In Edinburgh, the Falls Care Bundles were developed to directly link to the risk levels identified by the Screening Tool. The Falls Care Bundles offer a structured, evidence-based approach to improving care and outcomes. The information contained consist of practical, proven interventions and resources which, when used together, help enhance safety and reduce avoidable harm.
The EHSCP Framework and Risk Stratification Tools allow for targeted, proportionate interventions to be implemented. This ensures timely, person-centred support and helps reduce avoidable harm by matching the right level of care to each person’s needs.
Based on the level of risk identified, the appropriate corresponding Falls Care Bundle can be offered. Following this screening, people are categorised into falls risk levels starting at level 0 (very low risk), level 1 (low risk), level 2 (moderate risk) and level 3 (high risk).
Care Pathway for Falls Level 0 (Very Low Risk) – Signposting to Public Health Information
Information
NHS Inform National Health Information Service, giving quality-assured health information to the people of Scotland.
Health and Wellbeing
Physical Activity and Exercise
Care Pathway for Level 1 (Low Risk of Avoidable Harm) – Falls Care Bundle 1
Information
Social Care Direct
Contact Social Care Direct Team if help and support to live independently at home is needed. The Social Care Direct Team will assist on establishing contact with the best team that may help.
NHS Inform
Age Concern Scotland
Physical Activity and Exercise
- Strength and Balance Exercises
- Walking Scotland: Paths to Health
- Health Scotland Up and About booklet
- Get up and Go – A Guide to staying steady
- Age concern Scotland – Keeping Active in Later Life
Edinburgh Leisure
- Balanced Life
- Active Balance
- Ground Balance
- Dynamic Balance
Health and Well Being
Podiatry Self Referral
Care Pathway for Level 2 (Moderate of Avoidable Harm) – Falls Care Bundle 2
Physical Activity and Exercise
Edinburgh Leisure
- Balanced Life
- Balance Plus
- Referral Portal
Health and Well Being
Provision of small aids/equipment provision
- Walking Aid: Self referral – Edinburgh Health and Social Care Partnership
- Self referral for a walking aid assessment at the Disabled Living Centre
Referral to Physiotherapy / Occupational Therapy for targeted exercises and / or equipment provision
- Living Independently
- EHSCP Physiotherapy
- For specialist services that do not offer self-referral, e.g. Orthotics, Audiology, etc, If assistance to obtain a referral to these services, please engage with your / a healthcare practitioner.
Environment
- Self referral for:
- Community equipment and minor adaptations
- Handrails and ramps: Care and Repair
Referral for Telecare Service Community Alarm and Assistive Technology Enabled Care
- Telecare Service – Edinburgh Health and Social Care Partnership
- Assistive Technology Enabled Care 24
Care Pathway for Level 3 (High Immediate Risk of Harm)
Resources for practitioners who are competent to complete Multifactorial Falls Assessments (MFA) with people who have been identified as level 3 falls risks and are at high risk of falling. An MFA is used to identify and address the wide range of factors that may contribute to a person’s risk of falling. The Multifactorial Falls Assessments is delivered as part of the Level 3 Clinical Pathway and is tailored to the individual’s specific needs.
Level 3 Clinical Pathway Resources and Referral Routes
A-E
Assistive Technology Enabled Care (ATEC) 24
Assistive Technology Enabled Care 24 (ATEC24) brings together services that use technology to help people live safely in their homes as long as possible.
ATEC24 is made up of:
* Community Alarm and Telecare Service
* Community Equipment Service
* Bathroom Equipment Assessment Team
* Sheltered Housing Support Service
* Communities and Families Occupational Therapy Team
For general enquiries contact:
Telephone: 0131 200 2324
Email: socialcaredirect@edinburgh.gov.uk
Website: https://www.edinburghhsc.scot/livingindependently/atec24/
Bladder Bowel Continence
Bladder Bowel Continence Service:
Staff Advice Line: 0131 446 4324
Bladder and Bowel Product Team: 0131 446 4307
Continence Care Team (process pharmacy prescriptions and place orders for patients):
0131 537 4572
Email: BBPTeam@nhslothian.scot.nhs.uk
MSK Physiotherapy Continence Service:
Continence and Pelvic Health Physiotherapy Service – Edinburgh Health and Social Care Partnership: Physiotherapy
Day Hospital
For combined medical, nursing and rehabilitation assessments to reduce falls risk:
South Edinburgh – Liberton Day Hospital via SCI Gateway
North-West Edinburgh – WGH MOE ARC via SCI Gateway
Patients in the North-East Edinburgh can be referred to LCTC MOE OPRA via SCI Gateway
Edinburgh Community Equipment Loan Service
Community Equipment and Minor Adaptations – Edinburgh Health and Social Care Partnership
Edinburgh Community Stroke Service (ECSS)
Email referral: neurorehaboutpatientservice@nhslothian.scot.nhs.uk
H-L
Hub Therapy
For Falls Assessment
Social Care Direct: 0131 200 2324
Email: socialcaredirect@edinburgh.gov.uk
Ask Social Care Direct for advice – The City of Edinburgh Council
SAS Falls Pathway via Request for Service
Urgent Therapy and Social Care via FlowCentre:
Call: 0300 013 4000; option 1 and 4 between 08:30 – 14:00
Hydration and Nutrition
Dietetics(Internal Link)
M-Q
Medicine of the Elderly incl. Day Hospital
Orthotics
Orthotics – RefHelp
Orthotics referrals via TRAK: TRAK Referrals – Referrer Guide
Orthotics GP referrals via SCI gateway
Pharmacy
Referral Guidance
The Referral Guide is for staff visiting the homes of those who might benefit from a review of their medications or their medications might be contributing to their falls risk. Please email the following details to:
PC.Prescribing@nhslothian.scot.nhs.uk
Information to include in email:
Heading: Referral for Polypharmacy Review
In body of email:
* Please could this person be considered for a review of their medications
* Person’s name and CHI number
* GP practice
* Reason for referral -Suspect that medications may be contributing to falls
Referral for Polypharmacy Review
Physiotherapy (MSK)
Edinburgh Health and Social Care Partnership – Musculoskeletal Physiotherapy
Physiotherapy (Physio@Home)
GP Referral via SCI Gateway: https://apps.nhslothian.scot/refhelp/guidelines/musculoskeletalphysiotherapy/physiohomeedinburgh/
Email: ecps.physioathome@nhs.scot
Walking aid self referral: Loth.edinwaselfref@nhslothian.scot.nhs.uk
Podiatry
Podiatry (Internal Link)
R-V
SMART Centre (Assistive Technology Disabled Living Centre Wheelchair Provision)
Intranet: SMART Centre
Intranet: SMART Centre – NHS Lothian’s Southeast Scotland Mobility and Assistive Technology Centre
Smart Home
Annie Seath, Senior Care and Support Worker for Digital Technologies:
Number: 0131 443 3837 or 07761330031
Email: COTRS@edinburgh.gov.uk or anne-marie.seath@edinburgh.gov.uk
Speech and Language Therapy (Swallowing – Eating/drinking Communication)
RefHelp
NHS Lothian Intranet: Adult SLT Services
Telecare Services
W-Z
Walking Aids
Internal Directory: Walking Aids (includes recourse to Edinburgh Community Equipment Stores)
Walking aid self referral: Loth.edinwaselfref@nhslothian.scot.nhs.uk
Self referral: Edinburgh Health and Social Care Partnership: Physiotherapy
