Primary Care for Frail Elderly

This research project is a collaboration of investigators in Ontario, Quebec, and Alberta to support stronger primary care for older adults living with frailty. Effective assessment of frailty will allow older adults to remain in their homes and communities. Primary care clinicians will use the Assessment Urgency Algorithm tool, which uses a scale of one to six, to determine frailty level. Caredove has configured services to display results in 3 main categories: Prevention & Health Promotion for scores 1 & 2, Community Support Services for 3 & 4 and Specialized Geriatric Services for a score of 5 or 6. This ensures a client is connected to the right type of service, at the right time.

This research project is a collaboration of investigators in Ontario, Quebec, and Alberta to support stronger primary care for older adults living with frailty. Effective assessment of frailty will allow older adults to remain in their homes and communities. Primary care clinicians will use the Assessment Urgency Algorithm tool, which uses a scale of one to six, to determine frailty level. This ensures a client is connected to the right type of service, at the right time.

Caredove has configured services to display results in 3 main categories:

  • Prevention & Health Promotion for scores 1 & 2
  • Community Support Services for scores 3 & 4
  • Specialized Geriatric Services for scores 5 & 6
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Funded ByProject Sponsor

Canadian Frailty Network

Network Search SiteAlberta Network Waterloo Wellington Network

Find and book from organizations in Alberta and Waterloo Wellington areas

Lead Agency

University of Waterloo

Overview

  • Reintegration Care Units (RCU)
    These units support patient transitions from the hospital to short-term transitional care units in the community that provide a safe and supportive place to help patients increase strength, mobility and endurance to support their transition home or into an alternative care setting.
  • Caregiver ReCharge Programs
    These programs provide caregiver relief and improve their capacity to transition their loved one home and continue to provide care for the client while promoting their own wellbeing.  These services include in-home respite (day/night), away from home overnight respite, and/or supervised programming in a group setting during the day (i.e. Adult Day Programs).



  • The Process
    The Centralized Referral Management Team members will confirm eligibility and the client will be matched to a health service provider (of the selected program) by their unique needs and availability, with consideration given to geography where possible.
    The Health Service Provider Team members will then work with the caregiver and/or the clients’ families on a plan for service provision.
  • Agencies
    Bellwoods, Hillcrest Reactivation Centre, LOFT Community Services, Pine Villa Sprint, Providence Healthcare, Reconnect Community Health Services, Rekai Centre Transitional Care Unit, St. Hilda’s Towers Senior Care Unit, Storefront Humber, The Neighbourhood Group, West Neighbourhood House, West Toronto Support Services for Seniors, Woodgreen Community Services

Results

December 2018 project performance

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An effective referral management system that helps primary care provide timely access to community services for frail seniors in areas of Alberta and Quebec, and the Waterloo-Wellington area of Ontario.

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