Primary care led integrated falls prevention programme: early outcomes of the SAFE Pilot

Introduction: Falls in older adults are prevalent, costly and frequently under-managed. We developed the Screening, Agility, Frailty & Falls prevention, Empowerment (SAFE) pathway to operationalise guideline-aligned multifactorial assessment, medication optimisation, osteoporosis risk trigger and rapid linkage to community rehabilitation at the first point of contact. We aim to describe implementation of SAFE in the pilot polyclinic, compare delivery of interventions pre- and post-implementation, and assess feasibility for scale-up with a focus on clinical effectiveness, patient safety and improved access.

Methods: Pre–post pilot evaluation in one polyclinic in Singapore for adults ≥65 years who reported a fall within the past 6 months. SAFE comprises: (1) screening and risk stratification by a care coordinator; (2) risk-based education and multidomain functional assessment by a care manager for at-risk patients; and (3) detailed medical assessment and targeted interventions by doctors/APNs and pharmacists (e.g., medication deprescribing, osteoporosis assessment with Bone Mineral Density for high OSTA, and referrals to day rehabilitation centres and/or Active Ageing Centres).

Results: Eighty fallers received the full SAFE bundle. Compared with baseline, the proportion of fallers receiving at least one evidence-based intervention increased from 65.0% to 78.2% (+13.2 points). Completion of full functional assessment rose from 1 to 80 cases. A mean of 3.5 previously unrecognised deficits per patient was detected (e.g., vision/hearing impairment, cognitive issues, fall-risk medications, medication side effects). Among eligible women, 73.7% completed BMD testing. Patients were linked to community exercise/rehabilitation (DRC 32.5%; AAC 12.5%).

Conclusion: Embedding a multidisciplinary, guideline-aligned falls/osteoporosis pathway within routine primary care is feasible and improves completeness of falls care delivered and access to key services, with early signals of better clinical effectiveness, safer prescribing and improved access to community-based rehabilitation. Next phase evaluation will compare BAU vs partial vs full SAFE with 12-month outcomes including recurrent falls, function/frailty and healthcare utilisation.