Canadian Frailty Network

Our findings from the previous CIHR funded InfoRehab study, allowed us to develop an in-depth understanding of health system challenges for older persons. Specifically, we found that:

  • Older adults often have limited involvement in decision-making around their care
  • Family caregivers both have and need knowledge, but often have a limited role in care planning and decision-making
  • There is a limited use of technology in the system
  • Coordination and communication between providers and services is often inadequate
  • Primary care could play a key role in identifying at-risk older persons and coordinating their care, but there needs to be support for this role

To build on the InfoRehab findings and further understand the engagement experiences of older adults, our group completed a series of Canadian Frailty Network (CFN) funded projects.

The CHOICE Project

This knowledge synthesis project considered the evidence for how older adults should be engaged in healthcare decision-making. Through this project, we examined how to engage older adults in healthcare research and planning, as well as in healthcare decision-making. This led to the creation of the CHOICE framework, which can be used to guide older adults engagement in healthcare.

Frailty Implementation Grant

To address the final conclusions of InfoRehab, we worked with three primary health care practices in Ontario to implement and test a brief screening tool to identify at-risk older patients. Following the positive results of this pilot, we delved deeper to look at models of care coordination in primary care.

CFN-funded fellowship: Care coordination in primary care

Jacobi Elliott received a CFN-funded fellowship to:

  1. Understand the current primary care context
  2. Implement tools for care coordination
  3. Evaluate the process of care coordination, including patient, caregiver, and provider preferences

A co-design approach was used to implement a model of care coordination in primary care. A risk screening tool and referral mechanism were implemented in one rural and one urban primary care site in Ontario. The coordination components of these tools involved the use of the screening tool, patient/caregiver engagement in decision-making and the referral system that connected to community and specialist services. These tools were evaluated based on interviews with patients, caregivers, and providers, as well as through monitoring the referral pathways. 

CFN Catalyst Grant

To build on the CHOICE framework, we received a CFN Catalyst Grant to answer the following questions:

  • How do the frameworks and principles identified through the CHOICE project correspond with actual experiences of engagement?
  • What factors currently facilitate or hinder patient engagement?
  • What resources, materials and implementation strategies (for patients, caregivers and providers) are needed to support patient engagement?