COACH Program (Caring for Older Adults in Community and at Home)

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. From these, the TOP FRAILTY INNOVATION OF THE YEAR was recognized — the Seniors’ Community Hub based in Edmonton, Alberta.

Attendees at the Conference had the opportunity to vote for the “Conference Choice” innovation after the presentations, and the COACH Program from Health PEI was recognized by attendees.

Left to right: John Muscedere (CFN Scientific Director), Joyce Resin (CFN Citizen Engagement Chair), Kirsten Mallard, Tim Stultz, Elaine Campbell (Project Lead), Russell Williams (CFN Board Chair)

Click here to see the storyboard presented at the Conference.

COACH Program

With the older adult living with frailty and their family at the center, the COACH program is delivered by an integrated interdisciplinary expert team of health professionals who collaborate with existing resources in partner programs; Home Care, Primary Care and Geriatrics. The COACH team includes a Geriatric Nurse Practitioner, the client’s Primary Care Physician and a Care Coordinator.   The Nurse Practitioner plays a key role on the team, as the interconnecting “glue” between various areas of the healthcare system*.

The COACH team provides direct client care at home, on a timely basis, in an effort to predict and prevent (or proactively manage), health crises when they occur and ideally decrease the need for emergency services or admission to hospital. The team encourages advanced care planning and access to community support, with the goal of improved quality care for older adults living with frailty. System utilization data from the COACH pilot demonstrated decreases in hospital inpatient stays by two thirds, emergency visits by one third and primary care visits by one half.  COACH clients are better able to self-manage and make informed decisions that positively impact their quality of life at home and, when necessary, support smoother transitions to and from acute care or long-term care.

Seniors must be referred to the COACH Program by a health professional.  Program admissions are approved by a panel of health care professionals from Home Care and Geriatric Programs, based on established eligibly criteria, assessed need and available program and partner resources.