Before the fall: Building health systems that detect functional decline earlier

An older woman in a nursing facility does not fall. She is not sent to the hospital. No new diagnosis appears on her chart. No incident report is filed.

Yet over several weeks, she stops walking to meals. She begins needing help to stand. She spends more of each day seated. Eventually, the wheelchair that once waited in the corner becomes how she moves through the building.

Nothing dramatic happened.

That is precisely the problem.

Healthcare systems are designed to notice events. Functional decline often happens between them.

Healthcare sees events. Patients live trajectories.

A fall triggers an incident report. An infection triggers treatment. A hospitalisation generates a discharge summary. These events have dates, diagnoses and workflows attached to them.

Functional decline rarely arrives with the same clarity.

It may begin with a person walking slightly less than the week before. Then she needs supervision. Later, a hand to help her stand. Eventually, assistance becomes routine. Each change can appear too small to demand attention. Together, they represent a fundamental deterioration in health and independence.

A fall is an event. Functional decline is a trajectory.

If a health system is built primarily to recognise events, it may detect the trajectory only after the consequences become difficult to reverse.

This is increasingly difficult to justify. WHO’s Rehabilitation 2030 initiative specifically calls for information on functioning to be collected to strengthen health information systems. More recently, WHO has argued that functioning should be recognized as a third dimension of population health alongside mortality and morbidity. The unresolved question is not whether function matters enough to measure. It is how to make meaningful change visible in everyday care.

What U.S. post-acute care taught me

Across my rehabilitation career, including practice in India and the United States, I have watched healthcare generate extraordinary amounts of information.

In American post-acute care, a single patient may generate nursing assessments, therapy notes, vital signs, care plans and functional observations every day. Yet more documentation does not automatically produce earlier recognition.

Documentation tells us what happened today. Surveillance tells us what is changing.

That distinction became central to my own work in post-acute care. I began exploring how mobility information already generated during routine care could be organized so that deterioration became easier to see. That work was recognized with Gold in the Tech Champion category at the 2026 McKnight’s Excellence in Technology Awards.

The recognition reinforced a simple lesson. We may not need substantially more data. We need to make better use of the data closest to the patient.

India should not import an American solution

For India, however, the answer cannot be to copy a technology-heavy American model.

The constraints are different.

World Physiotherapy’s 2024 data estimated 0.36 practising physiotherapists per 10,000 population in India. More broadly, WHO identifies equitable access to rehabilitation, including for rural and remote populations, as a priority for health-system strengthening.

A system that depends on frequent specialist assessment, expensive sensors or intensive documentation risks excluding many of the people it is supposed to reach.

India needs a different design principle:

Measure less, but make what is measured matter.

Five signals could offer a starting point

A minimum mobility framework could begin with five pieces of information already observed in routine care:

Walking status. Is the person walking independently, with supervision, with assistance, or not walking?

Transfer ability. Can the person rise from a bed, chair or toilet without help, or is increasing assistance required?

Walking exposure. Is the person actually walking during ordinary life, not simply demonstrating the ability to walk during an examination?

Change from baseline. Is today’s function meaningfully different from that person’s recent function?

Response to change. When meaningful deterioration appears, does it prompt clinical review?

This is not a validated clinical instrument. It is a conceptual starting point for considering what a minimum mobility dataset might contain.

The important information is not the isolated observation.

It is the direction of travel.

A person who has always required assistance is different from someone who was independent two weeks ago and requires assistance today. A health record that captures both observations but fails to connect them has documented the decline without detecting it.

Technology should make deterioration visible

India is in a particularly important position to act on this now because its digital health infrastructure is expanding at enormous scale.

By July 2026, the Ayushman Bharat Digital Mission had created more than 94 crore ABHA numbers, linked more than 100 crore health records, and registered more than five lakh health facilities and ten lakh healthcare professionals.

That infrastructure should not be confused with a functional surveillance system. But it creates an opportunity to ask a more ambitious question:

What if digital health made visible not only what disease a person has, but whether that person is losing the ability to live independently?

The first step does not require artificial intelligence.

A structured mobility field can capture repeated observations. Repeated observations can reveal a trend. A meaningful change can prompt clinical review.

Only after that pathway works should sophisticated technology be layered onto it.

The purpose of technology should be to reduce the cognitive burden on clinicians, not increase the documentation burden on them.

Build the response before buying the technology

For policymakers, this means treating functioning as health information, not as a rehabilitation detail recorded only after referral. India’s digital-health evolution offers an opportunity to explore a small set of interoperable functional fields that can follow patients across settings.

For healthcare leaders, the priority should be workflow before software. Before purchasing another platform, ask four questions: What change are we trying to detect? Who sees the signal? What triggers escalation? Who is responsible for responding?

For clinicians, perhaps the most important change costs nothing.

Do not ask only:

“Can this person walk?”

Ask:

“Is this person walking less than before?”

The first question measures capacity at one moment.

The second may reveal a trajectory.

Detect decline before it becomes an event

India does not need to monitor every step taken by every older adult. Nor should every variation in mobility trigger specialist intervention.

It needs something more practical: a health system capable of recognizing meaningful change and directing scarce clinical attention toward the people whose function is deteriorating.

That principle matters far beyond rehabilitation. WHO estimates that one in three people globally lives with a condition that could benefit from rehabilitation, and in many countries more than half of those needing rehabilitation do not receive it.

Return to the woman who stopped walking to meals.

The first warning was not the wheelchair. It was not a fall, a hospitalization or a new diagnosis. The warning came earlier, when she began walking less, when standing became harder, when her ordinary pattern of movement started to change.

Those signals were there. The challenge was making them visible.

That is where the next phase of digital health should take us. Not toward collecting every possible data point, but toward identifying the few changes that matter and making sure the right person sees them in time to respond.

India has an opportunity to make function visible within its digital health evolution while that infrastructure is still expanding at scale. It does not require placing sophisticated technology around every older adult. It requires deciding that function is important enough to follow.

Because by the time functional decline becomes a fall, a hospitalization or permanent dependency, the health system has certainly detected something.

It may simply have detected it too late.

The future of functional care should begin before the fall.