HomeMedicine By SpecialtyGeriatrics and AgingWorking in partnership to help frail seniors extend their ability to live...

Working in partnership to help frail seniors extend their ability to live at home

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By Patti Enright

Eighty-nine years young, Lenore lives alone in a seniors’ apartment in Don Mills. Her goal is to remain there for as long as possible.

Like many people well into their late eighties, Lenore has experienced some health challenges. She had become prone to falls, and her back and hips often feel painful.

In 2015, the situation was taking a toll. “I felt down,” she said. “I didn’t feel like doing anything.”

Lenore was at risk of admission to hospital or having to move to a long-term care home.

Many other frail seniors are in a similar position. Identifying and helping them avoid admission to hospital and further decline in their health or their independence is a strategic priority for the Ministry of Health and Long-Term Care and the Local health Integration Networks (LHINs).

However, in spite of providence-wide initiatives to address this issue there is a lack of referral options available to staff in emergency departments to support frail seniors and provide them with innovative and timely programs focused on restoration. Primary care providers continue to search for solutions and resources for frail seniors who present in their offices. Care coordinators and nurse practitioners at Community Care Access Centres (CCACs) are limited by the narrow range of options available to them when they have a client who requires more care than can be provided in the client’s home yet is not appropriate for admission to an acute care facility.

To bridge this gap, a partnership led by Providence Healthcare is helping frail and vulnerable seniors at risk of hospitalization or admission into a long-term care home to remain at home for an extended time.

The Community Referral Pathway brings together four health sectors in Providence’s catchment area – hospitals, CCACs, primary care providers and community services – to create a solution for complex, frail seniors living in the community who have restorative potential that will delay the need for institutional care.

The new standardized expedited care pathway provides referral options for direct admission to inpatient or outpatient programs.  The initiative leverages Providence’s existing Frailty Intervention Team, an interprofessional assessment team providing patients with a one-stop comprehensive assessment.

The program has been up and running since funding was obtained from the Toronto Central LHIN in the fall of 2015. From April 2015 to December 2016, 196 patients received assessments from the Frailty Intervention Team.


“The team working on this initiative feels extreme satisfaction knowing that we have helped a vulnerable population at risk of falling through the cracks get access to the health services they need, and in a timely manner,” said Kelly Tough, Patient Flow Manager at Providence Healthcare.

Lenore understands firsthand what a difference the program can make.

In 2015, her daughter Hazel was working at Providence and heard about the newly launched standardized care path. Hazel suggested the pathway to her mother; Lenore agreed it was worth trying and obtained a referral.

Through the care path, Lenore received an assessment from the Frailty Intervention Team that concluded she should come to Providence for two weeks as an inpatient for a “wellness stay.”

Lenore noted her spirits began to lift when she was admitted.

Since completing her two-week stay, she has started the next phase of her recommended treatment plan – weekly sessions at Providence’s Falls Prevention Clinic as an outpatient.

At the clinic, physiotherapist Nicola Bell is working with Lenore to improve her strength, endurance and posture. Through a combination of using a seated stepper machine that simulates walking and performing specific exercises in the Clinic and at home between appointments, Nicola notes Lenore now has more energy and is stronger since she first came to the clinic.

Her spirits are up, too. Lenore says she looks forward to her time at the clinic and that she cannot say enough about the friendliness of the staff. “It is a wonderful place,” she beamed.

For Lenore’s daughter the experience has been a relief. “I had a feeling of ‘whew’,” she said.

Hazel particularly found seeing one interprofessional team instead of requiring numerous appointments with different health professionals to be very helpful. “I appreciated not feeling like you have to jump through 1,500 hoops to get results.”

To access the Community Referral Pathway a Community Referral Checklist must be completed and signed by a physician or nurse practitioner; the document is available at www.providence.on.ca/referrals. For more information contact the Admissions Hotline at 416-285-3744, email admitting@providence.on.ca or visit www.providence.on.ca

Patti Enright is a Corporate Communications Manager at Providence Healthcare.




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