Transforming primary health care for frail elderly Canadians

This project, with support from researchers, collaborators, health care providers and older adults from across Canada, worked to transform primary health care for older Canadian adults living with frailty.

About the Project

Improving the health of older Canadians means identifying health problems early. It means providing timely support so that manageable concerns do not spiral out of control. And, above all, it means helping health care providers actively engage older patients and their family caregivers as partners in care. Patients want to make informed choices about their health and the care they receive, based on their personal values, preferences and goals, and informed by available evidence.

Nine primary care clinics in three provinces (Québec, Ontario, Alberta) used a quick screening tool to identify older patients who are at risk of becoming frail. This helped initiate referral to health care or support services where necessary. Innovative technology was used to streamline the referral process and help assist older adults in decision-making about their care.

The project team worked in partnership with a number of stakeholders including older adults, health care providers, health administrators and policy makers.

Please see below for more details on the project rationale, hypothesis and research design, as well as implementation resources.

Project Team

Principal Investigators:

Paul Stolee, PhD — University of Waterloo

Anik Giguère, PhD — Université Laval

Sara Mallinson, PhD — University of Calgary

Kenneth Rockwood, MD, FRCPC, FRCP — Nova Scotia Health Authority

Joanie Sims-Gould, PhD, BSc, MSW — University of British Columbia


G. Ross Baker, PhD — University of Toronto

Veronique Boscart, PhD — Conestoga College

Catherine Burns, PhD — University of Waterloo

Kerry Byrne, PhD — University of Waterloo

Andrew Costa, PhD — McMaster University

Jacobi Elliott, PhD — University of Waterloo

Dorothy Forbes, PhD — University of Alberta

Justine Giosa, MSc — University of Waterloo

Kelly Grindrod, PhD — University of Waterloo

Mohammad Hajizadeh, PhD — Dalhousie University

Heather Hanson, PhD — Alberta Health Services

George Heckman, MD — University of Waterloo

Jayna Holroyd-Leduc, PhD — University of Calgary

Wanrudee Isaranuwatchai, PhD — University of Toronto

Lucille Juneau — CEVQ

Edeltraut Kröger, PhD — CEVQ

Ayse Kuspinar, PhD — University of Waterloo

Samantha Meyer, PhD — University of Waterloo

Josephine McMurray, PhD — Wilfrid Laurier University

Marie-Josée Sirois, PhD — Université Laval

Olga Theou, PhD — Dalhousie University

Holly Witteman, PhD — Université Laval

Knowledge Users and Partners:

Céline Allard — CIUSSS

Carol Anderson — Continuing Care/Alberta Health Services

Carol Annett — VHA Home Healthcare

Jacques Bouchard — CIUSSS

Seigrid Deutschlander, PhD — Alberta Health Services

Nancy Drouin — CIUSSS

France Falardeau — CIUSSS

Susie Gregg, OT — CMHA

Sharon Harper — Health Canada

David Harvey, MSc — Alzheimer Society Ontario

Nadine Henningsen — Canadian Home Care Association

Michael Hillmer, PhD — Ontario Ministry of Health and Long-Term Care

Kenneth LeClair, MD — brainXchange

Christine Maika — Canadian Foundation for Healthcare Improvement

Duncan Robertson, MD — Alberta Health Services

Project Contact: Dr. Paul Stolee —

Explore the project’s implementation resources

TG 2015-24

Rationale, Hypothesis & Research Design

Rationale: It is well known that older Canadians are high users of health care services. What is less well known is that the health care system is not well-designed to meet the needs of those who use it most. Older persons look to their primary care practitioners to assess their needs and coordinate their care. Unfortunately, the health concerns of older persons are often missed in too-short office visits. They may need care from a variety of providers and services, but this care is often not well coordinated. Older persons and their caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, they may have health problems that are not properly assessed, managed or treated resulting in poorer health and preventable and expensive emergency department visits and hospital stays.

Research Question and Hypothesis: Compared to usual care in primary care settings, does our proposed model improve health, social and economic outcomes for frail and at-risk older Canadians (aged 70+)? We hypothesize that older adults will benefit from screening, active engagement in care planning, and appropriate referrals to services earlier in their care trajectories. In addition to improving health outcomes and quality of life for patients, more proactive interventions can reduce costly emergency department visits and unplanned hospital admissions.

Research Design: Our project required active participation of health care providers, patients and caregivers. Within a quasi-experimental control group design, we utilized a mixed-methods approach. Our project was divided into the three phases following Sidani and Braden’s (2011) recommendations for complex health interventions: Phase 1) Tailoring the intervention; Phase 2) Implementing the intervention; and, Phase 3) Evaluating the intervention (each described in greater detail later in this section). Both qualitative (interviews, focus groups) and quantitative data (surveys) were collected and analyzed using appropriate methods.