Transforming Primary Healthcare for Older Canadians Living with Frailty


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.


Paul Stolee, PhD is a Professor in the School of Public Health and Health Systems at the University of Waterloo. His research focuses on health system challenges affecting older persons, primary care, and engagement of patients and caregivers in health care decision-making. At Waterloo, he leads the Geriatric Health Systems Research Group, and is the Director of the University of Waterloo Network for Aging Research.

Jacobi Elliott, PhD holds adjunct appointments with the University of Waterloo and Western University. Jacobi is the Evaluation Lead in Specialized Geriatric Services at St. Joseph’s Health Care London. Her research focuses on care transitions, patient and family engagement, and geriatric health system challenges. Jacobi is a member of Canadian Frailty Network’s Citizen Engagement Committee.

Anik Giguère, PhD is a Professor in the Department of Family Medicine and Emergency Medicine at Laval University in Quebec City (Canada). She is also a researcher at VITAM, the research centre on sustainable health, and at the Quebec Excellence Centre on Aging. She studies the design and implementation of educational programs and decision aids to enable older adults to make health decisions based on evidence and on their experiences and values.

Susie Gregg, OT Reg. (Ont.) is a Waterloo Wellington Geriatric Clinical Resource Consultant for Primary Care at CMHA Waterloo Wellington, based in Guelph, Ontario.

Sara Mallinson, PhD is a sociologist and health services researcher, originally from the UK, but now living and working in Calgary, AB. I am an Adjunct Assistant Professor in the University of Calgary’s Community Health Sciences Department and Senior Consultant in the Provincial Clinical Excellence portfolio of Alberta Health Services. My interests include people-powered health, lay knowledge and experiences of health and health care, and health equity/social determinants of health.  I am primarily a qualitative researcher but I also have experience with mixed-methods research, policy analysis, and diverse evidence synthesis.