C5-75: Case-finding for Complex Chronic Conditions in persons 75+

The FRAILTY MATTERS Innovation Showcase received 80 applications from across the country. From these, the TOP FIVE INNOVATIONS were selected by a panel of leading experts. These five initiatives presented on the stage at the FRAILTY MATTERS Innovation Showcase on Thursday, September 20 in Toronto at the CFN National Conference.

Click here to see the storyboard presented at the Showcase.

C5-75: Case-finding for Complex Chronic Conditions in persons 75+

LOGO -- Centre for Family Medicine

Given the aging population, Canada’s critical shortage of geriatricians, and a healthcare system adapting to meet the needs of persons living with frailty, it is increasingly recognized that primary care must accept a greater role in caring for older adults living with frailty. Yet early recognition of frailty and its contributing conditions has been challenging. To address this need, the Centre for Family Medicine Family Health Team created the C5-75 program as a way to identify and manage frailty within primary care.

Through annual screening during routine office visits, C5-75 aims to systematically identify and better manage frailty and unrecognized associated medical and psychosocial conditions that contribute to poor health outcomes, enabling individuals to maintain health and quality of life and community living for as long as possible. With iterative revisions to increase efficiency, the program has demonstrated feasibility and acceptability, having been sustained for over 5 years in 19 family practices; 1073 persons aged 75+ have been screened and 7% identified as frail.  As well, the program has demonstrated feasibility within a less-resourced family practice setting in collaboration with a community pharmacy.

Elements that make C5-75 suitable for Canadian family practices include: (i) the development of a feasible, objective, valid means of screening for frailty during busy clinical practice using gait speed with hand grip strength; (ii) its structured, multidisciplinary, evidence-informed approach to systematically screen for and manage frailty and associated conditions, and (iii) being developed by practicing primary care practitioners, tested, and designed for integration into Canadian primary care.

Presenting at the Showcase:

Linda Lee (Project Lead), Tejal Patel