As a partnership between hospitals, community support service agencies and the Toronto Central CCAC, this project helps frail older adults without immediate support to arrive home safely upon discharge from hospital and receive follow-up services at home.
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.
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An effective referral management system that helps hospitals reduce readmissions by referring to community support service agencies in the Toronto Central region.