Care of frail, acutely ill older persons: Making health care work like a system

The results from this study identified those individuals at higher risk of requiring an acute hospitalization, predicted the need for nursing home resources after an acute episode of hospitalization and defined the added value of a standardized geriatric assessment to predict outcomes after an acute care hospitalization.

About the Project

This project aimed to better understand the trajectory of care (what makes older persons vulnerable and what are risk factors for them ending up in hospital and intensive care units) and once admitted, what determined their long term function and how they recovered from acute illness. We then developed several strategies to provide evidence-informed information for nursing home, home care and hospital professionals to assist them in discussing treatment choices and plans of care for older persons living with frailty. The many studies in this program of research aimed to develop and conduct early feasibility studies of information tools kits, with electronic platforms to make them easy to use, with up-to-date information at the point-of-care.

This research also provides all of the foundational elements to initiate widespread implementation and evaluation of decision support tools. These tools were designed to provide health professionals with useful information about the patient’s trajectory in order to facilitate evidence-informed discussions with families or patients while in nursing homes or once they arrive in the acute care setting.

Project Team

Principal Investigators:

Paul Hébert, MD — Centre Hospitalier de l’Université de Montréal (CHUM)

John Hirdes, PhD — University of Waterloo


Andre Amaral, MD — Sunnybrook Health Sciences Centre

Sean Bagshaw, MD, MSc, FRCPC — University of Calgary

Andrew Costa, PhD — McMaster University

George Heckman, MD, MSc, FRCPC — University of Waterloo

Joon Lee, PhD, BASc — University of Waterloo

Fahad Razak, MD — University of Toronto

Henry Stelfox, BMSc, MD, PhD — University of Calgary

Amol Verma, MD — University of Toronto

Knowledge Users and Partners:

Assessment & Intelligence Systems, Inc.

BlackBerry Limited

Canada Institute for Health Information (CIHI)

Project Contact: Paul Hébert —

SIG 2014F-31


Heckman GA, Hirdes JP, Hébert PC, Morinville A, Amaral ACKB, Costa A, McKelvie RS. Predicting Future Health Transitions Among Newly Admitted Nursing Home Residents With Heart Failure. JAMDA 2018 12 17 online. DOI:

Adekpedjou R, Heckman GA, Hébert PC, Costa AP, Hirdes JP. Outcomes of advance care directives after admission to a long-term care home: DNR the DNH? BMC Geriatr 22, 22 (2022). DOI: