Population aging has led to a greater number of seniors, many of whom suffer from multiple ongoing health problems. Unfortunately, the health care system is currently designed to deal with single, sudden and usually curable problems. Providing care to older adults living with frailty is challenging due to comorbidities, multiple providers, multiple care settings, long wait times, inefficient referral processes and insufficient transitional care across settings. As a result, many of these seniors living with frailty have no other choice than to visit crowded hospital emergency departments. One way to respond to these pressures is to improve the ability of Canada’s primary health care providers to deliver care to older people living with frailty.
Very brief tools were used to screen all seniors in the primary care practice, and identify those who were at greater risk of developing problems. Those at higher risk could then be evaluated in greater depth, and connected with appropriate health care services as soon as possible. Our highly qualified team worked with these care practices to develop and evaluate a model of care to accomplish these tasks.