Storyboard Forum Presenters

Primary Care

The Balance Toolkit: A Clinic-in-a-Box to Assess Human Balance and Mobility: Ben Cornish, University of Waterloo


Poor balance and mobility is a major challenge in health. Older adults living with frailty and others with strokes or injuries often suffer from balance/mobility issues. About 180,000 falls annually result in serious injuries in Canada. Assessing balance and walking to guide clinical decision-making is critical to preserving health, maintaining independence and lowering healthcare costs. Current precise measurement equipment is expensive ($20,000+), out-of-reach for rehabilitation clinics, physicians, retirement and long-term care facilities. Timed tests and visual observation used in clinics lack sensitivity and precision to detect important changes. A low-cost, easy-to-use, point-of-care assessment of balance to inform clinical care is needed.

Our team wanted to create an affordable way to assess balance, mobility and cognition precisely in literally any healthcare setting. The imagined toolkit needed to be simple to use, portable and cost significantly less than $3,000 so family physicians, physiotherapists or other healthcare professionals could assess balance and mobility. We imagined a toolkit providing precise, accurate measurements so better assessment of conditions leading to falls. The envisioned system, sampling data from several wearable devices, would produce a large data set of clinical results that can be analyzed for further insights into frailty and other balance related medical conditions.

It couples a tablet-based data collection, analysis, and reporting system with light-weight wearable wireless devices (accelerometers) to monitor standing and walking activities. One accelerometer is attached to the waist and one on each ankle. It uses sensor technology to wirelessly interact with an easy to use software interface that can provide immediate reporting of relevant outcome measures.

We are on our third round of usability testing to evaluate the technology by physiotherapists on their clients in a clinic.

The system aims to preserve the ease-of-use of traditional assessment tools while improving diagnostic and prognostic potential. The Toolkit provides a sensitive and precise method for measuring balance and it captures data from each session for present and future big data analysis. If successful, the toolkit could serve both as a rapid screening tool and also as an essential source of quantitative information to guide clinical decision making.

MyCareMapp: Kassandra Lemmon, University of Waterloo


Older Canadians living with frailty often receive care from a variety of providers across multiple health care settings, which requires effective coordination and communication. Mobile health technologies can play an important role in facilitating patient-provider interactions and improving the experience of older adults living with frailty.
MyCareMapp is an innovative mobile health application co-designed by older adults, caregivers, health care providers and researchers as part of the Canadian Frailty Network-funded grant, “Transforming primary care for older Canadians living with frailty”. Older adults living in various care settings can use MyCareMapp to store, monitor and share their health care information with caregivers and their health care providers.
MyCareMapp includes tabs for:
• Profile to store personal information and record notes on details such as health conditions and medication lists
• Care Team to organize detailed contact information of all their caregivers and health care providers
• Calendar to record appointments and set reminders (e.g. daily medication reminders)
• Health Tracker to track and graph any relevant health details (e.g. weight, blood pressure or physical activity)
• Notifications to view a list of all upcoming appointments and scheduled reminders
An evaluation of MyCareMapp will occur from March to September 2019 as five to seven older adults at each of the nine primary care study sites across Alberta, Ontario and Quebec engage in the app trial. Qualitative interview data will be transcribed verbatim and analyzed with NVivo12 software and emerging themes will be identified. Quantitative usage data will be analyzed related to each unique app feature.
MyCareMapp supports and promotes self-management of health providing an important link between patients, their caregivers and health care providers. MyCareMapp facilitates health communication and may be useful in showing patterns and changes in health status or to identify areas of health where additional assistance is required. With MyCareMapp available at no cost through the App Store and Google Play, users from across the country can access and use this tool to coordinate and manage their care.


Camrose Primary Care Network Collaboratory– Geriatric Assessment Program and Integrated Care: Siu Mee Cheng, Ryerson University

Camrose is a small rural Alberta community that is comprised of approximately 18,000 inhabitants. Approximately 25 per cent of the population is 65 and over. The aging population has been a key driver towards integrated health and social care by the Primary Care Network (PCN) and its various health and social care partners. A geriatric assessment program (GAP) was created by the PCN, that provides family physicians in the communities served, including the physicians in the PCN with greater supports for a growingly more complex aging patient population. This GAP was developed in partnership with Alberta Health Service’s Mental Health Outreach Team (MHOT) that provides in-home assessment and other supports and referrals. The establishment of GAP launched an active engagement with various healthcare and social care organizational partners in order to seek greater services collaboration in order to provide a more holistic approach to vulnerable seniors living in the community. As a result, an informal collaboratory has been established the comprises a mix of healthcare and social care partners that has been in existence for approximately seven years in the community. The initiative comprises patient assessments, referrals to health and social care services, patient and caregiver education, and health and social services provision. The other partners include homecare, homemaking and Meals on Wheels, financial support services, and Alzheimer’s Society, to name a few. The aim of the collaboration is to ensure that vulnerable elderly patients and their caregivers are better supported in the community. The collaboration has resulted in positive outcomes for patients. There are high levels of patient satisfaction, patients are able to stay in the community longer, and greater caregiver relief and support. Other positive outcomes include greater services coordination among the organizational partners, greater referrals among the organizational partners, and higher levels of trust among partners.



Long-Term Care

Supportive Oral Health for Seniors: Nelly Villacorta-Siegal, RHD, Baycrest

Regular, preventative oral health care treatments have shown to decrease incidence of oral disease and systemic illnesses, in addition to preserving eating abilities and reducing mouth pain . However, the practice of preventive mouth care is poorly executed with frail seniors living in long-term care homes (LTCH) due to physical and behavioural challenges. To meet the growing demand to provide appropriate and timely oral healthcare to LTC residents, Baycrest Health Sciences launched a novel oral healthcare delivery model called Supportive Oral Health for Seniors (SOHS). This model empowers personal support workers (PSWs) and nurses to screen for oral health issues, and refer residents directly to a self-initiated dental hygienist (SIDH).

Supportive Oral Health for Seniors (SOHS) is a systematic process intervention for older adults living in Long term care (LTC). The program includes three key activities:

(1)         PSWs and nurses completed an education session, which incorporated effective oral care techniques, and screening for dental concerns.

(2)         A referral tool, built into the electronic medical record of the LTCH enables staff to refer to a self-initiated dental hygienist.

(3)         The referral will generate:

Facilitated inter-professional coaching sessions on the unit for residents and formal and/or informal caregivers who required extra support. Fee for service dental hygiene treatment of scaling and root planning.

SOHS successful developed, implemented, and evaluated a new interactive eLearning oral care module for frontline LTCH staff. It also resulted in the development and refinement of a reproducible, streamlined SIDH referral process that is currently operational in three LTCH in the GTA.

SOHS met the growing demand to provide appropriate and timely oral healthcare to LTCH residents, this model revolutionizes the traditional oral care delivery process by prioritizing preventive oral care and empowering frontline LTCH staff to provide these services.

SeeMe: Understanding frailty together: Andrea Liu, MHA, Perley Rideau Veterans’ Health Centre

At the Perley Rideau and Veterans’ Health Centre, we see first-hand the increasing number of seniors living with more chronic conditions, with more advanced stages of frailty. Because frailty has an impact on health outcomes, we wanted to shift current long term care practices within our organization such that frailty is at the forefront of every aspect of care in order to better improve the care of residents.
SeeMe: Understanding frailty together is a comprehensive frailty-informed framework that recognizes and assesses frailty as part of a person’s overall health and supports residents and their families to make informed decisions around treatment that may be helpful or harmful within the context of frailty. Some of the tools of the frailty-informed care program include a Comprehensive Frailty-Informed Assessment which reviews several drivers of frailty and assigns a frailty score, and a Goals of Care tool which is embedded within the annual care conference structure that discusses the resident’s values, preferences, and goals in relation to future health and personal care preferences. These tools help guide the management of acute health events with a resident and family-centred frailty perspective.
The evaluation is currently in development and will be implemented shortly. The evaluation consists of surveys for families and front line staff that ask about factors like the usefulness of the training, the utility of the tools, and satisfaction with the new processes. It will also examine health outcomes at the person and system level, including adherence to care preferences such as transfers to hospital and care pathways. The evaluation will also help us make improvements to the model and develop an approach for sharing the model with other LTC homes.
It is anticipated that residents and families will feel that the care team understands what is important to them, that their care preferences are being followed, and that the model contributes to a greater sense of well-being and quality of life for older adults living with frailty. At a system level, it is anticipated that the number of unwanted/unnecessary transfers to hospitals following acute health events would decrease.

ABLE – Arts-Based exercise enhancing LongEvity: Caitlin McArthur, BSc(KIN), MScPT, Ph.D., GERAS Centre for Aging Research, McMaster University


PrescribingVR: Lora Appel, PhD., UHN OpenLab

Older adults living with frailty experience reduced mobility, often becoming confined indoors and isolated, which aggravates symptoms of depression, anxiety, and apathy. As Virtual Reality (VR) technologies become increasingly accessible and affordable, there is a unique opportunity to enable these older adults to escape from their confined reality and be transported to interesting and calming places, an experience that may reduce boredom, apathy and depression, and improve wellbeing. Studies already demonstrated benefits of VR in other patient populations (managing anxiety in pediatric patients; reducing pain in burn patients undergoing wound dressing changes); however, to date no systematic evaluations of the feasibility of using VR with older adults living with frailty have been undertaken. VR may prove to be a safe and inexpensive means of managing symptoms in this growing demographic.

The objectives of this innovation is to evaluate the safety, tolerability and ease of use of immersive VR head-mounted-displays and explore the potential for VR experiences to reduce symptoms such as apathy and depression in older adults living with frailty.

Sixty-six older adults living with frailty (avg. age= 81) with different degrees of physical (requiring wheelchair/ walker) and cognitive impairment (normal=28, mild=17, moderate=12, severe=3), were recruited into a non-randomized intervention study at four sites across Toronto (senior hospital, rehabilitation hospital, long-term care home, centre for memory loss). Data was collected through a pre-intervention survey, standardized observations during the intervention, and post-intervention semi-structured interview. The intervention session consisted of viewing 5-20 minutes of 360° VR-footage of nature scenes displayed on SamsungGearVR.

All participants completed the study; no negative side effects were reported (no dizziness or disorientation, no interaction with hearing aids). Participants tolerated well the VR headset; some stating they “forgot I had it on”, others reporting “it was worth the mild discomfort”. Image focus was critiqued and increasing the narrative content could improve experiences. Most participants reported feeling more energetic, 40% indicated VR helped them relax; 80% wanted to try VR again, and 75% would recommend the experience to a friend.

It is safe and feasible to expose older adults living with frailty to immersive VR. We recommend further research to evaluate the potential psychological and bio-physiological benefits of VR.


ABLE – Arts-based exercise enhancing LongEvity: Caitlin McArthur, BSc(KIN), MScPT, Ph.D., GERAS Centre for Aging Research, McMaster University

Older adults with frailty are often prescribed home exercises by physical therapists to improve functional outcomes, but they often are unmotivated or forget how to practice them. Interactive technology can guide older adults through proper technique and make exercise pleasurable, increasing the likelihood of use. Current such experiences (e.g., Nintendo Wii, Xbox Kinect) do not meet the distinct needs of frail, older adults with cognitive and physical impairments. Most offer sports activities not geared to older adults’ interests or balance and strength building needs. ABLE (Arts-Based Exercise Enabling Longevity) fills these gaps, offering an arts-based experience providing exercise that is playful and engages users socially. Art and music are powerful therapeutic activities that motivate physical activity and may enhance cognitive, physical and emotional health.

ABLE translates the movements of older adults into artistic expressions—a colorful path of footprints and musical effects appear in direct response to participants’ movements. ABLE provides tutorials demonstrating correct exercise practice. The system includes: a wireless shoe sensor, tablet, and a screen with speakers (e.g., television). When the older adult steps, balances or lunges, the sensors transmit data, producing the audio-visual response on tablet or TV. The tablet is used both by the physical therapists to prescribe exercises and older adult and/or family members to start and end the experience. We have held 2 focus groups with older adults and 2 with service providers to obtain input on the design of the ABLE app and experience. We are currently pilot testing in the homes of 25 older adults to be completed in August 2019, and measuring the effects on older adults’ physical activity, strength, balance and falls. We will continue to gather feedback from stakeholders to design to participant needs and interests.

ABLE allows older adults, with or without cognitive impairment, to engage in pleasurable, art-based exercise, while socializing with family, peers, and care providers. ABLE reduces boredom and stimulates new learning, while exciting enthusiasm in physical activity. Offering exercise, creative activity, and socialization, ABLE aims to reduce isolation, while keeping older adults physically and mentally fit.

Home Care

Ring of Support: Linda Kaleis, Memotext; Joe Au-Yeung, SE Health

MEMOTEXT, leader in personalized digital health solutions, has developed the Ring of Support (RoS) program which will support both caregivers/care providers and the seniors they are caring for who are living with mild cognitive impairment/early-stage dementia. RoS is a personalized digital engagement system incorporating the use of smart assistants (the Amazon Echo) to prolong independence for seniors at home and provide peace of mind while reducing the burden of stress for the caregiver.

RoS supports individuals to age in the comfort of their own home as independently as possible, at the same time providing the necessary supports to the often unrecognized second individual affected by the disease, the caregiver themselves. Seniors will: have access to medication/event/appointment reminders; be monitored through morning and evening wellness check-ins; and have access to in-person support through SE Health’s community response team. Caregivers will: receive remote-monitoring updates about the senior with senior dashboard access to track trends over time as well as adaptive mental/caregiving strategy supports. Both end users can interact with the system through personalized multi-modal communications that use interactive voice response (IVR), SMS, e-mail, and the Amazon Echo.

RoS will be piloted with one of Canada’s leading and diversified home health companies, SE Health, and their senior population for a 6-month user experience study with ~60 clients. A high touch escalation service is included for homecare clients, featuring a community response team that can be deployed to support the senior in the home if risk is detected, with the eventual goal of predicting risk.

The expected results of the evaluation are that the client experience is improved, which will be captured using satisfaction of technology use/program experience surveys. Our evaluation of user experience with RoS will also measure clients’ feelings of support (expected to improve), in particular due to the specific component of 24/7 access to community field staff. We also expect an increase in seniors’ self-reported feelings of support to age at home. Lastly, we might also see an increase in caregiver self-reported comfort with the older adult they care for to age at home.

SE Health

Alternate Level of Care Prevention Pathway Pilot for Seniors with COPD and/or CHF: Melissa Aldoroty, B.Sc, B.ScOT, OT Reg. (Ont.), MHM (in progress), Mississauga Halton LHIN

Patients requiring an alternate level of care (ALC) is a top issue being addressed within the Mississauga Halton LHIN. Seniors with COPD and/or CHF were found to frequently be deemed as needing an ALC, having frequent hospital utilization and are not able to return home. The purpose of this pilot project is to conduct a test of change, implementing a multidisciplinary intervention approach to support this population. The program involves the provision and teaching of self-management strategies for patients with chronic disease, geared towards supporting patients with COPD and/or CHF within their homes, with an attempt to reduce hospital utilization and subsequent ALC designation.

The program is a 12-week intervention approach whereby the patient receives ongoing intervention from a personal support worker (PSW), rapid response nurse (RRN), occupational therapist (OT), physiotherapist (PT) and ad hoc nurse practitioner (NP). The patient’s care coordinator through the LHIN identifies the patient through the hospital inpatient unit or community and supports the patient as needed through the program. Intervention consists of clinical visiting, symptom screener PSW calls and biweekly care team case conferences. The PSW within this program is not providing personal care, but rather using a new skill set remotely, conducting a screener with the patient over the phone weekly while on the program. Through the screener results, if the patient is found to be having difficulty, the concern is escalated to the RRN. An NP is available for further escalation if the RRN has exhausted all resources.

Evaluation will include process of the program, patient satisfaction, whether the patient felt self-management skills were adopted at program end, as well as were goals and expectations met from patient and clinician perspectives. Data will be also be obtained for pre- and post- hospital utilization, pathway length of stay, number and percentage of ALC cases related to chronic disease and average cost of patient on the pathway.

Observed and reported impact includes increased efficiencies accessing needed services and promotion of inter-professional care, as well as a focus on better patient care with improvements to medication management and self-management.

Caring Near and Far: Lorie Donelle, RN, PhD., Western University

Older adults face health challenges that may lead to decline and frailty. Despite these challenges, older adults want to remain in their homes. Twenty-five percent of Canadian adults 65 years of age and older receive only partial home care services. Family/friend caregivers may be key to whether or not these older adults can remain in their own home. Remote monitoring technologies (RM) in the home may support older adults to remain in their homes. The primary aims of our pragmatic randomized clinical trial (PRCT) are to test whether RM along with usual home care (intervention) versus usual home care alone (control) can support these older adults to remain in their home longer and delay or avoid admission to higher levels of care and reduce caregiver burden.

Two provincial home care providers partnered with a company that provides RM technology which monitors the activity of clients in their home. The vendor offers customizable sensors that are adapted to client’s patterns of behavior. Together with the vendor, the client and caregiver determine the “rules” for sensor notification based on the typical activities of the client and these ‘rules’ are programmed into the system. Notifications can be received by the caregiver via text, email, or phone. The caregivers only receive notifications for activities (or non-activities) that are out of the norm for the older adult.

The study is gathering quantitative and qualitative data at baseline, 6 months and 12 months from home care clients and their family/friend caregivers in Ontario and Nova Scotia. This presentation will describe the study’s preliminary data analyses. Baseline profiles of home care recipients and family caregivers; levels of caregiver burden, risk of hospitalization, positive aspects of caring will be presented.

Findings from this PRCT will provide data to help healthcare decision-makers and providers understand the benefits and challenges to offering RM to home care clients. With an aging population, this technology may reduce institutionalization and promote safe and independent living for the elderly as long as possible and reduce caregiver burden.

Community Care

Paul’s Club: Alison Phinney, PhD. RN, University of British Columbia

Paul’s Club is an independent social activity group in downtown Vancouver for people with dementia. It began as a grassroots social enterprise in 2012 when Nita Levy, a retired nurse, became aware of the growing numbers of younger people living with dementia who were at risk for social isolation and whose families were experiencing significant stress. She learned that social activity programs were beneficial, but existing models were focused on older people with physical frailty. People who were cognitively frail but physically well were falling between the cracks. With this knowledge, and a community grant in hand, she and her husband hired a recreation therapist and Paul’s Club opened a few months later. By January 2013, the club had 15 members. It has continued unabated ever since. With a broad referral base, membership now approaches 30, including men and women of diverse backgrounds between ages 46 and 78.

Paul’s Club is about having fun in an everyday environment; the group meets in a hotel and there is no “program” per se. Mornings begin with coffee, pastries, and friendly conversation. Group activities like dancing, yoga, or exercise may follow. Everyone eats lunch together at a nearby restaurant, and then goes for a leisurely walk in the afternoon, ending always at a gelato shop.

Since their start, Paul’s Club has conducted two formal evaluations based on family surveys and interviews, and UBC researchers conducted an ethnographic study to understand the impact of the program and how those outcomes were achieved. Beyond this, the leaders have conducted regular informal evaluations to inform ongoing program development and sustainability.

By keeping the focus off dementia and creating a place of belonging in the community, Paul’s Club helps members experience improved quality of life and better physical and emotional well-being. They enjoy renewed social connections, they are happier, and many have improved sleep. Families themselves feel better able to cope, with some even returning to work. Evidence suggests that Paul’s Club may help some people stay at home for up to two years longer than they might otherwise have done.

Connections for Seniors: Mohamed Abdallah, Connections for Seniors


Connections for Seniors is a very newly established (2018) non-profit organization designed as an innovative and inclusive response to older adults’ need for emergency housing. Many socially isolated, older adults living with frailty have no place to turn when they are evicted from housing or even when they are discharged from hospital requiring moderate supervision. Connections for seniors programs include a shelter program for older adults as well as an outreach program that supports older adults in crisis or at risk of losing their housing. Connections for Seniors staff liaise with health care systems to facilitate wrap-around services such as home care, nursing, equipment borrowing, and incontinence support in a way that preserves dignity and allows older adults to pursue sustainable housing that meets their needs and levels of care. This is the first homeless shelter catering specifically to older adults in Newfoundland & Labrador.
Upon referral from diverse organizations, including hospitals and non-profit organizations, Connections for Seniors staff meet with the older adult to complete intake. Using a case management approach, Connections for Seniors provides emergency housing, and works to connect the older adult to resources in the community as needed, including transportation, outreach, community support, and recreation. The overall goal of Connections for Seniors is to aid the individual in securing long-term housing, such as placement in long-term care, living with family, or moving into independent housing.
Statistics have been tracked and compiled since the beginning of the program including the total number of individuals who have been admitted and turned away from Connections for Seniors, the reason for being turned away, and referral sources. Connections for Seniors is currently developing an exit survey for clients to evaluate Connections for Seniors and its services. A formal evaluation of the program has not yet been undertaken.
Connections for Seniors provides a comprehensive case management approach to managing the complex needs of socially isolated older adults living with frailty. In addition to the important element of emergency shelter, case managers at Connections for Seniors work with older adults to connect them to essential services, to address the root cause of homelessness and, ultimately, to acquire long term safe and appropriate housing.

Health TAPESTRY: Julie Datta, MSW, RSW, McMaster University


An aging population with varying health conditions creates a myriad of challenges for a health care system that has limited human and financial resources. Despite health care system changes in the past decade, Canada still lags behind other developed countries in many areas of primary care reform, including timely access to care, coordination of care and patient-centred approaches, and team-based care. The Health TAPESTRY approach integrates components within primary, home, and community care to enable person-centred coordinated care at the population and individual level.
Health TAPESTRY is a community-based program that aims to help people stay healthier for longer in the places where they live. In Health TAPESTRY, volunteers visit patients at home to learn about what matters most to that person and their health goals. This information is collected and recorded using a special web-based technology call the TAP-App. The TAP-App is equipped with a number of evidence-based and open-ended surveys that collect information on a number of domains related to frailty, such as mobility, falls, polypharmacy, physical activity and sedentary behaviour, quality of life, and daily life activities. This information is then electronically sent to the person’s primary health care team via the TAP-App. The team uses the information to identify any gaps in their care and connect them to supports that will help address their goals. Volunteers also play a role in connecting patients to health and social services in the community by identifying and addressing access barriers, filling a gap in the formal health care system while enhancing the efficiency and effectiveness of that system.
This proactive approach helps to identify older adults living with frailty, risk of falls, polypharmacy, loneliness, or poorly controlled complex medical conditions early so that they are connected with supports to slow or prevent their risk trajectories. To date, 301 people have been enrolled in our current implementation of Health TAPESTRY across six sites in Ontario. Of the 150 intervention patients, 139 (93%) had sub-optimal physical activity, 113 (75%) had some walking mobility limitation, 55 (37%) had a previous fall within the last year, and 49 (33%) were taking 5 or more prescription medications. Other risks and needs were identified through the reports that are not included in this submission, including nutrition, sleep, memory, and advance care planning, as well as patient-articulated health goals. Information is used in planning care by the interprofessional health care team during ‘huddles’ at the clinic.
Our initial randomized controlled trial evaluating Health TAPESTRY showed that participants experienced a decrease in hospitalizations, increased visits to primary care, and increased time walking. The approach also strengthened team-based care planning among interprofessional teams. The research also highlighted learnings about the experience of volunteers, who found the role meaningful and beneficial because it led them to reflect on their own health. We are now implementing this program in six communities across Ontario to learn whether similar results can be replicated. Using the RE-AIM framework and Normalization Process Theory, the evaluation will measure the program’s impact on patients and their health care teams. We are also conducting a volunteer program evaluation and a cost-effectiveness analysis to learn about the program’s scalability, with the overall goal of spreading this program nationwide.



The Windsor-Essex Compassionate Care Community: A compassionate community initiative for improving the quality of life of individuals living with or at risk for frailty: Kathryn Pfaff, BSc(NUR), MScNUR, Ph.D., University of Windsor,University of Windsor

Social isolation is a serious public health issue. Older adults who are lonely and social isolated are at risk for frailty, which increases the risk of disability, hospitalization and death. Compassionate Communities (CC) is a theory of practice that emphasizes the responsibility of society to address the universal needs of its most vulnerable citizens. Citizens are mobilized as partners with health and social care entities and other stakeholders to connect them to resources and/or empower them to act on their self-identified needs, preferences and goals.

The theory can be applied to any community’s context. The Windsor-Essex Compassionate Care Community (WECCC) is an exemplar CC model. Since 2014, WECCC has mobilized over 85 organizations to improve the health of vulnerable clients in Windsor Ontario, and its surrounding municipalities. WECCC staff and community volunteers work with at-risk adults to reflect on their quality of life and develop goals/care pathways to address unmet health or social needs. Over 300 students, caregivers, and community members received training as community volunteers. The pillars are: volunteerism, interprofessional collaboration, technology, social networks, policy and engagement. A novel artificially intelligent platform supports people to co-design their unique integrated, personalized care programs. Social network analysis enables WECCC to map the community to a social graph and apply social network analysis and machine learning techniques to optimize the community care network for older adults who are socially isolated and/or at risk for social isolation.

Using routinely collected data, WECCC is able to measure the cumulative impact of activities on population level outcomes for at-risk older adults, including quality of life, social connectedness, and health care utilization. As a learning health system, the data are fed back into the system to improve efficiencies and to translate lessons learned to other communities undertaking similar work.

Feasibility and pilot work demonstrate the program’s effectiveness in increasing social networks, improving access to resources, and improving personal care and social networks for individuals at risk for social and physical frailty, and their families.

Empowering Patients: 5 Questions to Ask: Alice Watt, ISMP Canada

Medication errors continue to be a significant source of preventable harm, especially for older adults living with frailty. There is a need to empower patients and correct the imbalance of knowledge among patients and their care providers. A National Medication Safety Summit in Canada identified the need to create a communication tool used to improve patient engagement in medication safety and to prevent harm from medication errors.

A review of medication errors leading to harm at transitions helped to develop the intervention to empower patients. A communication tool called the ‘5 questions’ was co-developed and tested by patients, for patients. Using small tests of change to improve content and design. The primary goal of the ‘5 Questions’ is to help patients, including those living with frailty and their caregivers, have a meaningful conversation with their health care provider about their medications.

Prompting older adults living with frailty and their caregivers to ask their health care provider what each medication is for, why they need to continue this medication and to review all their medications to see if any could be stopped or reduced, can help reduce harm from polypharmacy, adverse drug reactions and medication errors as well as prevent drug-related falls.

In a recent Canadian Patient Safety Week survey, 63 per cent of healthcare providers said that patients are asking more questions about their medications, and 60 per cent of patients said they are asking more questions about their medications. Healthcare providers say they are distributing the 5 Questions to patients, posting them in examination rooms and clinics, and using the tool as a guide for conversations between patients and providers.

The ‘5 Questions’, with translation in 25 languages and visible endorsements from over 200 organizations, has demonstrated a shared interest in empowering patients living with frailty and their caregivers to improve safe medication use.

“This poster helps patients identify which questions to ask to help improve their own medication safety. This one simple tool is effective, and its use will reduce medication harm.” (Patient Advocate, Patients for Patient Safety Canada)

Acute Care

Use of a Gait Tracking Device to Count Steps of Older Emergency Department Patients: Jose Estrada-Codecido, Sunnybrook Health Sciences Centre

Delirium is a common complication among older people who need care in the emergency department (ED). Delirium and functional decline have been shown reduce when patients are compliant to mobility strategies such as ambulation. Gait tracking devices have been used in previous studies to accurately measure steps, engagement and intensity of physical activity in older hospitalized patients. Although mobility may be compromised in older adults with frailty, it cannot itself be used to define frailty. This study aims to compare feasibility and validate the accuracy of three novel, accelerometer-based gait tracking devices. We also aim to describe the relationship between mobility and frailty, delirium and cognitive status in older ED patients.

This is a prospective, observational study of patients 65 years of age and older during their ED visit. Consenting participants will wear the gait trackers and perform a repeated 6-meter walk test while an observer manually records their steps and speed. Next, participants will wear the devices for a maximum of 8 hour, and ambulate as normally as they would in their home. A Clinical Frailty Scale (CFS), Mini-Mental State Exam (MMSE) and Confusion Assessment Method (CAM) will be completed for each participant. Our primary feasibility measure is the proportion of eligible patient with recovered trackers and steps recorded. The primary validation endpoint will be the concordance of step count between device and observer. We will assess associations by measuring the correlation between gait speeds and step counts with the values obtained from the cognitive, delirium and frailty tests.

Preliminary data from an initial pilot phase includes 18 participants who wore a gait tracking device during their ED visit. Devices were worn by participants and recovered in all cases (100%, 95% CI: 81 – 100). Data from online interface has been collected from 17 participants (94%, 95%CI: 72 – 99).

Our preliminary data suggests that use of gait-tracking devices in the ED is feasible. We expect to find a positive association between step count and gait speed and frailty, cognitive and delirium status. These results will help us better understand the relationship between mobility, frailty and cognitive status in older ED patients.


Elder-friendly Approaches to the Surgical Environment (EASE): Rachel Khadaroo, MD, PhD., University of Alberta

Seniors (≥65 year old) are the fastest growing sub-population in Canada and are estimated to account for greater than one third of surgical patients. Standard hospital care is designed to improve operational efficiency and rarely account for the needs of the elderly, who present with a complex baseline vulnerability. Acute Care for Elderly models that emphasize specialized environments, patient-centered care, and interdisciplinary teams have demonstrated improved outcomes for patients in medical settings. We hypothesize that Elder-friendly Approaches to the Surgical Environment (EASE) within a major surgical center in Alberta will realign current resources, implement evidence-informed practices, and improve health outcomes in a cost-effective manner.

Prospective, concurrently controlled, before-and-after study at 2 tertiary care hospitals in Alberta. Four cohorts of elderly patients receiving emergency abdominal surgery were enrolled. Interventions included co-locating older surgical patients, interdisciplinary team-based care, evidence-based practices, a self-directed bedside reconditioning program, and optimized discharge planning. Charts of patients were reviewed for their hospital stay, then in-person or telephone interviews were conducted 6 weeks and 6 months after discharge. The primary outcome measured was postoperative major in hospital complication or death. Secondary outcomes measured included readmission within 30-days of discharge, length of stay, functional, cognitive, and nutritional status, and health care resource utilization and costs. Within-site mean change scores were computed for the composite primary outcome and the overall covariate-adjusted between-site pre-post difference were the dependent variable analyzed using generalized linear mixed model procedures including adjustment for clustering.

A total of 6570 acute care surgery patients were screened with 684 patients eligible for study inclusion. EASE interventions demonstrated a significant decrease in major complications and death, as well as significant decreases in delirium, time to foley removal, time to mobilization and length of stay. Elderly-friendly interventions resulted in significant cost reduction without reducing quality of life. Given the current aging population, the EASE program has promising capacity to support health system cost savings while improving quality of care. It is a unique model of patient-oriented, value-based care that could be applicable to all centers who care for older surgical patients.




Complex Care Hub: Michelle Grinman, MD, FRCPC, MPH, Alberta Health Services

Alberta’s population is aging where 1 in 5 Albertans are projected to be over age 65 by 2031. With advanced age comes increased medical complexity that requires more intensive community care. Hospitalized seniors’ risk of morbidity and mortality compared to those provided with hospital-at-home care requires an innovative approach to address the needs of seniors with lower acuity issues.

The Complex Care Hub (CCH) is an integrated healthcare service delivery model that offers hospital-at-home services to eligible patients presenting to hospital with low-acuity conditions. This partnership between General Internal Medicine, Community Paramedics (CPs), Home Care and inpatient services enables patients to be recognized as inpatients, facilitating expedited treatments and diagnostic testing. A shared electronic health record and telemedicine enable mobilized CP services in consultation with physicians and nurse navigators.

Since implementation in February 2018, CCH admitted 96 patients, of which 14 were subsequently readmitted to the program, either avoiding ED or reducing length of stay. Eighty-two percent of patients felt CCH helped them regain their function and independence “quite a bit or completely.” Average pre/post patient ratings of their overall health status (EQ-5D) increased by 8 points. Eight-four percent of care providers rated their experience on CCH as “good or excellent.”

CCH is fostering integration of GIM with primary care in Calgary to provide timely and appropriate access to care for medically complex seniors ranging from 65 to 101 years of age. Preliminary analyses from the first year suggest potentially lower cost per patient encounter, reduced 30 day readmission rates and increased connection of heart failure patients with ambulatory care after discharge when compared to matched controls (analysis to be finalized in summer 2019). Furthermore, preliminary snapshots of ED patient flow suggest an average reduction of 6.4 hours of wait-time when a patient is admitted to CCH.




Inter-Rater Reliability of the Clinical Frailty Scale by Geriatric and Intensive Care Medicine Physicians in Patients Admitted to the Intensive Care Unit: Megan Surkan, MD, FRCPC, University of Alberta

Frailty is a state of exaggerated vulnerability, unmasked in acute illness, which may explain its high prevalence in critically ill patients admitted to the intensive care unit (ICU). The Clinical Frailty Scale (CFS) is a judgment-based frailty measure that was validated in an outpatient setting after completion of Comprehensive Geriatric Assessment (CGA). It has become the most commonly used measurement tool in ICU; however, there is limited data regarding its reliability in this setting. We sought to examine inter-rater reliability of the CFS in patients admitted to the ICU, comparing geriatricians and intensivists.

We conducted a prospective observational cohort study of 158 admissions to the General Systems ICU in Edmonton, Alberta. The CFS was measured independently by the admitting intensivist, and both a senior resident and staff consultant in Geriatric Medicine (GM). Frailty was defined as a score of 5 or more on the 9-point CFS. Inter-rater reliability was represented by Cohen’s kappa. We also tested the predictive validity of the CFS by different raters in relation to hospital mortality.

Of the 158 enrolled ICU patients, median (IQR) age was 60 years (46-69), 56% were male. In total, 39% (n=61) and 49% (n=82) of patients were classified as frail by intensivists and geriatrics, respectively. Patients with a CFS score ≥5 had greater in-hospital mortality (frail 30% v. not frail 10%; p=0.003). Inter-rater reliability varied significantly by comparisons, with agreement being minimal for intensivists and GM resident (kappa 0.27; n=158), moderate for intensivists and GM staff (0.45; n=18), and substantial for GM resident and consultant (kappa 0.79; n=20). However, the predictive validity of the CFS for in-hospital mortality was similar for all raters.

Our results suggest that compared to specialists or residents in Geriatric Medicine, intensivists may utilize different cues and parameters when using a judgment-based frailty measure and may have a different conception of how frailty manifests in acutely ill patients. Further research to elucidate what factors contribute to this difference is required. Reliable case finding could trigger strategies to optimize care during ICU stay and improve outcomes and expectations during and after hospitalization.

The 3 Wishes Project: France Clarke, RRT, McMaster University

Frailty is common among critically ill patients, associated with increased risk of death. For most frail patients, dying is an institutionalized experience – particularly in the ICU. The 3 Wishes Project (3WP) is a novel, humanistic, low-cost, high-impact palliative care intervention which has been shown to improve the quality of the dying experience for critically ill patients, their families, and clinicians.

The 3WP reinvigorates simple acts of compassion. The first element is eliciting meaningful wishes by learning more about the patients and their families, and the second is implementing personalized terminal wishes. Supportive tools include a Wish Bank of common wishes, ‘get-to-know-you’ forms for families, and peer-to-peer mentorship to enhance staff skill and comfort eliciting wishes. Wishes are usually simple (e.g., a favorite beverage, religious rituals, co-creating a keepsake) but sometimes more elaborate (e.g., planting a tree, renewal of wedding vows).In a mixed-methods research evaluation spanning 6 years, we have gathered data from 6 sites on over 800 patients, including baseline and demographic information and wishes implemented. We have interviewed over 200 family members and 100 clinicians. Our evaluative focus has included: the initial influence of the 3WP demonstration project, the multicenter implementation of the 3WP, the interface between 3WP and other end of life programs (i.e. organ donation), the educational value of the 3WP for trainees, a narrative medicine framework of word clouds, and the influence of sympathy cards in the 3WP (disseminated in peer-review manuscripts).

Collaborative, patient-family-partnered decisions inform these terminal wishes. Qualitative evaluation by family interviews confirm that the 3WP has high value for frail, dying critically ill patients and their family members. However, death is only one of the losses older adults living with frailty face – they may also lose their home and independence; thus, spreading the 3WP to other venues/transitions where frail adults lose their personhood could also improve the quality of life for patients and their caregivers.

Applying a Frailty Lens to Care on Medicine Inpatient Units: Melissa Buckler, Nova Scotia Health Authority

The Nova Scotia Health Authority (NSHA) Frailty Strategy was developed with the vision of optimizing provider, patient, and caregiver experiences in frailty. A key initiative within the Strategy involves creating a common understanding (among providers and health care consumers) of what frailty is and why it requires a different approach to care. Due to previous Strategy work, frailty is routinely measured on all patients admitted to medicine services at the largest hospital in the province. Building on this success, our focus turns to how to respond to frailty. A suite of frailty education tools for providers and patients/families including the Frailty Passport. The Passport offers frailty level-specific care guidelines for front line, acute care staff.

The Frailty Passport offers evidence-based care considerations on patient/family frailty awareness, physical/social activity, cognition, decision making, supportive care, and caregiver stress. An on-line module on frailty has been developed for health care clinicians to support use of the Passport. Corresponding patient/family resources that introduce frailty-specific care considerations to patient/families and provide local resource information have also been developed. Topics include understanding frailty, stages of frailty, social connections, and specifics about care considerations at each frailty level.

Evaluation will include chart audits, direct observation, feedback sessions/interviews and surveys with front line providers.   We propose to answer the following questions:

  • What impact has using the frailty care guidelines (i.e. the Frailty Passport and related tools)  had on provider comfort and self-efficacy for care planning?
  • What are the barriers/facilitators to using the guidelines in acute medicine settings?
  • What impact has using frailty care guidelines had on addressing frailty amongst patients and    families?

Results will inform rollout of the Frailty Passport and related resources to additional acute medicine sites as well as emergency departments, primary care and continuing care.

Pharmacist led intervention to improve medication use in older in-patients living with frailty: the Drug Burden Index: Emily Reeve, BPharm (Hons), PhD, Nova Scotia Health Authority

Polypharmacy and potentially inappropriate medication use is common in older adults and is associated with adverse outcomes such as falls, hospitalization, reduced quality of life and mortality. Older adults living with frailty may be more susceptible to these adverse effects. Hospitalization provides a unique opportunity to optimize medication use and discontinue harmful medications (deprescribe). However, healthcare professionals recognize that we need better tools and procedures to make sure that people are taking the right medications at the right time.

The Drug Burden Index (DBI) Calculator© is an innovative web-based medication review tool which can be used to identify older adults at high risk of medication associated harm. Increasing DBI score has be linked with negative health outcomes, such as impaired physical and cognitive function. We are conducting a pharmacist-led prospective interventional implementation study across multiple sites and hospital settings in Nova Scotia, Canada. In this innovation, hospital pharmacists will use the tool to enhance their normal clinical activities. It will help them identify which medications (and combinations of medications) may be harmful to older people. The tool also produces a report to facilitate communication between the pharmacist and other members of the health care team.

*Using a retrospective (pre-intervention) cohort, we will determine the effectiveness of the tool at improving medication related and clinically important outcomes, such as change in DBI score, rehospitalization and mortality. We are also evaluating the success of implementation by conducting a multiple case analysis which includes interviews with patients, caregivers and clinicians to determine the barriers to and facilitators of optimizing medication use in older adults with frailty during hospitalization.

* Use of the DBI calculator© may lead to improvements in how medications are managed in hospital. This would mean less drug costs and drug-related adverse effects both in hospital as well as after discharge. Overall, the innovation may lead to improved quality of life for older Canadians.

*Planned evaluation and anticipated results and impacts (work in progress)

Identifying Frailty – There’s an App for That: Paige Moorhouse, MD, MPH, FRCPC, MSM, Nova Scotia Health Authority

Appropriate care planning and delivery is contingent on routine, accurate recognition of frailty. In response to a demand for a practical, easy tool for identifying frailty outside of geriatric medicine (e.g., surgeons, anesthetists, and nephrologists), the Palliative and Therapeutic Harmonization clinic developed The Frailty App. This free App uses the validated methodology of the Frailty Assessment for Care Planning Tool (FACT) (1), which provides frailty levels compatible with the CFS (2).

A unique algorithm is used to formulate questions specific to the patient’s circumstances. It assesses function, mobility, and cognition in a hierarchical manner and gathers reliable and useful information using the least number of questions. Unlike other measures of frailty, the App embeds validated cognitive testing.

The App can be used by any health care professional. Caregivers can complete part of the assessment in advance of appointments and health care provider assessment time is reduced. A “mini CGA” report details the patient’s baseline abilities and challenges in each frailty domain, whether the patient is at baseline and the trajectory of changes. Presence of falls, dementia, and delirium are highlighted. Provider actions for each level are provided.

The App can be used to:

  • Consider frailty when making surgical decisions, medical decisions (chemotherapy, renal        replacement therapy) or other complex interventions
  • Understand baseline frailty during episodes of acute illness (such as in the Emergency        Department)
  • Better understand suitability for rehabilitation programs
  • Augment team-based, patient intake processes

Evaluation of the usability of the App within four services areas will occur including: a tertiary Emergency Department, CV Surgery, an Orthopedic Assessment Clinic and a Community Seniors Health Team. Processes for use, ease of use, comparison to the FACT paper-based tool and impact on clinical practice will be measured.   Providers, caregivers and patients will participate.

The PATH Frailty App will support standardization and measurement of frailty to inform healthcare decisions (e.g. to pursue surgery and/or other interventions). Evaluation results will inform rollout of the App to other clinical settings with the goal to ensure frailty is accurately understood in decision making.

Seniors Transitions Enhancement Program: Jane Loncke, Clinical Director, St. Joseph’s Healthcare Hamilton

As part of our strategic focus for seniors’ care, this initiative emerged from the growing recognition of the needs of older persons who are discharged from St. Joseph’s in Hamilton (SJHH, SJV, SJHC). The Patient and Family Advisory Council at St. Joseph’s Healthcare Hamilton expressed concerns about discharges experienced by older individuals upon return to the community. In addition, we had received complaints, referred to Patient Relations, that relate to discharges of older adults (>75). As well, gaps in care have been shared among our own system’s partners pertaining to incomplete discharge communication, lack of critical information about the plan of care/ medications   or misinformation about the patient’s destination for discharge.

Our 3 organizations developed, endorsed & implemented a “Standard of Practice for Transitions” for patients transitioning between our organizations & to other settings — with a key element being “the warm handoff”. Care team members follow the standard in 4 distinct phases: upon presentation (to an organization), prior to care transition, at time of care transition and after care transition. Some key elements in the initiative are the care transition plan, self-management strategies, teach back & the after care transition call within 48 hours of discharge.

SJHC & SJV tracked performance involving transitions of patients entering and leaving their organization, in specific program areas to determine the frequency with which the “warm handoff” occurred. At SJHH within the Complex Care & Seniors Mental Health Programs 3 key elements were evaluated: the evidence of a transition plan, teach back and the after care transition call.

The impact of this initiative has been significant: 1. care team members from SJV and SJHC regularly complete warm handoffs, receive warm handoffs from SJHH with increased consistency, and have experienced improved respectful working relationships with SJHH; 2. SJHH has received valuable feedback from patients during the after care transition call and thereby improving the discharge process.

Caregiver Support

Senior Friendly Caregiver Education Project. Caregiving Strategies: Providing Care and Support for a Senior Living with Frailty: Sarah Gibbens, MN, RN, GNC(C), PhD(c), Regional Geriatric Programs of Ontario (RGPO)

In response to an aging population and a correlating increase in the number of seniors living with frailty who live at home, the Regional Geriatric Programs of Ontario (RGPO) has embarked on a project to co-design educational resources with family and friends who are caring for seniors living with frailty.

Family and friend caregivers are spending an average of 10 hours each week providing cognitive, functional and emotional supports to ensure their desired quality of life and allowing them to remain in their homes for as long as possible. In fact, caregivers across Canada provide approximately 75% of all patient care. This project explores the experiences of caregivers to understand their learning needs within certain areas of frailty in order to design educational resources that support them and build confidence in their care-giving abilities.

The purpose of this project is to co-create educational content with caregivers about frailty. To achieve this, the RGPO hosted a series of focus group sessions with caregivers across Ontario to share their experiences of caring, their learning needs in frailty and beyond, and their preferred methods of learning. The sessions primarily focused on seven areas of frailty, otherwise known as the Senior Friendly 7: delirium; mobility; continence; nutrition; pain; polypharmacy; and social engagement.

The learning needs of caregivers were compared across focus groups and themed. This data will inform the design and content of the educational resources; aligning and reflecting the voices of caregivers. Staying true to the co-design process, evaluation will be iterative; testing and revising the resources with caregivers and provincial stakeholders along the way. Long term evaluation includes a measurement of improved feelings of caregiver confidence in caring for a person living with frailty.

The RGPO is partnering with multiple provincial stakeholders, including caregivers, instructional designers and geriatric health professionals, to create and sustain the final product. The educational resource strives to reach a minimum of 25,000 caregivers across Ontario by March 2020. Opportunities to disseminate findings to a healthcare provider audience will continue to build synergy across sectors.