Improving Follow-up After Fall Risk Screening: A Quality Improvement Initiative In Primary Care After The Medicare Annual Wellness Visit

J Am Geriatr Soc. 2026 May 6. doi: 10.1111/jgs.70504. Online ahead of print.

ABSTRACT

BACKGROUND: Falls are a leading cause of preventable injury and disability among older adults. Although fall risk screening is routine in the Medicare Annual Wellness Visit (AWV), timely follow-up after a positive screen is often lacking. We implemented a primary care-based quality improvement initiative to increase the rate of fall risk prevention interventions provided to older adults at elevated fall risk.

METHODS: We conducted a retrospective study of patients aged ≥ 65 years who completed an AWV between September 2024 and October 2025 and screened positive for fall risk using a three-item screener and confirmed with an abnormal Timed Up and Go (TUG) test. On January 1, 2025, we implemented a package of two quality improvement strategies to improve the uptake of evidence-based fall prevention interventions. First, we implemented a SmartSet in the Electronic Health Record which guides clinicians to select a clinically appropriate follow-up after a positive fall risk screen, and second, the geriatrics clinic proactively reached out to eligible patients to schedule comprehensive fall and bone health assessments. We evaluated follow-up rates over time. Outcomes measured 120 days post-screening during the AWV included: (1) the proportion of patients ≥ 65 with any documented follow-up action post-screening (physical therapy referral, case management visit, geriatrics referral, or geriatrics clinic visit), (2) any geriatrics referral, (3) any geriatrics visit, (4) any physical therapy referral, and (5) any case management referral.

RESULTS: Three hundred thirty-five patients aged ≥ 65 years completed an AWV, screened as positive for fall risk, and had an abnormal TUG. Any follow-up increased from 53.8% to 67.8%. Follow-up geriatrics clinic visits increased from 7.5% to 40.4%. Primary care referral rates to geriatrics, physical therapy referrals and case management referrals remained stable.

CONCLUSION: A proactive package of implementation strategies embedded in primary care significantly improved follow-up rates after positive fall risk screening.

PMID:42089560 | DOI:10.1111/jgs.70504