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

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.