Implementing a Risk Screening Tool in Primary Care for Older Frail Adults

Read more about the project here.

Population aging has led to a greater number of seniors, many of whom suffer from multiple ongoing health problems. Unfortunately, the health care system is currently designed to deal with single, sudden and usually curable problems. Providing care to older adults living with frailty is challenging due to comorbidities, multiple providers, multiple care settings, long wait times, inefficient referral processes and insufficient transitional care across settings. As a result, many of these seniors living with frailty have no other choice than to visit crowded hospital emergency departments. One way to respond to these pressures is to improve the ability of Canada’s primary health care providers to deliver care to older people living with frailty.

Very brief tools were used to screen all seniors in the primary care practice, and identify those who were at greater risk of developing problems. Those at higher risk could then be evaluated in greater depth, and connected with appropriate health care services as soon as possible. Our highly qualified team worked with these care practices to develop and evaluate a model of care to accomplish these tasks.

Paul Stolee, PhD leads the Geriatric Health Systems Research Group at the University of Waterloo, where he is on faculty in the School of Public Health and Health Systems. Professor Stolee’s experience in research and planning in geriatrics includes work in academic, government and community settings. His CIHR-funded research program – “InfoRehab” – investigated the use of health information and health information systems in the rehabilitation of older person. This work led to increased research interest in the challenges experienced by older patients as they transition across care settings, in more meaningful engagement of older adults in healthcare decision-making, and in developing a stronger role for primary care in risk screening and care coordination. Professor Stolee leads a Canadian Frailty Network-funded project which is developing and testing approaches to strengthen primary care for older adults living with frailty. He is also a WorkPackage co-lead for the AGE-WELL Network of Centres of Excellence, conducting research on health system, policy and regulatory factors that can help or hinder technological innovation that could benefit older persons. Professor Stolee was the 2012 recipient of the Canadian Association on Gerontology Evelyn Shapiro Mentoring Award. He is the current Editor-in-Chief of the Canadian Journal on Aging/La Revue canadienne du viellissement. He also directs the University of Waterloo Network for Aging Research.

Jacobi Elliott, PhD completed her PhD under the supervision of Professor Stolee. She currently holds an Adjunct Associate Professor appointment with the University of Waterloo, School of Public Health and Health Systems. Jacobi has extensive experience with qualitative, evaluation, and case study research methods. Areas of expertise include care transitions, patient and family engagement, health care service research, and knowledge translation and exchange. A major current focus is care coordination and strategies to engage older adults in health care decision-making as they move through the system. Jacobi is a member of the Canadian Frailty Network – Citizen Engagement Committee.