The Phoenix VA had already partnered with local fire departments to identify chronically ill Veterans needing interim care. Using the existing infrastructure, this project applies additional intelligence to target patients at risk for fall and mitigate this risk through telehealth intervention. The revamped dashboard utilizes an innovative model that combines multiple fall risk factors and stratifies these patients with a weighted scoring system. Veterans at risk for fall are subsequently scheduled for a telehealth visit utilizing Community Paramedic programs and Nurse Practitioners. One year of pre- and post-intervention data has been obtained. The post-fall initiative cohort was much more likely to have an abnormal gait and history of fall. After the intervention, more orders were placed for: PT/OT consults, mobility aids, and fall related labs, imaging, and prescriptions. Our findings highlight a care model to successfully target and provide intervention to a high risk subgroup.