Seniors’ Community Hub

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.

2018 Frailty Innovation of the Year

Left to right: John Muscedere (CFN Scientific Director), Maria Judd (CFHI — sponsor), Marjan Abbasi (Project Lead), Sheny Khera, Susan Rogers (CIHR Institute of Aging — sponsor), Russell Williams (CFN Board Chair)

Click here to see the storyboard presented at the Showcase.

Seniors’ Community Hub

LOGO -- Seniors Community Hub     LOGO -- Edmonton Oliver PCN

The Seniors’ Community Hub (SCH) was co-created by a Care of the Elderly and a Primary care physician working in Alberta. The overarching goal of the initiative is to transform primary care into a central hub to better meet the dynamic health and social needs of older adults with frailty and their family/friend caregivers.

The objectives of the Seniors’ Community Hub are to: maintain and enhance seniors’ health and wellness; build integrated primary health care that is centered on the goals and priorities of older adults; develop effective information sharing between patients, care providers and settings; provide community-based support to family/friend caregivers to prevent or alleviate caregiver burden; and foster long-term sustainability in the primary care setting.

The SCH builds capacity in primary care by mobilizing available Primary Care Network resources, proactively supporting older adults and their family/friend caregivers in maintaining their intrinsic capacity, strengthening their resilience, and, ultimately, mitigating frailty. This has been achieved by the SCH structured process of care; education of the healthcare workforce; patient and caregiver empowerment; and building partnerships in care.

Successes of the program thus far have been improvements to quality of life with improvement or maintenance of patient independence, acquisition of self-management skills with respect to health and medications, improved chronic disease management, improved access to community resources through navigational support, lower caregiver sense of burden and stronger connections to their medical home and community.