Frail Seniors

Preventing functional decline and secondary falls among frail older adults

RCA initiatives support best practice care for community-dwelling older adults.

  • Post-fall rehabilitative care pathways

    The RCA developed evidence-based care pathways for primary care and emergency departments to connect frail older adults who fall with rehabilitative care to prevent functional decline and additional falls.

    The RCA piloted the pathways in several regions of Ontario to finalize them before moving to broader implementation. The RCA has released a report of findings from the pilot, including implementation strategies and tools.

    The RCA is currently supporting Ontario Health Teams and local regions to use a quality improvement approach to the implementation of the post-fall pathways. If interested, please contact Gabrielle Sadler, Project Manager.   
  • Developing best practices framework for geriatric rehabilitative care

    The RCA is also developing a best practices framework for standardized geriatric rehabilitative care across the continuum to support better clinical outcomes for frail older adults and improve flow within the system. The framework for bedded care has been released, as well as a guidance document on best practice rehabilitative care in the context of COVID-19. 

  • Implementing best practices framework for hip fracture

    The RCA is continuing to support the implementation of the best practices framework for hip fracture, including strategies for quality improvement.

A more detailed list of activities for all RCA initiatives is found here. Terms of reference and the membership for the advisory and task groups can be found on our governance page.

Frail Seniors Rehabilitative Care Best Practice Framework
Frail Seniors: Guidance on Best Practice Rehabilitative Care in the Context of COVID-19 Provides best practice recommendations to guide provision of rehabilitative care services to frail seniors and what should be considered as these services are reopened.
Frail Seniors Rehabilitative Care Best Practice Framework: Bedded Levels of Care Provides detailed evidence-based recommendations on how to deliver best practice rehabilitative care in a bedded setting.
Pathways to Post-Fall Rehabilitative Care
Pathways to rehabilitative care for frail older adults in the community presenting to primary care or ED post-fall: Pilot Report (July 2020) Initial findings from the pilot, including implementation strategies and tools. 
Post-Fall Pathway: Emergency Department (August 2021) Clinical pathway for ED assessment and referrals.
Post-Fall Pathway: Primary Care (August 2021) Clinical pathway for primary care assessment and referrals.
Direct Access Priority Process (DAPP)
DAPP  Supports early identification of individuals with restorative potential who require inpatient rehabilitative care and facilitates referrals directly from the community.
Geriatric Syndromes
Frail Senior/Medically Complex Compendium (2015) Summary of best practices from gold standard literature re: the assessment and treatment of geriatric syndromes. 
Hip Fracture Rehabilitative Care Best Practices

Hip Fracture Framework (March 2017/Rev September 2018)

Addendum to the Rehabilitative Care Best Practice Framework in the Context of COVID-19 (October 2020)

Includes the framework, referral decision tree, and process indicators for support performance monitoring and QBP-related outcomes. Additional resources are available here

Additional evidence-based recommendations that align with current COVID-19 restrictions.

A&R Evaluation
Assess & Restore 2018-19 Initiatives Summary (January 2020) Description and outcomes of all 2018/19 A&R initiatives.
Assess & Restore 2017-18 Initiatives Summary (October 2018) Description of all 2017/18 A&R initiatives.
Assess & Restore Shared Provincial Indicators (January 2018) Description and technical definitions of standardized indicators for Assess & Restore reporting.
Assess & Restore 2016-17 Initiatives Summary (November 2017) Description of all 2016/17 A&R initiatives.
Pan-LHIN A&R Logic Model (March 2017) Logic model to demonstrate the collective impact of all initiatives funded by A&R funding.