Fall Prevention Program Checklist

• Nursing Home

• Address
  Address

• Nursing Home Supervisor

• Conducted on

  Date

Needs Assessment, Target Audience & Available Resources

• Are fall prevention activities feasible and will best serve the needs of the elderly?

  Yes

  No

  N/A

• Does the program fit our organization?

  Yes

  No

  N/A

• Does the program complement other programs already being offered?

  Yes

  No

  N/A

• Is the program appropriate for our target older adult population?

  Yes

  No

  N/A

• Are older adults in the nursing home interested in the program?

  Yes

  No

  N/A

• Is safe, reliable, and low-cost transportation to and from the program available?

  Yes

  No

  N/A

• Do we have personnel with the expertise to conduct the program or is there a system in place to train program instructors?

  Yes

  No

  N/A

• Are the costs and resources needed within our budget?

  Yes

  No

  N/A

Program Characteristics

• Does the program require specially trained instructors?

  Yes

  No

  N/A

• Will the program provide education about fall prevention?

  Yes

  No

  N/A

• Does the program promote falls self-efficacy (confidence to prevent falls) among the participants?

  Yes

  No

  N/A

• Are there opportunities for social interaction among the participants? (Such opportunities contribute to program retention and sustainability.)

  Yes

  No

  N/A

• Does the program address modifiable risk factors (e.g., exercises to improve lower body strength and balance)?

  Yes

  No

  N/A

• Can the program be tailored to meet the differing abilities of the participants?

  Yes

  No

  N/A

• Are exercises progressive (get more challenging over time)? This is a key component of an effective fall prevention exercise program.)

  Yes

  No

  N/A

• Can your facility provide the amount of time needed to provide the recommended intervention dose (e.g. for a total of 50 hours for a Tai Chi program)?

  Yes

  No

  N/A

• Does the program include strategies to reduce the possibility of activity related injuries?

  Yes

  No

  N/A

Implementation

• Are there program materials and training manuals available?

  Yes

  No

  N/A

• Can the program be implemented with fidelity in your setting?

  Yes

  No

  N/A

• Does the program offer strategies for linking participants and the program itself with healthcare providers as needed?

  Yes

  No

  N/A

Evaluation

• Does the program include methods for maintaining and monitoring fidelity and program quality over time?

  Yes

  No

  N/A

• Does the program include easy-to-administer pre- and post-functional tests, such as the Timed Up and Go (TUG) test, to document improvements in participants’ functional abilities?

  Yes

  No

  N/A

Completion

• Additional Recommendation

• Nursing Home Supervisor Name & Signature

  Sign
Aged Care Workers

• Worker Name & Signature

  Sign