Hospital without Walls: Bridging the Gap in Health Disparities for Adults Living with Frailty

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 Conference.

Hospital without Walls: Bridging the Gap in Health Disparities for Adults Living with Frailty

LOGO -- Hamilton Health Sciences

Hamilton Health Sciences (HHS) is transforming care for patients at high risk for frailty by aligning its hospital and community-based teams. By following patients from the emergency department (ED) until they successfully transition back home, HHS is improving patient experience while reducing ED visits, admissions, readmissions, length of stay, and achieving cost savings.

Patients aged 65+ years are screened in the EDs, and those identified as high risk for frailty are referred to the Centralized Care and Transition Team (CCaTT), an interdisciplinary team with geriatric experience. The CCaTT assesses mood, memory, function, social supports, medications, and develop evidence-based interventions and recommendations aligned with Ontario’s Assess & Restore Guidelines. The CCaTT refers patients at highest risk to HHS’ Outreach Team.

HHS’ Outreach Team utilizes Ontario’s Health Links Model of Care. The Outreach Team partners with patients in their homes to identify: what is most concerning to them about their health, what is most important to them right now, and what they hope to achieve.  Goals are developed with patients, and the Outreach Team collaborates with partners such as: primary care, geriatrics, home care, and community service organizations to initiate actions that will help patients achieve their goals. Typically, the Outreach Team’s patients have: 4+ chronic conditions, lack of social supports, low health literacy, low mood, functional and/or memory impairment, limited finances, and high hospital visits.


Presenting at the Showcase:

Kelly O’Halloran (Project Lead)