An innovative decision tool to optimize hospital discharge in frail older patients living at risk

Anticipated Findings

We will provide both hospital and community-based clinicians with a refined version of this tool. Its aim will be to help clinicians facilitate conversations about difficult decisions related to a senior’s wish to return or stay at home.

About the Project

Discharge from hospital is a difficult time for older adults living with frailty and their family members. Most hospitalized older adults want to return home. However, many are at increased risk of harm after hospitalization. Older adults may be inclined to relocate due to safety concerns. Clinicians are thus faced with difficult decisions: How do you support the older adult’s wishes to return home and address the concerns of families, while reducing the older adult’s chances of injury?

It is reported that clinicians tend to override patient wishes regarding discharge location when risks are identified as a concern. Our project wants to reverse this approach by helping clinicians support older adults and their families to live “with risks” at home.

The ultimate goal is to find the most appropriate and acceptable way to minimize harm and increase the capacities of older adults to meet their goal to age in place. We will adapt a tool developed for use in the community to the hospital discharge setting.

Project Team

Principal Investigator:

Véronique Provencher, PhD – Université de Sherbrooke


Nathalie Delli-Colli, PhD – Université de Sherbrooke

Mary Egan, PhD – Bruyere Research Institute

Dominique Giroux, PhD – Université Laval

Marie-Jeanne Kergoat, PhD – Université de Montréal

Heather MacLeod, MSc (OT), OT Reg. (Ont.) – Bruyere Research Institute

Nathalie Veillette, PhD – Université de Montréal

Knowledge Users:

Shaen Gingrich – North East Specialized Geriatric Centre

Jennifer Klein – Glenrose Rehabilitation Hospital


Roy Frederick, CPA – Université de Sherbrooke

Project Contact: Dr. Veronique Provéncher  –

Key words: frailty; caregivers; hospital discharge; shared decision making; patient-centred care; risk assessment; risk management; independent living; patient autonomy; aging in place