, as demonstrated by Mikolaizak, Lord et al., ³⁰ may hinge on participant compliance, emphasising the importance of individualised and sustained approaches. The drawback of the research in this scoping review is that all studies used varied approaches to the provision of care and data sharing across healthcare professions, which makes it hard to determine which model has the most benefit for the patient and health system.

Patient education and support

A lesser theme present in the literature was the use of falls prevention programmes as an adjunct to a FERS. The Stepping On Programme by Paul et al.³¹ did not show an overall reduction in fall-related ambulance use or hospital admissions, but revealed a potential age-specific benefit (see Table 1 above). Quatman-Yates et al.¹ found that incorporating a community-level perspective, in this case the Community-FIT falls prevention programme, achieved a significant reduction in fall-related callouts and transports. Insights from Paul et al.³¹ highlight the necessity of considering demographic variations and tailoring interventions to specific age groups.

Conclusion

The 14 sources reviewed collectively advocate for a holistic and collaborative approach to falls prevention, encompassing clinical, community and telehealth dimensions. While tailored interventions demonstrate positive outcomes, especially when delivered by an OT, there is a need for more research to refine and optimise the intervention strategies used. An emphasis on participant compliance, demographic considerations and community-level interventions is important.

Falls by elderly in the community continue to be a health concern for multiple disciplines. The findings from this scoping review present a possible interprofessional solution to what appears to be an increasing issue. A joint response between OTs and paramedics in a FERS can provide valuable benefits. Occupational therapy assessments can help prioritise resources by providing a comprehensive and broad understanding of individuals’ needs, focussing on factors contributing to a person’s falls risk. Collaborating with paramedics, OTs can provide immediate on-scene interventions, reducing the likelihood of recurrent falls and mitigating further injury. OTs can assess a person’s home environment and performance factors while paramedics conduct an advanced patient assessment to determine if the clinical presentation requires transport to the hospital. Utilising this model could improve patient outcomes, reduce fall-related healthcare utilisation and improve quality of life for individuals at risk of falling. A joint service could ensure seamless coordination of care, with OTs providing post-fall support and paramedics facilitating referrals to ongoing support and documentation that could enable tracking of fall incidents, informing tailored interventions and ongoing research.