In Canada, 25% of the population aged 65 and over are considered clinically frail. Clinical frailty increases chances of hospitalizations, falls, social isolation, loneliness, and depression. We will implement an evidence-informed learning health system approach to optimizing community-based care delivery for older adults living with complex needs due to frailty in the communities of Port Hardy and the Gwa’sala-‘Nakwaxda’xw Nations on North Vancouver Island.
The intervention includes the following three components, an enhanced friendly visiting service, to identify seniors and elders who may have unmet needs in community; an integrated care team, to create formal partnerships and linkages in community to support frail elders live well at home; and flexible funding – provided through a philanthropic partner – to ensure seniors’ practical needs are being met.
This intervention seeks to assist seniors to prevent ED visits or acute care admissions by reducing the risk of frailty in this rural and remote population. The evaluation will help to describe how effective these upstream, preventative measures were to avoid inappropriate ED presentations and acute care admissions, while allowing seniors and elders to live well at home.
Keywords: Primary Care, Emergency Care, Health Services
Team members:
- Annalijn Conklin
- Ian Wood (Primary Applicant Co-Lead)
- Max Jajszczok (Executive Sponsor)
- Amy Salmon (Evaluation Co-Lead)
- Wei Zhang
- Denise Cloutier
- Mariko Sakimoto
- Claudia Lai
- Adam Easterbrook
- Benjamin Farnell
- Janet Kow
- Ken Tekano
- Jodi Wright
- Nicole Bennet-Boutilier
- Lisa Saffarek
- Jess McConnell
- Nathaniel Pottage
- Bretton Hills
- Nicky Ranger
- Rosie Dugas
- Colleen Ingliss
- Jenyo Banjo
- Dean Wilson
- Rob Stenstrom