Program overview :

Advancing Frailty Care in the Community Collaborative: Participating Teams

Vancouver Island Health Authority, British Columbia 

Lead Organization 

Island Health 

Target Population and Scope 

Patients over 75 years of age with a frailty score of 4–6 on the Clinical Frailty Scale (CFS). 

The Ladysmith Family Practice Clinic – Frailty Linkages and Improved Outcomes for Seniors 

Island Health aimed to implement the Fraser Health CARES model into the Ladysmith Family Practice Clinic, with the intention that the model would then be scaled out in other Patient Medical Homes in the Cowichan area of Vancouver Island. An in-practice nurse would work with the primary care team to perform a new standardized electronic comprehensive geriatric assessment (eCGA) for adults over 75 years of age who scored 4–6 on the CFS. The eCGA would produce an electronic frailty index. Each patient and their chosen caregivers (e.g. family or friend) would then co-develop their plan of care related to their goals of care with their primary care clinician.

Fraser Health Authority, Aboriginal Health, British Columbia 

Lead Organization 

Fraser Health, Indigenous (First Nations, Inuit and Métis) Health 

Partner Organization 

Fraser Region Aboriginal Friendship Centre Association

Target Population and Scope

Those 65 years of age or older and who were eligible for frailty screening and self-identified as First Nations, Inuit and Métis. 

This team intended to connect Indigenous patients 65 years of age (or older) to culturally safe community-based interventions and provide tools to support them to continue to self-manage their health after the program. The project would utilize a holistic approach in care plan development for First Nations, Inuit and Métis elders which would include spiritual, emotional, mental, physical and traditional approaches, as evidenced by an inclusion care plan.

Fraser Health Authority, Burnaby, British Columbia 

Lead Organization 

Fraser Health Authority; Burnaby Division of Family Practice 

Partner Organizations 

Burnaby Non-Governmental Organizations

Target Population and Scope

Patients 75 years of age or older would be systematically screened for frailty and those who scored 4–6 on the Clinical Frailty Scale (CFS) would complete a comprehensive geriatric assessment. Adults over 65 years of age would be screened for frailty if clinical signs and symptoms warranted it.

Improving Frailty Status in Seniors in the Burnaby Community

Utilizing the CARES model and electronic medical records (EMR) based electronic Comprehensive Geriatric Assessment (eFI-CGA) tool, this project would support multidisciplinary care planning and social prescribing through integration and collaboration between the primary care provider, Fraser Health Authority CARES Licensed Practical Nurse (LPN) and a Senior Community Connector, who would provide patients with tailored interventions to minimize and prevent social isolation. Patients would be followed by their primary care provider and supported in their self-management goals throughout the program so they would be able to better maintain or improve their frailty status (measured by the CFS and the frailty index). 

Fraser Health Authority, Jim Pattison, British Columbia 

Lead Organization 

Fraser Health Authority; Primary Care Clinic; Jim Pattison Outpatient Care and Surgery Centre 

Target Population and Scope 

Patients 75 years of age or older who scored 3–6 on the Clinical Frailty Scale (CFS). Adults 65–75 years of age would also be assessed for frailty if clinical signs and symptoms warranted it. 

Advancing Frailty Care in the Community Collaborative 

Jim Pattison Fraser Health Authority sought to test and adapt the CARES model of frailty care. Qualifying participants would undergo a Comprehensive Geriatric Assessment by a designated Licensed Practical Nurse. Tailored interventions, developed in collaboration with patients and significant others, would be supported by a senior community connector and a multi-disciplinary team. 

Alberta Health Services: North Zone, Alberta 

Lead Organization 

Seniors Health, North Zone, Alberta Health Services 

Target Population and Scope 

Home care clients with a risk of frailty (score of greater than 4 on the Clinical Frailty Scale (CFS)). 

INPACT (Implementation of a Nurse Practitioner Assess, Consult and Treat) model in AHS NZ 

Drawing on the learnings from the COACH PEI innovation and their use of nurse practitioners (NPs) in the community setting, Alberta Health Services (AHS) North Zone’s continuing care programs would implement new NP roles. These NPs would facilitate a collaborative approach, and client/family specific care planning and interventions, to enhance frailty care in the home and designated supportive living settings. Interventions would leverage informal and other community-based resources, helping clients to remain living in their community setting. It was anticipated that NPs would be a valuable resource toward improving patient outcomes and patient satisfaction as well as in supporting care teams to provide safe and quality patient care. 

Sage Seniors Association, Alberta 

Lead Organization 

Sage Seniors Association in collaboration with Athabasca University 

Partner Organizations 

Sage Seniors Association, Edmonton; Edmonton Oliver Primary Care Network, Seniors’ Community Hub; and Glenrose Rehabilitation Hospital 

Target Population and Scope 

All patients aged 65 years and older who scored 4–6 on the Clinical Frailty Scale (CFS). 

BuilDing Resilience And RespondinG tO SeNior FraiLtY (DRAGONFLY) 

Sage Seniors planned to use a modified version of the Seniors Community Hub intervention and existing systems in place to address three core elements of practice change: frailty identification, geriatric assessment and tailored intervention. Using a combination of both the CFS and Vulnerability/Resiliency assessment, this project aimed to identify opportunities for interventions that sought to decrease patients’ vulnerability and increase their resilience. After implementing the tailored intervention(s), the primary care providers would reassess the patient’s CFS score at three, six and 12 months.

Southern Alberta HIV Clinic, Alberta Health Services, Alberta 

Lead Organization 

Alberta Health Services 

Partner Organizations 

Southern Alberta HIV Clinic; Sheldon M. Chumir Health Center; Kerby Centre; HIV Community Link, Calgary, Alberta 

Target Population and Scope 

Patients aged 50 years and older living with HIV and who received HIV care at the Southern Alberta HIV Clinic. 

Platinum Navigation: A Clinical Care Pathway for Frail Older Adults Living with HIV 

The Southern Alberta Clinic would implement a clinical care pathway for frail older adults living with HIV to implement routine, annual frailty assessments for all patients 50 years and older. Patients would be assessed at each visit using the Clinical Frailty Scale (CFS), with those identified as vulnerable/frail by a score of 4 or above being further assessed for conditions commonly associated with frailty. The project would also focus on improvements in quality of life; caregiver burden; falls and impaired gait or balance; medication review, including number and type of non-antiretroviral medications; unintentional weight loss; loneliness; and subjective cognitive decline.

The Alex (Alexandra Community Health Centre), Alberta 

Lead Organization 

The Alex (Alexandra Community Health Centre) 

Partner Organization 

Calgary West Central Primary Care Network and Carya (formerly Calgary Family Services) 

Target Population and Scope 

Patients of the Alex Seniors Health Centre aged 65 years and older and who scored 4 or above on the Clinical Frailty Scale (CFS). 

Screening for Frailty in Low-income, Socially-isolated Older Adults with Complex Health Conditions (“Frailty Project”) 

The Alex Community Health Centre includes a Seniors Health Centre that provides comprehensive health and social care to low-income, socially-isolated seniors with complex health issues. The Frailty Project would determine if assessing low-income, socially-isolated seniors for frailty helps to ensure that they receive additional health and social services and if such services improve self-reported health, quality of life and social isolation. Patients scoring 4 or above on the CFS would be offered a referral to allied health professionals, health specialists and/or social programming provided by The Alex or by partner agencies. Assessment tools for frailty, self-reported health, social isolation and quality of life would be incorporated into the Alex’s social database system to link patients with health and social services.

Saskatchewan Health Authority, Saskatchewan 

Lead Organization 

Primary Health Care Network 5, Saskatchewan Health Authority 

Partner Organizations 

Cypress Regional Hospital, Swift Current; Associate Family Physicians Clinic, Swift Current 

Target Population and Scope 

Patients aged 75 years and older identified through Wellness Clinics, Home Care, Associate Family Physicians Clinic and other program areas where possible (e.g. Therapies). 

Frailty Assessment by Collaborative Teams in SHA Network 5 (FACT-5) – Assessment and Management of Frail Older Adults in Swift Current, Saskatchewan 

This project would combine features of the CARES model and C5-75 programs and take an interdisciplinary, team-based, patient- and family-centered approach. The team would offer Level 1 screening to older adults attending any Swift Current Wellness Clinic who identified as having a physician at Associate Family Physicians. In addition, the team would offer screening through the physician clinic, as well as through other program areas with capacity (e.g. Home Care, Therapies). If the patient should screen positive, they would be recommended a level 2 assessment at a separate scheduled visit. If the patient should screen negative, they would still be offered preventative educational materials and information on resources in the community. 

Winnipeg Regional Health Authority, Manitoba 

Lead Organization 

Winnipeg Regional Health Authority (WRHA) 

Partner Organizations 

WRHA Integrated Palliative, Primary and Home Health Services; Elemental Professional Health Centre – Fee for Service Physician at 1600 Pembina Highway Winnipeg; ACCESS Fort Garry – WRHA Primary Care Clinic; WRHA Rehabilitation, Healthy Aging & Seniors Care; A & O: Support Services for Older Adults; Shared Health, Interlake Eastern Regional Health Authority; and patient and caregiver advisors 

Target Population and Scope 

Patients of Elemental Professional Health Centre and ACCESS Fort Garry aged 65 years and older and living within the WRHA region. 

Addressing Frailty with Community Collaborative Teams 

Adapting the CARES Model, two WRHA primary care sites (Elemental and ACCESS Fort Gary) planned to use electronic medical records to identify adults aged 65 years and older to be screened for frailty. Primary care providers would use the Clinical Frailty Scale (CFS) to assess their level of frailty. Individuals who scored 1–3 on the CFS would not undergo further assessment but would inform discussion around health promotion and illness prevention. Individuals who scored 4–6 on the CFS would have further assessment using the Edmonton Frailty Scale to identify domains of frailty that may require additional community supports. Those with high scores, 7–9, might be directed to the Geriatric Program Assessment Team, the geriatric clinic or other regional supports such as palliative care for comprehensive assessment. Based on the assessment and the patient’s goals, the primary care team, patient and caregivers would jointly develop a personalized care plan and help to connect patients to appropriate resources.

Centre for Family Medicine, Ontario 

Lead Organization 

Centre for Family Medicine Family Health Team 

Partner Organizations 

Canadian Mental Health Association Waterloo Wellington; Schlegel-UW Research Institute for Aging; Waterloo-Wellington Specialized Geriatric Services 

Target Population and Scope 

The Centre for Family Medicine would include all people being assessed in four Multi-specialty INterprofessional Team (MINT) Memory Clinics within the project timeframe aged 65 years and older who consented to participate. 

Expanding C5-75: Primary Care Screening for Frailty in Older Adults with Cognitive Impairment 

The Centre for Family Medicine would extend the C5-75 program to systematically screen for frailty in older adults who have memory concerns. Dementia reduces the person’s ability to self-manage co-existing chronic conditions; the ability to self-manage is key to maintaining the stability of conditions such as heart failure, diabetes, Chronic Obstructive Pulmonary Disease and falls. Early identification of frailty in people who are cognitively impaired offers the opportunity to identify those at the highest risk of poor outcomes and target proactive primary care interventions accordingly. Therefore, this project planned to adapt and integrate the C5-75 program into four Multi-specialty INterprofessional Team (MINT) Memory Clinics.

New Vision Family Health Team, Ontario 

Lead Organization 

New Vision Family Health Team 

Partner Organizations 

eHealth Centre of Excellence; Waterloo Wellington Local Health Integration Network; Grand River Hospital; St. Mary’s General Hospital; Canadian Mental Health Association Waterloo Wellington; and Specialized Geriatric Services IGSW program 

Target Population and Scope 

All senior patients of the New Vision Family Health Team aged 65 years and older. 

Enhanced Complex Care Program 

New Vision Family Health Team would use a shared care program led by nurse practitioners who would work with nurses, a clinical pharmacist, the patient’s family doctor and a geriatrician. They would use the Assessment Urgency Algorithm for case findings, and patients identified would undergo an assessment based on the Canadian Geriatric Society 5M approach, with the program acting as the main point of access to primary care. The team would also work to standardize the comprehensive assessment by using the interRAI Self-reported Check Up instrument. The project sought to improve patient-centered outcomes and reduce health service use for frailty primary care patients with multiple complex chronic conditions and geriatric syndrome. The project also sought to strengthen community partnerships, including between home care and community services and hospitals to improve care transitions, with emergency medical services to promote appropriate ER diversion, and to promote eConsults by specialists. 

Champlain Care Network, Ontario 

Lead Organization 

Bruyère Research Institute and the Department of Family Medicine, University of Ottawa 

Partner Organizations 

Bruyère Continuing Care; Bruyère Research Institute; The Ottawa Hospital Research Institute; Hôpital Montfort; Ontario eConsult Centre of Excellence; Ottawa Practice Enhancement Network (OPEN); Ottawa Public Health; Perley and Rideau Veterans’ Health Centre; Regional Geriatrics Program of Eastern Ontario; The Ottawa Hospital, Riverside; University of Ottawa; Winchester District Memorial Hospital 

Target Population and Scope 

Each pilot clinic would identify its own target population and scope. 

Champlain Care Network Frailty Collaborative 

Hosted by the University of Ottawa Department of Family Medicine and Bruyère Research Institute, a network of partnering organizations would act as a hub, overseeing improvement projects in four pilot clinics (Family First Health Team, Greenboro Family Medicine Centre, Centretown Community Health Centre and Somerset West Community Health Centre) and supporting the staggered rollout in the other clinics. Each pilot clinic intended to develop an improvement project that met the needs of their patient population – the screening tools, geriatric assessments and interventions would all be based on the needs, preferences and resources of the individual clinics. The network would provide opportunities for the clinics to exchange experiences to keep learning and informing implementation through Plan, Do, Study, Act cycles. The network would also facilitate meetings with the participating clinics in order to develop recommendations for a common approach for frailty assessment and interventions.

Wawa Family Health Team, Ontario 

Lead Organization 

Wawa Family Health Team (WFHT) 

Partner Organizations 

Wawa Senior Goose Club Drop-in Centre; Fenlon’s Pharmacy; Canadian Red Cross; Alzheimer’s Society; Home and Community Care North East Local Health Integration Network; Lady Dunn Health Centre 

Target Population and Scope 

All rostered patients aged 75 years and older. 

Helping Hands Here for You 

Using a combination of Frailty or “Wellness” screening (based on the COACH model) and the C5-75 hand grip and gait speed measurement system, the team planned to screen patients aged 75 years and older. The providers would assess each patient seen and ask where they felt their initial assessment scoring was. The patients within the 4–6 score range or vulnerable to moderately frail would be referred on for the quantitative screen by additional WFHT staff. All patients and caregivers would be connected to available services and resources in their community to assist them in remaining in their homes for longer and improving their quality of life. The aim, past the project’s completion, was that early identification would become standard practice within the healthcare service.

Gateway Community Health Centre, Ontario 

Lead Organization 

Gateway Community Health Centre 

Partner Organization 

Canadian Association of Community Health Centres 

Target Population and Scope 

Gateway Community Health Centre (GCHC) rostered patients aged 65 years and older for screening. Patients who scored 4–6 on the Clinical Frailty Scale (CFS) would be eligible for system navigation. 

System Navigation as a Primary Care Model for Improving Care for Older People with Frailty and Supporting their Family/Friend Caregivers 

GHCH’s initiative would build on its System Navigation Model to advance frailty identification and assessment and improve patient outcomes. System navigation offers a single point of contact addressing the patient’s and family’s medical and social needs, reducing duplication of services. The system navigator (SN) supports frail patients through a Coordinated Care Plan (CCP), developed with the SN through the patient’s perspective, to identify their personal health and wellbeing goals and priorities. The SNs are bringing care for patients closer to home, by providing the right care at the right time, in the right place. GCHC would also implement the caregiver strain index for patients who have had support through a caregiver. The project would allow GCHC to leverage quality improvement and change management approaches.

Extra-Mural Program, New Brunswick 

Lead Organization 

EM/ANB Inc. 

Partner Organizations 

Medavie Health Services New Brunswick; Horizon Health Network – McAdam Health Centre and Saint Mary’s Health Centre 

Target Population and Scope 

Patients aged 65 years and older: 

  • with a high level of suspicion of frailty (e.g. unintentional weight loss, incontinence, delirium, dementia, declining functional status, immobility, recent falls, polypharmacy, social isolation and caregiver stress) and identified through a case finding approach. Patients would then be screened for frailty using the Clinical Frailty Scale (CFS) 
  • who were high users of the system – Extra-Mural Program (EMP) patients who visited the emergency department ≥ 3 visits a quarter and ≥3 hospitalizations a year. 

FRAILTY NB 

The EMP team would enhance their capacity to partner with primary care providers, patients and caregivers in primary care settings to apply evidence-based innovations (specifically the C5-75 and COACH tools) as well as a comprehensive frailty assessment in populations aged 65 years and older with a confirmed CFS of 6 or above. The key innovation the team would put in place would be a registered nurse (RN) Case Manager for patients identified as at risk for poor outcomes based on frailty. Patients scoring 6 or above on the CFS would be eligible for the RN Case Manager intervention.

Western – Eastern Health, Newfoundland & Labrador 

Lead Organization 

Western Health 

Partner Organizations 

Eastern Health (also piloting the project) and Central Health 

Target Population and Scope 

Patients aged 65 years and older who scored 4–6 on the Clinical Frailty Scale (CFS) and consented to a referral to the Community Support Program. 

Frail Older Adult Community Care Initiative (FOCI) 

Western Health’s project planned to focus on four clinics located in the Eastern Health and Western Health authority regions. Screening would be conducted by a Licensed Practical Nurse who would administer the CFS to patients aged 65 years and older. Patients who scored 4–6 on the CFS would be referred to the Community Support Program. After referral, patients would receive a comprehensive assessment via the RAI-HC by a case manager in consultation with a social worker. Care planning would engage other interdisciplinary team members as appropriate, including physiotherapy, occupational therapy, pharmacy and recreation therapy as well as the patient and caregiver.