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Falls Prevention and Mobility Enhancement in Older Adults

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About Falls Prevention and Mobility Enhancement in Older Adults

Falls are a major and preventable cause of injury, disability, loss of independence, and mortality in older adults. Approximately one in three adults aged 65 years and older experiences at least one fall each year, with risk increasing substantially with advancing age, multimorbidity, frailty, and functional decline. Falls often result from the interaction of multiple modifiable factors, rather than a single cause.

This care pathway focuses on falls risk identification, mobility preservation, and functional resilience, emphasizing early detection, conservative management, and interdisciplinary care. It applies to community-dwelling and institutionalized older adults and is relevant across the continuum from primary prevention (preventing a first fall) to secondary prevention (reducing recurrence and fall-related harm).

Falls prevention is not solely about avoiding injury; it is central to:

  • maintaining mobility, balance, and confidence
  • supporting independent living and participation
  • reducing healthcare utilization and long-term care placement
  • mitigating fear of falling and activity restriction

This pathway prioritizes:

  • comprehensive assessment of intrinsic and extrinsic risk factors
  • function-oriented physical examination
  • evidence-based conservative interventions (exercise, education, environmental modification)
  • identification of individuals requiring medical referral or multidisciplinary input

The pathway does not replace condition-specific disease management (e.g., Parkinson’s disease, stroke, advanced dementia), but supports risk stratification, referral, and co-management when such conditions contribute to falls risk.

About CCG Care Pathways

Purpose

CCG is a knowledge translation resource of the Canadian Chiropractic Association. Its care pathways help chiropractors and other clinicians organize conservative care for musculoskeletal conditions. Each pathway outlines the main steps of the clinical encounter and supports decisions about assessment, care, monitoring, referral, co-management, and discharge. The pathways provide a structured approach to care, not a fixed prescription.

Development

Pathways draw on relevant clinical practice guidelines, systematic reviews, peer-reviewed literature, and safety or professional sources. These sources inform, but do not determine, pathway content. Their findings reflect the questions, populations, outcomes, methods, and judgments used and may not apply to every person. Condition-specific sources are identified by author or organization and year, with full citations in one reference list at the end of the pathway.

Principles of Care

Musculoskeletal conditions are shaped by physical, psychological, social, cultural, and environmental factors, so no single approach fits everyone. Good care is ethical, evidence-informed, person-centred, culturally responsive, and tailored to the patient’s goals, preferences, circumstances, and response. Shared decision-making and informed consent guide care. Education, active rehabilitation, and self-management support recovery, functioning, participation, and long-term health. Regular reassessment shows whether the plan is helping and when to continue, adapt, stop, refer, co-manage, or discharge.populations.

Pathway Flow at a Glance

The pathway follows a recurring clinical cycle: understand the person and their goals; screen for safety and referral needs; develop a working clinical profile; agree on a plan and relevant outcomes; provide care; reassess response and safety; and continue, adapt, stop, refer, co-manage, or discharge as appropriate.

Disclaimer

CCG care pathways support professional clinical judgment; they do not replace it or the advice of a qualified provider. They are not prescriptive, authoritative, or regulatory and are not intended for diagnosis or billing. Clinicians remain responsible for practicing within their competence and scope, meeting applicable legal and regulatory requirements, obtaining informed consent, recognizing emergencies, and arranging referral or co-management when needed.

Falls Prevention and Mobility Enhancement in Older Adults Care Pathway

1. Record Keeping

Accurate, timely, and sufficiently detailed documentation supports safe, high-quality care. The record should reflect clinically relevant patient interactions, clinical reasoning, decisions, care provided, and progress over time. Documentation should meet the legal, regulatory, privacy, retention, and organizational requirements that apply where the clinician practices. A structured format, such as SOAP, may support consistency, clarity, and continuity and can be adapted to the encounter and practice setting.

Subjective: Record the patient’s concerns, symptoms, functioning and participation, goals, preferences, relevant history and context, and response or adverse effects from previous care.

Objective: Record relevant examination findings, outcome measures, diagnostic test results when available, and clinically important changes.

Assessment: Record the clinical interpretation of findings, working diagnosis or clinical profile, differential and safety considerations, relevant risk factors or modifiers, and the patient’s progress or response.

Plan: Record care provided or proposed, education and self-management, consent and patient decisions, changes to the plan, agreed outcomes and reassessment point, referrals or co-management, follow-up, and discharge planning.

Document at the time of the encounter or as soon as practicable. Corrections and additions should preserve the integrity of the record. Clear records support patient safety, shared decision-making, communication, continuity, and accountability.

2. Informed Consent
  • Definition: A continuing process in which a capable patient, or an authorized substitute decision-maker when required, voluntarily agrees to a proposed examination or intervention after receiving and understanding the information needed to make an informed choice.
  • Key Aspects:
    • Prior to interaction: Obtain consent before beginning an examination, procedure, or treatment, except where applicable law permits otherwise. Explain what is proposed and why. Revisit consent when the plan or material information changes.
    • Voluntarily and specific: must be voluntary and specific to the proposed care. Consider the patient’s capacity for the decision at the time it is required and follow applicable requirements for substitute decision-making when the patient lacks capacity. The patient may ask questions, refuse, place limits on, or withdraw consent.
    • Transparent process: Use honest, plain, and accessible communication. Offer interpretation or other communication support when needed and consider language, culture, health literacy, disability, and prior trauma. Written or digital information may support but does not replace discussion.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain relevant findings, the clinical impression or working diagnosis, important uncertainty, and the expected course in understandable language.
      • Treatment plan: Discuss the nature and purpose of proposed care, expected benefits, material risks and side effects, burdens, reasonable alternatives, the option of no intervention, and the likely consequences of accepting or declining.
      • Questions: Invite questions, explore goals and preferences, allow appropriate time for a decision, and confirm understanding, for example using teach-back.
    • Documentation: Record the consent discussion and decision, including material information provided, questions, capacity or substitute decision-maker where relevant, consent, refusal, limits or withdrawal, and any need to revisit consent. Follow documentation requirements applicable to the jurisdiction and practice setting.
3. Health History
  • Apply cultural awareness and trauma-informed care principles. Acknowledge prior falls, injuries, healthcare experiences, fear of falling, and the potential impact of ageism or stigma on care-seeking and participation.
  • Sociodemographic information: Age, sex, gender, race/ethnicity, living situation (alone, with family, congregate living, long-term care), language needs, access to transportation and caregiving support.
  • Falls history (question-based prompts):
    • Have you fallen in the past 12 months? If yes, how many times?
    • When and where did the fall(s) occur?
    • Were there injuries, medical visits, or hospitalizations?
    • What were you doing at the time of the fall?
    • Were there any warning symptoms (dizziness, lightheadedness, weakness, tripping)?
    • Are you worried about falling or limiting activities because of fear of falling?
  • Mobility and function:
    Current walking ability (distance, speed, need for aids), difficulty with stairs, transfers, or uneven surfaces, recent changes in mobility or endurance.
  • Body systems review: Neurologic (balance, sensation, strength, cognition), cardiovascular (syncope, orthostatic symptoms), musculoskeletal (pain, stiffness, joint instability), vision and hearing, vestibular symptoms, genitourinary (urgency, nocturia), mental health.
  • Health, lifestyle, and history: 
  • Chronic conditions (e.g., osteoporosis, arthritis, diabetes, cardiovascular disease, neurologic disorders).
  • Medication review with attention to polypharmacy and fall-risk–increasing drugs (e.g., sedatives, antihypertensives).
  • Physical activity level, sedentary time, sleep quality, nutrition, hydration, alcohol or substance use.Environmental and contextual factors:
  • Home layout, lig
  • Social determinants of health: Income security, housing safety, access to care, caregiver availability, social isolation, ability to obtain or use mobility aids.
  • Previous interventions and responses: Prior falls prevention programs, exercise therapy, assistive devices, home modifications, effectiveness and adherence..
  • Beliefs and expectations: Perceptions about aging and falls, confidence in mobility, goals related to independence and participation.
  • Flag considerations: Identify red, orange, and yellow flags for potential referrals.

​​Outcomes Assessments:  Select tools based on feasibility, safety, and relevance to the individual’s goals.

  • Falls Risk: History of falls; e.g., Falls Efficacy Scale (FES-I).
  • Mobility and Balance: Timed Up and Go (TUG), gait speed, Five Times Sit-to-Stand (5xSTS)
  • Function and Participation: Evaluate impact on daily activities (PSFS, WHODAS).
  • Quality of Life: Assess using tools such as SF-12.
  • Activity Status: Monitor return to activities, participation.
  • Sleep quality: Assess using tools such as PSQI.
  • Individual Goals: Set SMART goal setting (Specific, Measurable, Achievable, Relevant, Timely).
  • Patient Feedback: Gatherand integrate patient experience and satisfaction.
4. Red Flags : Differential Diagnosis Requiring Medical Attention

ACTION: Refer immediately to emergency care:

  • Head injury or suspected intracranial injury:
    Fall with head impact, loss of consciousness, confusion, new headache, vomiting, or anticoagulant use.
  • Suspected fracture or serious injury:
    Inability to bear weight, severe localized pain, deformity, or sudden loss of function following a fall.
  • Syncope or suspected cardiac cause of falls:
    Falls associated with loss of consciousness, chest pain, palpitations, unexplained shortness of breath, or known arrhythmia.
  • Acute neurologic signs:
    New or worsening unilateral weakness, facial droop, speech disturbance, acute visual changes, or sudden gait inability.
  • Acute infection or systemic illness:
    Fever, delirium, rapid functional decline, or falls associated with acute medical deterioration.

ACTION: Refer to appropriate medical provider:

  • Recurrent unexplained falls without clear mechanical cause
  • Orthostatic symptoms (dizziness, lightheadedness) suggestive of blood pressure dysregulation
  • Marked or progressive mobility decline over weeks to months
  • New or worsening cognitive impairment affecting safety
  • Severe pain or neurologic symptoms contributing to instability
  • Suspected osteoporosis with fall-related pain or height loss

ACTION: Consider referral or co-management when any of the following are present

  • High falls risk with multimorbidity, frailty, or polypharmacy
  • Fear of falling leading to activity restriction and deconditioning
  • Vision or vestibular impairment contributing to balance deficits
  • Environmental hazards requiring occupational therapy or home safety assessment
  • Need for medication review to address fall-risk–increasing drugs
  • Social vulnerability, including isolation, unsafe housing, or lack of caregiving support

Notes:

  • Falls are often multifactorial; absence of a single red flag does not imply low risk.
  • A fall may be the first sign of acute illness or neurologic disease in an older adult.
  • Early identification and referral can prevent recurrent falls, injury, and loss of independence.
5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

  • Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
  • Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
  • Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

  • Suicide or self-harm thoughts: thoughts without immediate danger.
  • Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
  • Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

  • Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
  • Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
  • Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
  • Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

6. Yellow Flags: Factors that May Affect Recovery or Participation

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

  • Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
  • Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
  • Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
  • Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
  • Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
  • Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

  • Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
  • Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
  • Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
  • Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
  • Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.
7. Physical Examination

The physical examination should focus on balance, strength, gait, sensory input, and functional performance, with attention to safety, fatigue, and cardiovascular tolerance. Findings should inform risk stratification, intervention selection, and referral, rather than serve as isolated diagnostic tests.

  • General observation:
    Posture, alignment, use of assistive devices, footwear, movement confidence, and need for upper-limb support during standing or walking.
  • Vital signs and physiologic response (as appropriate):
    Resting heart rate and blood pressure; consider orthostatic measures if dizziness or unexplained falls are reported. Monitor exertional tolerance during testing.
  • Gait assessment:
    • Observe gait speed, step length, cadence, symmetry, foot clearance, and turning
    • Note use and appropriateness of mobility aids
    • Assess ability to dual-task if safe (e.g., walking while talking)
  • Balance assessment:
    • Static balance: feet together, semi-tandem, tandem stance
    • Dynamic balance: turning, reaching, stepping responses
    • Observe postural sway, stepping strategies, and need for support
  • Strength and power:
    • Lower limb strength, particularly hip extensors/abductors, knee extensors, and ankle plantarflexors
    • Functional strength testing such as repeated sit-to-stand
  • Range of motion and joint integrity:
    Screen lower limb and spinal mobility relevant to gait and transfers; identify pain, stiffness, or instability affecting movement.
  • Sensory and neurologic screening:
    • Sensation (particularly feet), proprioception, and reflexes as indicated
    • Brief screening for coordination or focal neurologic deficits
  • Vision and vestibular screening (as indicated):
    Gross visual acuity, contrast sensitivity (by history), head movement tolerance, dizziness with positional changes.
  • Functional mobility tasks:
    Assess performance and safety during:
    • Sit-to-stand and stand-to-sit
    • Transfers (bed, chair)
    • Stair negotiation (if relevant)
    • Reaching, bending, and turning tasksFear of falling and movement behaviour:
      Observe hesitancy, guarding, or excessive reliance on supports that may contribute to deconditioning.

The examination should be progressive and repeatable, allowing reassessment over time to monitor response to intervention and evolving risk.

8. Clinical Presentation

Clinical presentations related to falls risk and mobility impairment in older adults are heterogeneous and often multifactorial, reflecting interactions between physical capacity, health conditions, medications, environment, and psychosocial factors. Presentation may range from subtle mobility decline to recurrent injurious falls.

Common Presentations

  • Recurrent or near falls:
    Multiple falls or frequent loss of balance over the past 6–12 months, often without a single identifiable cause.
  • Gait and balance impairment:
    Slowed walking speed, reduced step length, widened base of support, difficulty turning, or unsteadiness on uneven surfaces.
  • Lower limb weakness and deconditioning:
    Difficulty rising from a chair, climbing stairs, or sustaining walking; fatigue with minimal exertion.
  • Fear of falling and activity restriction:
    Reduced participation in physical and social activities due to fear, leading to further deconditioning and increased risk.
  • Sensory or perceptual contributors:
    Balance challenges associated with vision impairment, peripheral neuropathy, or vestibular symptoms.
  • Medication-related instability:
    Dizziness, sedation, or postural hypotension associated with polypharmacy or recent medication changes.

Typical Symptom Behaviour

  • Symptoms often worsen with fatigue, divided attention, low lighting, or unfamiliar environments.
  • Mobility confidence may fluctuate day to day, particularly in individuals with chronic conditions or cognitive impairment.
  • Falls risk may increase following acute illness, hospitalization, or periods of inactivity.

Atypical or Concerning Presentations

  • Sudden onset of frequent falls or rapid mobility decline
  • Falls associated with loss of consciousness or neurologic symptoms
  • Marked asymmetry, focal weakness, or new gait pattern changes
  • Falls occurring predominantly at night or associated with confusion or delirium

These presentations warrant prompt reassessment and possible medical referral (see Red Flags).

Clinical Interpretation

  • Ongoing reassessment is essential, as falls risk can change rapidly with health status, medication use, or environmental context.
  • Falls are rarely due to a single deficit; most presentations involve combined impairments in strength, balance, sensory input, cognition, or environmental safety.
  • Absence of a recent fall does not imply low risk; fear of falling, near falls, and mobility decline are clinically meaningful indicators.
9. Conservative Management Considerations for Falls Prevention & Mobility Enhancement in Older Adults

Conservative management is the cornerstone of falls prevention and mobility preservation in older adults. High-quality evidence consistently supports multifactorial, exercise-centred interventions, tailored to individual risk profiles, functional capacity, and living context. The recommendations below reflect established standards of care from international clinical practice guidelines and systematic reviews.

Core Principles

  • Falls prevention should prioritize mobility, confidence, and participation, not just fall avoidance.
  • Interventions are most effective when individualized, progressive, and sustained over time.
  • Single-component interventions are less effective than multicomponent approaches, particularly in higher-risk individuals.

Exercise Therapy 

Exercise is the most effective single intervention for reducing falls and improving mobility.

Recommended characteristics:

  • Balance-focused and functional (e.g., standing balance, weight shifting, stepping, turning)
  • Progressive and challenging, yet safe
  • Performed at least 2–3 times per week
  • Continued for ≥12 weeks, with longer duration associated with greater benefit

Key components:

  • Static and dynamic balance training
  • Lower limb strengthening (hip, knee, ankle)
  • Functional mobility (sit-to-stand, stair negotiation, gait tasks)
  • Dual-task or cognitive-motor challenges when appropriate

No single exercise program is superior; adherence and progression are critical.

Education and Self-Management

Education should support risk awareness without fear amplification.

Key elements include:

  • Understanding modifiable falls risk factors
  • Encouragement of continued movement and avoidance of unnecessary restriction
  • Strategies for pacing, fatigue management, and safe activity participation
  • Addressing fear of falling and building confidence

Education alone is insufficient but enhances adherence and engagement when combined with exercise.

Mobility Aids and Footwear

  • Appropriate prescription and training in assistive device use can reduce falls risk
  • Footwear should be well-fitting, low-heeled, and slip-resistant
  • Reassessment is essential as mobility status changes

Environmental and Home Safety Interventions

  • Home hazard assessment and modification are recommended for individuals at moderate to high risk, particularly those with prior falls

Medication and Medical Review 

  • Review and modification of fall-risk–increasing medications (e.g., sedatives, antihypertensives) by medical providers
  • Vision assessment and management of cardiovascular contributors (e.g., orthostatic hypotension) are important adjuncts

Interventions with Limited or Selective Role

  • Passive physical modalities alone
  • Non-individualized exercise programs
  • Short-duration or low-intensity balance activities

These should not replace structured, progressive exercise-based care.

10. Risk and Prognostic Factors and Prognosis

Risk and Prognostic Factors

Falls risk and recovery trajectories are influenced by interacting intrinsic, extrinsic, and contextual factors. The following are consistently associated with higher falls risk, recurrence, or delayed mobility recovery:

Intrinsic factors

  • History of falls, particularly multiple falls in the past 12 months
  • Impaired balance and gait, slowed gait speed, reduced lower-limb strength
  • Frailty and deconditioning
  • Cognitive impairment, delirium risk, or executive dysfunction
  • Sensory deficits (vision, vestibular function, peripheral neuropathy)
  • Chronic conditions (e.g., osteoporosis, arthritis, Parkinson’s disease, stroke, diabetes)
  • Orthostatic hypotension or cardiovascular instability

Medication-related factors

  • Polypharmacy
  • Fall-risk–increasing drugs (e.g., sedatives, hypnotics, antidepressants, antihypertensives, anticholinergics), especially recent changes or dose escalation

Psychosocial and behavioural factors

  • Fear of falling and activity restriction
  • Low confidence with mobility
  • Depression, anxiety, or social isolation

Environmental and contextual factors

  • Unsafe home or community environments (poor lighting, uneven surfaces, stairs without railings)
  • Inappropriate footwear or assistive device use
  • Limited access to rehabilitation or caregiving support

Protective factors associated with better outcomes include:

  • Early identification of risk and multifactorial assessment
  • Progressive, balance-challenging exercise with adequate dose and duration
  • Appropriate assistive device prescription and training
  • Home hazard modification when indicated
  • Addressing fear of falling and supporting confidence and participation

Prognosis

  • Reassessment is essential after acute illness, hospitalization, medication changes, or environmental transitions, as risk status can change rapidly.
  • Falls are predictable and preventable in many older adults with appropriate intervention.
  • Exercise-based, multicomponent programs can reduce falls by improving mobility, balance, and confidence.
  • Prognosis improves with early intervention, sustained participation, and adherence.
  • Without intervention, falls risk often progressively increases due to deconditioning, fear-driven inactivity, and accumulating comorbidity.
11. Ongoing Follow-up

Ongoing follow-up is a shared review of whether the plan remains safe, useful, acceptable and aligned with the patient’s goals. The timing of review should reflect symptoms, risk, the care being tried, goals and access rather than a fixed visit schedule.

  • Review symptoms and safety: ask what has changed in symptoms, functioning and daily activities; review adverse effects; and check for new or worsening Red Flags and relevant Orange or Yellow Flag concerns. Arrange earlier or urgent assessment when the findings require it.
  • Review outcomes: repeat the small set chosen at baseline and use the same measures when possible. These may include the Patient-Specific Functional Scale, WHODAS 2.0, quality of life using the patient’s own rating or a measure such as WHOQOL-BREF, symptom impact, participation and the patient’s own assessment of change. Interpret measures with the patient and alongside what has changed in daily life rather than relying on a score alone.
  • Review goals, preferences and consent: ask whether care remains acceptable, feasible and worthwhile; revisit goals and priorities; and confirm consent when the plan or circumstances change.
  • Adapt care: continue what is useful and acceptable, and change, pause or stop what is not. If progress is not sufficient from the patient’s perspective, review the clinical impression, the fit and amount of care, barriers to participation, other health or social factors and whether other expertise is needed.
  • Support self-management and participation: review the strategies the patient is using, including physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Ask what is helping and which barriers can be addressed.
  • Referral and co-management: arrange emergency assessment for Red Flags requiring urgent care. Consider referral or co-management when findings or needs are beyond the clinician’s role, the patient’s condition is worsening, progress remains insufficient after the plan has been reviewed, or the patient requests another opinion.
  • Plan the next step: agree whether to continue, change the interval between visits, move toward more self-directed care, or apply the Criteria for Discharge section.
12. Criteria for Discharge

Discharge is a shared decision about ending or transferring a course of care. It does not require complete symptom resolution, a normal outcome score or a fixed number of visits.

  • When discharge may be appropriate: consider discharge when the patient’s goals have been met to a degree they consider satisfactory; the patient feels able to manage with less or no clinician involvement; the patient chooses to end care; continued care is not providing enough benefit to justify its burden, cost or time; or care is being transferred to another provider.
  • Reassess before discharge: review symptoms, functioning, participation, selected outcomes, goals, adverse effects, confidence and preferences. Check for new or worsening Red Flags and any Orange or Yellow Flag concerns that still require action. If the condition is worsening or a safety concern remains, arrange the required assessment or referral rather than routine discharge.
  • When progress has slowed: review the clinical impression, response to care, goals, barriers and access, other health or social factors, and other reasonable options before deciding with the patient whether to continue, change or end care.
  • Plan after discharge: agree on self-management, physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Explain which changes should prompt earlier or urgent assessment and when and where to seek care.
  • Future access to care: explain how the patient can return if symptoms recur, functioning declines, or goals or demands change. Any planned future review or supportive care should have an agreed purpose, expected benefit and review point.
  • Referral or transfer: explain the reason, share a relevant summary with the patient’s consent, and clarify who will address outstanding concerns when possible. Avoid an unintended gap in care when safety or ongoing needs remain.
  • If the patient ends care or does not return: respect the patient’s right to stop. Record what is known and unknown about the outcome, advice or referral offered, attempts to communicate when clinically warranted, and any unresolved safety concern. Follow applicable record keeping and communication requirements.
  • Documentation: record the reason care ended, the patient’s status and selected outcomes, goals and preferences, unresolved concerns, advice and self-management plan, referral or transfer details, and how to seek care again if needed.

References