Transforming Primary Care for Older Canadians Living with Frailty

Transforming Primary Care for Older Canadians Living with Frailty is a Transformative Grant funded project from the Canadian Frailty Network (CFN).

The interdisciplinary research team created an approach – with input from primary care professionals and in collaboration with patients and caregivers – to help primary care professionals care for their older patients (70+), in the hopes of improving their health, social and economic outcomes.

This approach helped identify older patients who were at risk of, or living in the early stages of, frailty and, using a quick screening tool and applying Shared Decision Making, helped refer patients and their caregivers to community-based services. This approach, which used various models, was tested with the support of primary care clinics in three provinces (Quebec, Ontario, Alberta) to prove the viability of this approach in multiple primary care settings.

The following resources are designed as guides to help primary care clinics implement this approach in their own settings.

How to implement this model in primary care settings

Three guides were created as a starting point for primary care providers and collaborators to help with local implementation. The guides are based on learnings in Alberta, Ontario and Quebec. You can take the learnings from these provinces and apply them to your setting.

If we work together, researchers, collaborators, health care providers and older adults from across Canada can transform primary care for older Canadians.

Customizing the approach for a Primary Care setting

This primary care approach is about improving patient experiences, health outcomes and quality of life for older adults living with, or at risk of, frailty. This practice change may align with your quality improvement priorities.

As primary care teams consider this approach, begin by setting up a Working Group that can collaborate on the planning and support the practice change implementation. The Working Group should oversee the development of a project plan and a supporting communications plan. Remember to consider what change management strategies might be needed to ensure success.

To support primary care planning and implementation, we’ve created the following resources:

Downloadable worksheet

This worksheet is designed to help make sure primary care providers are asking the right questions as the approach is implemented:

Step-by-step implementation plan checklist

The approach to implementation will differ depending not only on the region, but also on the healthcare setting. We’ve created an overview of the seven components of the approach, with a variety of options to help guide primary care providers through implementation.

Three sample models

Here are three sample models that were implemented as a part of the research project:

Decision Boxes

As mentioned in the implementation guide, Decision Boxes provide evidence-based information to help patients, caregivers, and providers, together, make informed choices about care options. They set out the available options and allow you to weigh the pros and cons of each, and to reflect on what’s important to the person concerned. They are designed to:

  • Inform people of the benefits and harms of the available options
  • Prepare people to discuss options with healthcare professionals
  • Help people choose an option that respects their priorities

Decision Boxes have been created to focus on Depression, Mild Problems with Thinking or Memory, Stress in Caregivers, Maintaining Independence and Malnutrition.

Explore the Decision Boxes.


Visit our patient/caregiver page