Implementing the ‘Frailty Portal’ in Community Primary Care Practice: Evaluating feasibility, effects and expansion needs

Read more about the project here.

In this community-based study we assessed the implementation feasibility and impact of the ‘Frailty Portal’ in the identification, raising awareness of, care planning and delivery of appropriate care for the frail population in community primary care practice. Primary Healthcare (PHC) providers regularly encounter frail persons in their daily clinical work. However, routine identification and measurement of frailty is not part of primary care standard practice and there is a general lack of awareness about, and consistency in approach to, frailty. The ‘Frailty Portal’ was developed to aid in the identification, screening and care planning for frail patients.

This project undertook an in-depth evaluation by: 1) Identifying and understanding factors influencing the implementation feasibility of the ‘Frailty Portal’ program among frail patients, their family caregivers (where applicable) and PHC providers, 2) Assessing the impact of the ‘Frailty Portal’ on frail patients, their caregivers and PHC providers and, 3) Identifying the core components required to successfully scale-up the initiative to a broader community of PHC providers within and across health jurisdictions.

The deliverables of this project aid in the planning and delivery of optimal, timely and relevant care for the frail in the community which over the long-term, is expected to include a reduction in service duplication, improved continuity, coordination of care, reduced wait time for provider and appropriate community services and greater confidence in the care patients receive by healthcare providers and the degree to which family/caregivers can provide.

Paige Moorhouse, MD, MPH, FRCPC is an Associate Professor of Medicine (Geriatrics and Internal Medicine) at Dalhousie University. Dr. Moorhouse draws on her clinical experience to inspire her research in clinical care delivery in frailty, end-of-life care, and technology solutions for team-based care. Dr. Moorhouse is co-founder of the Palliative and Therapeutic Harmonization Program (PATH), a multi award winning program dedicated to helping patients and their caregivers make health care decisions that reflect individual values and quality of life. The PATH program and its associated methodologies (FACT screening for frailty and Collaborative Comprehensive Geriatric Assessment) have been recognized as leading practices by Accreditation Canada. Dr. Moorhouse is the co-chair of the Frailty Strategy for the Nova Scotia Health Authority. Dr. Moorhouse is the recipient of the Kauffman Award and the Killam Scholarship, the 3M Quality Award and the 2012 Public Sector Leadership Award. In 2016 she was awarded the Meritorious Service Medal by the Governor General for her work in frailty.

Tara Sampalli, PhD, MASc is Director, Research and Innovation in Primary Health Care and Chronic Disease Management at Nova Scotia Health Authority, and Assistant Professor of Medical Informatics at Dalhousie University. Dr. Sampalli obtained her BEng from Bangalore University, followed by Masters of Applied Science in Computational Analysis of Indoor Environment from Dalhousie University. Most recently, she obtained her PhD in Interdisciplinary Studies specializing in Health Informatics from Dalhousie University. Dr. Sampalli’s research interests include chronic disease management and multimorbidities, integrated models of care, knowledge management, and application of innovative IT solutions in healthcare.

Ashley Harnish, BSc, MScOT, OT Reg. NS is a Health Services Manager at the Nova Scotia Health Authority supporting Primary HealthCare. Her portfolio supports a broad range of programs including; collaborative practice teams, frailty portal and strategy, Care By Design supporting primary care in long term care, fracture liaison services, and prideHealth supporting health needs for the LGBTIQ community. An occupational therapist by background, Ashley has clinical experience working in community palliative care, geriatric assessment and rehabilitation unit, and acute care. In addition to her work clinically, Ashley managed the Integrated Stroke Unit in Ontario, a unique model of integrated stroke care. During her time working in stroke care, Ashley lead her team to be one of the first in Canada to be awarded Accreditation Canada’s Stroke Distinction designation for both acute and rehabilitation standards of care.