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), and is the first funded project that was focused on primary care.

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 phase of, frailty and, using a quick screening tool and applying Shared Decision Making, helped refer patients and their caregivers to community-based services. The approach, using different 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 your own setting

There are three regional implementation guides designed to help you implement the approach in Alberta, Ontario, or Quebec. The implementation guides were created as a starting point for you as a primary care provider, in the hopes that it helps you improve the health of the older adults in your practice.

Alberta Implementation Guide

Ontario Implementation Guide

Quebec Implementation Guide

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 your Primary Care setting

The approach to implementation differs, depending not only on your region, but also on your healthcare setting. We’ve created an overview of the seven components of the approach, with a variety of options to help guide you through the implementation process.

Here are four examples of models that were implemented as part of the research project:

Model 1: Patient Self-Screen in Waiting Room

Model 2: Pre-appointment Screening by Phone

Model 3: RN or NP Complete Screening

Model 4: Screening Tool Only

Downloadable worksheet

We’ve also created the following worksheet, to help you ask the right questions when considering implementation


Decision Boxes

As mentioned in the implementation guide, Decision Boxes provide information to help in making healthy decisions, and are intended for individuals, their friends and family, as well as health professionals. 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!