Towards an integrated falls response service for Aotearoa New Zealand: occupational therapy and paramedicine in community care

Falls are the leading cause of injury among older adults, with Hato Hone St John attending approximately 34,000 fall-related incidents nationwide each year and processing 3,970 fall-prevention referrals in 2021.¹ Low- to moderate-acuity falls continue to overwhelm emergency services and hospitals,² with around 30% of patients in emergency departments nationwide waiting more than 6 hours to be seen and treated.³ In 2024, there were 825,437 new claims for fall-related injuries, contributing to a total of 971,596 active claims and incurring costs exceeding NZ$2.5 billion.⁴ Falls impact seniors’ mental health and can contribute to depression, anxiety, isolation and caregiver burden.^5–7 Disappointingly, falls management for older adults in Aotearoa New Zealand still has critical gaps in assessment and follow-up care.^8–9

To address these urgent challenges, alternative models of care are being explored worldwide, shifting falls management from reactive, hospital-based treatment to proactive, community-led intervention.¹⁰ By addressing medical conditions, environmental hazards and medication risks, falls response services take a holistic approach to falls prevention.^11–13 Successful models in Canada, Australia, the United Kingdom (UK), Ireland and the Netherlands show improved health outcomes, fewer secondary falls, reduced healthcare strain and high patient satisfaction.^14–18

Methods

This paper reviews international evidence on joint occupational therapy and paramedic falls response services for older adults, focussing on the tools, procedures and their effectiveness to address the urgent need for culturally responsive care in Aotearoa New Zealand. It also explores how these models and findings can inform improved healthcare pathways to better address falls-related challenges in Aotearoa New Zealand’s ageing population. Building on a prior scoping review,¹⁹ this study replicated and refined the literature search to uncover new or previously missed research, with particular attention to alternative terminology. As the previous scoping review was done a year earlier, we expected few changes to the results. The aim here was to identify and describe the various service models implemented internationally that utilise a co-joint falls response approach. Our focus shifted attention from merely summarising the available literature to a more practical examination of how occupational therapists and paramedics collaborate within established service frameworks. By analysing these operational models, we aim to provide a clearer understanding of the structural and procedural elements that characterise successful co-joint falls response services, offering valuable insights for potential adoption and adaptation within the local context. Due to the broad role of occupational therapy and its prominence in overseas research and Enable New Zealand–funded home modification assessor criteria, this article specifically examines occupational therapy’s impact within a combined service environment.

A systematic search was performed across four major databases (MEDLINE, CINAHL, Scopus and Google Scholar) alongside grey literature searches via Google to identify globally operational co-joint occupational therapy and paramedic falls response services. The following search terms were used: (“fall prevention” OR “falls response” OR “fall” OR “accidental falls”)* AND (“occupational therap” OR “emergency medical technician” OR paramedic OR ambulance OR pre-hospital OR prehospital OR EMS OR “emergency medical services”)* AND (“older adults” OR “senior citizens” OR “middle-aged” OR “65+”). The search results were imported into EndNote 20, where duplicates were removed and titles/abstracts were screened based on predefined and inclusion/exclusion criteria used in the earlier scoping review.

Results

From the 14 peer-reviewed articles included in this review, seven evaluated internationally active co-joint occupational therapy and paramedic services and six examined occupational therapy–led follow-up care for falls prevention (Table 1). Seven of these had been identified in the 2025 published scoping review,¹⁹ but due to the refinements made here additional sources were found. Among existing falls response service models, two followed a rapid response approach, one adopted an early response model and four used a hybrid model integrating both. Research designs varied and sample sizes ranged from small-scale qualitative studies to large-scale service evaluations, offering diverse insights into service implementation and effectiveness. Two studies (Table 1: Watson et al. and Kanne et al.) were included as exceptions, as they demonstrated the benefits of a dedicated rapid response service for older adults at risk of falls and other health issues²⁰ or presented strong long-term follow-up care strategies proven to reduce recurrent falls.²¹ This article has drawn more from grey literature than the earlier review¹⁹ as the reports from service providers proved a very useful resource for model exploration.

View Table 1–2, Figure 1.

Grey and organisational literature reviewed in this study included six government reports, policy documents, healthcare evaluations and research priority reports from key organisations such as Clinical Excellence Queensland, the National Health Service (NHS) in the UK, and the Canadian and British Occupational Therapy Boards (Table 2). Three articles classed as grey literature described active co-joint occupational therapy and paramedic services in Australia and the UK.

Discussion

There is no consistent, established model for co-joint falls response services but they typically follow either a rapid response or early response model, the latter often incorporating short- or longer-term follow-up care components to support ongoing patient needs.

Rapid response models

Rapid response falls services deliver immediate, onsite care to prevent complications, reduce hospital admissions and support ageing in place. When an emergency call is received, a vehicle staffed by paramedics and a rotating occupational therapist, physiotherapist, social worker or nurse is dispatched in real time.^22,23 Across Britain, Australia and Ireland, falls response services use specially equipped ambulances or non–blue light response cars, depending on the acuity of the fall.^{11,14,17,22,24–26} Referral pathways include direct service calls, on-scene crew calls, emergency call centre triage and secondary triaging hubs.^{11,13,14,17,20,24,26}

All response vehicles are equipped with essential medical supplies, mobility aids, stretchers and lifting equipment. All response staff are trained in fall intervention and prevention techniques.^11,17 Pilot programmes have run with limited shifts while established programmes commonly run 12-hour daily shifts such as those in Queensland, East Midlands and Ireland.¹⁶ Furthermore, integrating rapid response services with telecare enhances safety and wellbeing for vulnerable people, providing swift assistance during falls, reducing hospital strain, easing caregiver burden and improving seniors’ confidence in remaining at home.²⁰

The hallmark of this model is dual assessment by a paramedic and occupational therapist, ensuring both immediate medical evaluation and a comprehensive functional and environmental assessment.^14,23 While other disciplines have been used (e.g., physiotherapists, nurse practitioners), occupational therapists are well placed in Aotearoa New Zealand to facilitate this kind of service due to the Enable New Zealand requirements for housing modification accreditation. Paramedics assess vital signs, consciousness, fractures and potential head trauma, while identifying acute conditions like infections or dehydration that may have contributed to the fall.^11,18,26 In parallel or after stabilisation, the occupational therapist assesses mobility, balance, strength, cognition and functional impairments contributing to the fall.^11,14,18 Occupational therapists perform home-hazard checks, recommending or providing mobility aids and safety modifications as needed on site.^14,18,23,24

Effective collaboration between paramedics and occupational therapists relies on strong communication and integrated information technology (IT) systems,^11,16 and together with the patient and family they develop a care plan for immediate and long-term fall prevention.¹⁷ The assessment may take up to 2 hours.¹⁴ The response concludes with referrals and follow-up, but adherence to referrals remains a challenge. Studies show that referrals alone are often ineffective without structured support and proactive follow-up.^10,27

Early response models and follow-up

The difference between rapid and early response models is that in early response models, occupational therapists and allied health professionals engage within 1 to 72 hours after ambulance assessment and treatment, rather than immediately. The Scottish Ambulance Service partnered with community occupational therapists to create a care pathway granting direct access to allied health professionals for non-hospitalised patients.¹⁶ Occupational therapists assessed patients and implemented home modifications on the same day or within 48 hours if referrals occurred outside standard hours. This reduced unnecessary hospital transports, lowering conveyance rates from 38% to 28%. In comparison, small-scale overseas research on a combined occupational therapy and paramedicine rapid (or immediate) falls service showed that of the 250 referrals only 4% needed transport to hospital—a reduction in conveyance rate from 47.6% to 15.6%.^28,29 The initiative also improved paramedics’ confidence and professional growth, demonstrating the value of cross-professional collaboration.

The Pathfinder service in Ireland integrates rapid response with follow-up care, making it one of the most effective falls response services.^18,24 After rapid response, physiotherapists and occupational therapists provide mobility aids, home modifications, and rehabilitation for a week or more, reducing unnecessary hospital visits. Reports show 64% of patients remained at home post-intervention, with low re-presentation rates. High patient satisfaction reflects its person-centred approach, aligning with older adults’ preference for home-based care and improving health outcomes.^15,18,24

Follow-up care and patient adherence

Follow-up care is essential for falls response services, with evidence underscoring the value of early, interprofessional intervention. Effective follow-up care begins with a medical assessment (polypharmacy, cardiovascular health, cognition and locomotor function), and a follow-up 1-hour occupational therapist home visit addressing home hazards, home modifications and required mobility aids.^30,31 The iPREFER Trial³² examined older adults who received paramedic care but were not transported to the hospital, and incorporated physiotherapist and other community health services. They found that adherence was a key factor for positive outcomes. Those who did adhere decreased their falls and healthcare utilisation by 47%. The On the Move Falls Prevention Clinic²¹ highlighted the need for comprehensive strategies including follow-up meetings and the use of motivational interviewing techniques to overcome barriers. Logan et al. showed that community-based interventions (physiotherapist-led strength and balance sessions, occupational therapist home assessments, floor recovery training and nurse-led reviews) lead to a 40% decrease in ambulance calls, and a longer median time to first fall (166 days vs 21 days in the control group).³³

Proposed model for Aotearoa New Zealand

We propose a comprehensive hybrid model that combines an immediate joint response with structured follow-up (Figure 1). This model has the potential to reduce conveyance and hospitalisation rates and enhance patient outcomes.

1. Falls vehicle activation: The emergency call centre would triage falls as red (high risk, requiring ambulance transport) or orange/green (moderate/low risk). The latter is best suited to this kind of service. An extended care paramedic (ECP) would conduct secondary triage before dispatching a falls response vehicle with an ECP and occupational therapist for onsite assessment and treatment. If the patient deteriorates or is incorrectly assessed or misjudged, the team stabilises them until ambulance transport arrives. On-scene crews may also activate this service for non-critical cases. Thorough on-scene assessments would take between 60 and 120 minutes, depending on patient needs.

2. Immediate assessment by ECP: Paramedics play a crucial role in falls risk screening after initial medical assessment and treatment. They can perform tests like the Romberg test and the Timed Up and Go (TUG) test and assess key risk factors such as prior falls, fear of falling, and frailty.^13,14 In Aotearoa New Zealand, current paramedic assessments often overlook incontinence, a major but underassessed falls risk,³⁴ which the proposed rapid response falls service, led by an ECP, could address. Additionally, ECPs are well placed to assess modifiable medical risk factors such as polypharmacy (e.g., sedatives, antihypertensives, psychotropics) and acute conditions (e.g., infections, cardiac issues, dehydration, malnutrition). However, research shows paramedic referrals are often under-utilised³⁴ and do not guarantee implementation,²⁷ particularly when patients lack support or motivation.²¹ Effective falls management requires interprofessional assessment and structured follow-up care, beyond mere referral.

3. Immediate assessment by occupational therapist: Home-hazard assessments and modifications are most effective for fall prevention,⁹ yet occupational therapists are not currently involved in immediate post-fall assessments. Paramedics will complete TUG and Romberg tests, forming the foundation of balance and mobility assessments.³¹ Occupational therapists may then assess functional ability using the Barthel Index,^13,27,33 while the Accident Compensation Corporation (ACC) Home Safety Checklist³⁵ will identify environmental hazards. Given the risk of cognitive decline associated with falls, the Mini-ACE cognitive screening and the 4AT delirium screen¹³ are carried out. To improve efficiency, paramedics and occupational therapists may conduct concurrent assessments, and if time is limited core assessments may be prioritised, with additional assessments integrated into follow-up care. Occupational therapists may also provide essential mobility aids¹⁴ and initiate immediate home-safety modifications, such as non-slip mats, portable grab bars, and sensor night lights, to enhance patient safety and confidence while awaiting follow-up care and approval of permanent home modifications.

a. Culturally safe practices: Culturally responsive assessment must go beyond physical and environmental factors to support mana (spiritual power within a person), recognise wairua (spiritual wellbeing) and consider whakamā (embarrassment).^36,37 Wairua, deeply tied to wellbeing, can be disrupted by a fall, impacting confidence and sense of self.³⁶ Whakamā may prevent kaumātua (elders) from disclosing key risk factors like incontinence or fear of falling, necessitating an empathetic, person-centred approach.³⁶ By integrating mana-enhancing communication and addressing whakamā and wairua, paramedics and occupational therapists can foster trust, engagement and better outcomes.

4. Structured follow-up care: While structured longer-term care requires initial investment, cost analyses confirm its high return on investment, making it a sustainable strategy.^17,24,25,27 A follow-up team, modelled after the Pathfinder service,^13,15 may involve Health New Zealand – Te Whatu Ora–funded initiatives and ACC-funded initiatives with community-based occupational therapists, physiotherapists and nurses to provide in-home support over 12 weeks.³³ Alternatively, allied health professionals could work from a local falls clinic²¹ conducting 24–72-hour post-fall follow-ups, as recommended by the Health Quality & Safety Commission Te Tāhū Hauora,³⁴ including medical reviews, vision and hearing assessments, and addressing barriers like transport, anxiety and health-related beliefs.³² Ongoing follow-up addresses patient lifestyle, social engagement, functional decline, psychological wellbeing, fear of falling and mobility, with dynamic balance and strength assessment offering deeper insight into fall risk and mobility challenges.

a. Occupational therapists would focus on functional independence, home safety, fall-prevention education, adaptive equipment and floor recovery training to reduce fall-related anxiety.^33,38 Physiotherapists would provide strength and balance retraining, targeting gait stability, lower-limb strength and postural control,³² and support referrals to community-based programmes.³³ A nurse may conduct two in-home sessions focussed on medication reviews, ensuring that polypharmacy, sedatives and other high-risk medications are used responsibly to minimise dizziness, hypotension or cognitive impairment.³³ The nurse may also monitor blood pressure along with signs of dehydration or nutritional deficiencies.^32,33 Telecare at 8 and 10 weeks would maintain engagement,²¹ with a 12-week end-of-sessions survey tracking patient outcomes and satisfaction. Standardised tools would allow practitioners to measure progress and evaluate service effectiveness.

Conclusion

This paper has examined the effectiveness of joint occupational therapist and paramedic falls response services for older adults, highlighting gaps in Aotearoa New Zealand’s current approach. Evidence consistently shows that early allied health involvement, targeted rehabilitation and structured follow-up lead to improved patient outcomes and reduce long-term healthcare costs. A specialised service in Aotearoa New Zealand, piloted regionally and informed by international models, could improve care integration, patient satisfaction and systems efficiency. Success factors include interprofessional collaboration, early assessments, strong referral pathways and home-based care. Challenges include patient adherence, protocol standardisation, telecare integration and resource availability. This kind of service would enhance older adults’ quality of life and relieve pressure on ambulance services, hospitals and long-term care facilities. By embedding cost-effective, community-based solutions within our health system, Aotearoa New Zealand has the chance to fundamentally reshape falls prevention, ensuring greater independence, dignity and wellbeing for its ageing population.