Resources Archive - Provincial Geriatrics Leadership Ontario

Resource Name	Topic	Type
Aging Care in Ontario Summit Reports On February 21, 2024, Provincial Geriatrics Leadership Ontario and the Behavioural Supports Ontario Provincial Coordinating Office (BSO PCO) convened partners from across Ontario to co-design an answer to the important question of “how to design the health and social care system we all want to age in?". This resource includes two reports.		Report
Quick Reference Guide: Implementing Nurse Led Outreach Teams in Ontario Nurse Led Outreach Teams (NLOTs) are one of Ontario’s specialized geriatric services. This Quick Reference Guide supports organizations who are implementing and operating NLOT Teams.	Program Implementation	Toolkit
Customizable Templates for Frailty Screening & Management in Primary Care This document accompanies the resource guide "Frailty Screening & Management in Primary Care".	Program Implementation	Toolkit
Customizable Templates for Frailty Screening & Management in the Community This document accompanies the resource guide "Frailty Screening & Management in the Community".	Program Implementation	Toolkit
Frailty Screening & Management in the Community The "Frailty Screening & Management in the Community" resource is intended to guide the implementation of frailty screening and management in community settings.	Screening and Assessment	Toolkit
Frailty Screening & Management in Primary Care The "Frailty Screening & Management in Primary Care" resource is intended to guide the implementation of frailty screening and management in primary care settings.	Screening and Assessment	Toolkit
Fracture Prevention in Long-Term Care (Toolkit) The Ontario Osteoporosis Strategy for Long-Term Care (LTC) aims to increase awareness about fracture prevention specifically for older adults living with frailty in LTC and to support fracture risk-reduction. With a well-established bone health research program, the Geras Centre for Aging Research has been involved in leading the Osteoporosis Strategy in LTC and, in collaboration with key stakeholders has developed a variety of awareness raising and fracture prevention knowledge products and tools targeted to health professionals and LTC resident and their families.	Screening and Assessment	Toolkit
Developing & Implementing a Geriatric Emergency Management Program	Clinical Models	Presentation
Assessing Caregiver Needs This presentation summarizes a rapid review of Caregiver Screening and Assessment tools conducted by members of the Ontario Collaborative for Aging Well, led by Ontario Caregiver Organization and Seniors Care Network.	Clinical Models	Presentation
ALC Leading Practices – Community Current State Assessment Tool This implementation tool is intended to be used in conjunction with the Alternate Level of Care (ALC) Leading Practices to Prevent Hospitalization and Extended Stays for Older Adults (2021) and the Leading Practices in Community Based Early Identification, Assessment & Transition: Preventing Alternate Level of Care (2022)	Clinical Models	Presentation
Response Guide – Ontario Health 2023-2024 Expanding and Enhancing IPCs This EOI Response Guide provides content to aid in the completion of the Ontario Health EOI for ICTs template. Teams that are interested in focusing on addressing the needs of older adults in their community may find the included information can support their application.	Clinical Models	Presentation
Provincial Common Orientation to Caring for Older Adults – Program Outline The Provincial Common Orientation is a tiered approach to learning that enables health and social care providers interested in the care of older adults living with frailty to engage in relevant and progressive professional development. The Provincial Common Orientation is intended to support a holistic approach to geriatric care through learning activities that integrate the complex physical, cognitive, social and mental health concerns frequently experienced among older adults.	Clinical Models	Presentation
Leading in the Care of Older Adults Series: Capacity Planning	Clinical Models	Presentation
Holistic Approach to Frailty for Ontario Health Teams	Clinical Models	Presentation
2022-2023 PGLO Priorities Downloadable version of PGLO's 2022-2023 priorities.	Clinical Models	Presentation
Frailty: A Primary Care Approach (Video Presentation) In this video, Dr. Jo-Anne Clarke, Geriatrician and Medical Director of the North East Specialized Geriatric Centre, presents about frailty to the Project ECHO Primary Care participants.	Clinical Models	Presentation
Rehabilitative Care for Older Adults Living With or At Risk of Frailty Provincial Geriatrics Leadership Ontario and the Rehabilitative Care Alliance have released a new best practice framework to guide rehabilitative care for older adults living with/at risk of frailty.	Interprofessional Practice	Framework
Consensus Statement: Care for the Older Adult with Complex Health Conditions – Reframing ‘Frailty’ in an Ontario Context This statement is intended to provide clarity about concepts related to complexity and frailty as they relate to the planning and delivery of care required by older adults in Ontario.	Interprofessional Practice	Framework
Geriatric Continuing Professional Education Links	Interprofessional Practice	Framework
Sample Chart Review Tool	Interprofessional Practice	Framework
NEW – 2019-2022 Specialized and Focused Geriatric Services Asset Inventory The Provincial SGS Asset Mapping Initiative informs a current state view of the supply and utilization of health services designed for older people living with complex health conditions.	Interprofessional Practice	Framework
ALC Leading Practices: Supporting Ontario Health Teams to Influence Alternate Level of Care In concert with colleagues leading Senior Friendly Care initiatives across Ontario, Provincial Geriatrics Leadership Ontario is pleased to share information to support OHTs in their efforts to help individuals at risk for protracted hospital stays (e.g. ALC designation).	Interprofessional Practice	Framework
An Implementation Rubric for Operationalizing Integrated Care for Older Adults An implementation rubric can be used by health authorities and organizations to strengthen consistency in the operationalization of integrated care for older persons living with complex health and social care requirements and their care partners.	Interprofessional Practice	Framework
A Conceptual Model for Integrated Older Persons Care This conceptual model illustrates the interconnected relationships between abstract concepts, organizing structures, and desired courses of action at macro, meso and micro levels of support that bring about quality integrated care across the continuum of care for older persons living with complex health conditions and care partners.	Interprofessional Practice	Framework
A Systems Level Logic Model for Integrated Older Persons Care A systems level logic model was developed to provide a road map of the theory-to-practice relationships important for implementing a sustainable integrated system of care for older persons and care partners living with complex health and social care requirements.	Interprofessional Practice	Framework
Performance, Implementation and Measurement Framework PGLO undertook a multi-pronged initiative to develop a Performance Implementation and Measurement Framework to guide the design, implementation and measurement of a system of integrated care to support older persons living with complex health and social care requirements in Ontario and their care partners.	Interprofessional Practice	Framework
Alternate Level of Care Leading Practices Self Assessment Tool The Self-Assessment Tool: Alternate Level of Care (ALC) Leading Practices to Prevent Hospitalization and Extended Stays for Older Adults is intended to be used in conjunction with the Leading Practices to Prevent Hospitalization and Extended Stays for Older Adults.	Interprofessional Practice	Framework
Alternate Level of Care Leading Practices Guide The Alternate Level of Care Leading Practices guide was developed by the Ontario ALC Leading Practices Working Group and identifies evidence-based leading practices for the care and proactive management of hospitalized older adults at risk of delayed transition to an appropriate setting that can be implemented in the emergency department, acute care and post-acute care settings. While the focus of this guide is on ALC prevention and management in hospitalized older adults, many of these leading practices can be applied to other patient populations.	Care Planning and Intervention	Toolkit
Coordinating Access to Specialized Geriatric Services: A Review of Evidence and Current Practice This report summarizes the results of a review of available literature, organizational processes and expert opinion and informs best practices in coordinated access mechanisms. The results can aid improved coordination between services and create scalable mechanisms for coordinating access to required services, optimizing care for older adults living with complexity in the community.	Care Planning and Intervention	Report
Delirium Awareness Resources Delirium is a medical emergency. Delirium may be under-recognized in older adults. Learn more about what you can to to identify and help to manage delirium.	Core Geriatric Knowledge	Report
Pandemic Recovery Planning for Older Adults Infographic An infographic describing key principles to guide pandemic recovery planning and system transformation in older adult care.	Core Geriatric Knowledge	Report
PGLO Annual Activity Report 2020-2021 A detailed report on the activities of PGLO and its network for the fiscal year 2020-2021	Core Geriatric Knowledge	Report
Looking Forward: Perspectives on Long Term Care of the Future This report summarizes a consultation held with members of the Canadian Geriatric Society (CGS) and Provincial Geriatrics Leadership Ontario (PGLO) Long-Term Care (LTC) Interest Group to inform National Standards for Long-Term Care.	Core Geriatric Knowledge	Report
Find Specialized and Focused Geriatric Services in Ontario	Core Geriatric Knowledge	Report
Achieving Consensus on a Core Set of Indicators For Integrated Older Persons Care in Ontario – Study Information	Core Geriatric Knowledge	Report
An Integrated Approach to Preventing Fall-Related Injuries among Older Adults in Ontario A framework describing key requirements for fall prevention in Ontario.	Core Geriatric Knowledge	Position Paper
An Environmental Scan of Older Adult Fall Prevention Indicators	Core Geriatric Knowledge	Position Paper
Screening and Assessment Tools for Falls in Older Adults in Ontario	Core Geriatric Knowledge	Toolkit
Fall Prevention Knowledge Products	Core Geriatric Knowledge	Toolkit
Prevention Research Initiatives – Fall Prevention in Older Adults with Cognitive Impairment	Core Geriatric Knowledge	Toolkit
Delirium Quality Standards – Knowledge Translation Resources PGLO partnered in the development of the Ontario Health Delirium Standard. Find resources to support knowledge translation here.	Core Geriatric Knowledge	Toolkit
Segmenting the Population Fact Sheet – Older Adults Living with Complex Health Conditions This fact sheet describes approaches to population segmentation in older adult living with complex health conditions. It is one of a series of resources intended to bring trusted and credible information and support to the efforts of Ontario Health Teams, specific to the needs of an older adult population living with complexity.	Population Health	Ontario Health Team Supports
First Nations Aging Study This study, completed in 2019, through a partnership between the Chiefs of Ontario and university researchers was the first Ontario-wide profile of aging in First Nations populations.	Population Health	Report
Virtual Care Decision Tool for Older Persons’ Care This Virtual Care Decision Tool is a resource that aims to provide a structured approach to critical decision making about determining the a best approach to a comprehensive geriatric assessment (e.g. virtual or in-person)	Screening and Assessment	Toolkit
Caregiving Strategies Handbook (All Languages) The Caregiving Strategies Handbook is available in four languages.	Caregiver Assistance	Toolkit
Caregiving Strategies Handbook (Mandarin) Mandarin translation of the Caregiving Strategies Handbook.	Caregiver Assistance	Toolkit
Caregiving Strategies Handbook (Cantonese)	Caregiver Assistance	Toolkit
Vaccine Myth Busting Resources for Clinicians This resource includes responses to common myths, notes about vaccination in immunosuppressed older populations, ideas for having the conversation about vaccine hesitancy and several current clinical resources.	Core Geriatric Knowledge	Toolkit
Myth-busting: Addressing Vaccine Hesitancy (Video)	Core Geriatric Knowledge	Presentation
Cognitive Screening Toolkit This new Toolkit can serve as a resource for clinicians to better understand cognitive screening tools, which have been validated in Primary Care settings and are available for free. This toolkit can help in selecting the appropriate cognitive screening tool to use with primary care patients.	Screening and Assessment	Toolkit
Frailty Estimates by Census Division and Ontario Health Region The Provincial Geriatrics Leadership Office has estimated the prevalence of frailty by census division and projected these estimates to 2040 to facilitate planning for health services for older adults living with complex and chronic health concerns.	Screening and Assessment	Population Health
Designing Integrated Care for Older Adults Living with Complex and Chronic Health Needs: A Scoping Review This scoping review , developed by the Provincial Geriatrics Leadership Office, examines the literature to highlight core design elements that can assist planners, policy makers, health leaders and clinicians in their health system design work. It is also relevant to older persons and family/friend caregivers who, with this information in hand, can contribute to design and evaluation of the services intended to support them.	Screening and Assessment	Report
Asset Mapping Data Entry Portal	Screening and Assessment	Report
Reflecting on the COVID-19 Pandemic: Themes from Long Term Care – An International Virtual Town Hall Held September 25, 2020, this international event convened a wide range of experts and reviewed evidence briefs and experience from around the world to inform future planning in Long Term Care and Older Person’s Care.	Screening and Assessment	Presentation
Family Presence in Older Adult Care – A Statement Regarding Family Caregivers and the Provision of Essential Care This statement been prepared to support the restoration of family presence, to aid the fulfilment of commitments to patient and family centred care across health organizations and to enable the integration of Family Caregivers across the health care system moving forward.	Screening and Assessment	Position Paper
Chronic Disease Management in Long-term Care: Diabetes Dr. Ruth Ellen, BScH, MD, FRCP(C), brings her experience in geriatric and internal medicine, along with her past practice as an MRP in Long Term Care, to a practical discussion about optimizing diabetes management in LTC, at this challenging time. While taking a focus on times of high stress, Dr. Ellen's advice applies to overall management and will be of interest to primary care physicians, nurse practitioners, RN, RPNs, LTC pharmacists, and others.	Core Geriatric Knowledge	Presentation
Chronic Disease Management in Long-term Care: Heart Failure This session provided specific information for the Long Term Care (LTC) environment with a focus on effective chronic disease management that can lessen care requirements and promote comfort and quality of life for those living with chronic disease in any setting. This session may be particularly important for primary care physicians, nurse practitioners and others caring for individuals living with heart failure during COVID-19 outbreaks.	Core Geriatric Knowledge	Presentation
Virtual Approaches to Cognitive Screening During Pandemics Published May 8, 2020 by the Canadian Geriatrics Society (CGS) by authors Dr. Kristen Clark and Dr. Philip St John, “Virtual Approaches to Cognitive Screening During Pandemics” reviews the evidence and approach for eight virtual screening tools for cognition and provides advice to clinicians at a time when many are increasingly using virtual means to reach their patients.	Core Geriatric Knowledge	Toolkit
Guide de stratégies pour les aidants naturels Le Guide de stratégies pour les aidants naturels : offrir soins et soutien à un aîné fragilisé a été préparé pour vous, parents et amis qui soutiennent un aîné. Créé en consultation avec des aidants dans tout l’Ontario, il a été révisé par des professionnels de la santé.	Caregiver Assistance	Toolkit
Social Distancing Yes – Social Isolation No – Key Messages Social Distancing Yes -Social Isolation No - Key Messages	Caregiver Assistance	Toolkit
Clinical Pathway for Community Care of Older Adults screening COVID-19+	Screening and Assessment	Toolkit
Managing Respiratory and End-of-life Symptoms for Frail Elderly Patients with COVID-19	Screening and Assessment	Toolkit
Goals of Care Script – Long Term Care	Screening and Assessment	Toolkit
Virtual CGA – Practical Advice	Screening and Assessment	Toolkit
Patient Poster – Notice to Home Care Workers	Screening and Assessment	Toolkit
Searchable COVID-19 Specific Resource List (Geriatric Care)	Screening and Assessment	Toolkit
Sample Telephone Script Sample script for teams making calls to patients/families.	Screening and Assessment	Resource
SGS In-Home Screening Tool/Guide This tool may assist teams who are calling and screening patients for urgent geriatric care.	Screening and Assessment	Resource
General Guidance – Pandemic Planning and Specialized Geriatric Services This document summarizes emerging advice and experience from the field, including guidance for community based care of older adults living with frailty.	Screening and Assessment	Resource
Pandemic Clinical Resources and Supports – Older Adults Living With Complexity This information has been compiled to support the continued delivery of care to older adults living with complex health conditions (e.g. frailty), during the current COVID-19 pandemic.	Screening and Assessment	Resource
Seniors Services – Trillium Health Partners Referral Form Seniors Health Services at Trillium Health Partners include a variety of hospital and community based services that specializes in the care of older adults with complex health care needs. For more information, visit	Screening and Assessment	Resource
Caregiving Strategies Handbook Caregiving Strategies are a collection of educational resources that have been developed and/or curated for family and friend caregivers who provide care and support for seniors experiencing frailty.	Caregiver Assistance	Toolkit
PGLO Older Adult Experience Survey – Implementation Guide The Older Adult Experience Survey (OAES) is an evidence-informed, collaboratively developed experience survey designed specifically for appointment-based SGS programs/clinics. Current findings support the survey being valid and reliable, and consistent from individual to individual, across settings and at different points of time in care. The survey is designed to support SGS programs regionally and provincially as well as to identify quality improvement initiatives. This Implementation Guide supports consistent use of the OAES in practice and is recommended reading prior to initiating use of the OAES.	Caregiver Assistance	Toolkit
PGLO Older Adult Experience Survey The Older Adult Experience Survey (OAES) is a measure to better understand the experience of older adults accessing specialized geriatric services.	Caregiver Assistance	Toolkit
Pictorial Fit-Frail Scale (PFFS)	Screening and Assessment	Resource
Submission – Ontario’s Seniors Strategy (July 2019) In May 2019, in anticipation of the Ministry of Seniors and Accessibility’s consultation, the Regional Geriatric Programs of Ontario canvassed clinical leaders from across the field of geriatrics. The purpose was to gather expert insights pertinent to the needs of seniors living with frailty, in order to inform the anticipated Ontario Seniors Strategy. This report summarizes the input received from 65 clinical experts from across Ontario, whose daily work focuses on the unique needs of older people living with frailty, and their caregivers.	Screening and Assessment	Report
A Population-Based Study of Older Adults in Ontario: Dementia, Frailty and Utilization of Physician Specialist Services This current report provides information on the number of older adults in Ontario, and by local health integration network (LHIN) to identify potential needs related to health services for these populations in Ontario.	Screening and Assessment	Report
iGeriCare iGeriCare is a free, online dementia education program developed by experts in geriatrics, mental health and online learning at McMaster University	Screening and Assessment	Other
Caregiver Conversations- Progress Report 3	Screening and Assessment	Other
Support for Ontario Health Teams in Caring for Older Adults OHTs – Senior Friendly Care The need for an authentic focus on the goals and aspirations of older people living with frailty (or at risk of frailty) is especially important as health service providers work towards a new model of service delivery as part of an Ontario Health Team (OHT). Older adults living with frailty or at risk of frailty require a specialized, senior-friendly approach to care across the healthcare continuum in order to meet their unique needs. The Regional Geriatric Programs of Ontario are pleased to offer their support as a strategic partner in achieving this goal.	Screening and Assessment	Position Paper
What We Heard Report To understand and respond to the learning needs of family and friend caregivers of seniors living with frailty, the Regional Geriatric Programs of Ontario (RGPO) initiated the Caregiver Education and Training Project. Based on a co-design process to develop educational resources for caregivers of seniors living with frailty, we hosted 10 focus groups in communities across Ontario. Connecting with 133 caregivers and 78 interprofessionals, this report highlights what we heard.	Screening and Assessment	Report
Position Statement on The Need for Expert Clinical Care for Older People Living with Complex Health Conditions If we are to end hallway medicine, all Ontario Health Teams must demonstrate the necessary policy, clinical and funding focus on older people living with complex and multiple interacting health conditions (including dementia). Each Ontario Health Team must include specific services that focus on this population and engage the appropriate clinical leadership necessary to carry out this work.	Professional Practice	Position Paper
Specialized Geriatric Services in Ontario RGPO – Physician Human Resources Report This project is intended to produce a partial current state view of specialized geriatric services across the province of Ontario, with a focus on the supply and utilization of health services designed for older people living with frailty	Professional Practice	Report
Planning for Older Adults Living with Frailty – SGS Asset Mapping Report This exercise was envisioned as a first step in capacity planning, with a primary goal of informing a current state view of the supply and utilization of health services designed for older people living with frailty (e.g. specialized geriatric services) to contribute to future capacity planning.	Professional Practice	Report
Caregiver Conversations – Progress Report 2 Progress as of March 2019. This newsletter shares insights into what we are hearing and lets you know about upcoming events and other ways to engage with the project.	Caregiver Assistance	Report
Caregiver Conversations – Progress Report 1 Progress as of December 2018. This newsletter shares insights into what we are hearing and lets you know about upcoming events and other ways to engage with the project.	Caregiver Assistance	Report
Compendium of Educational Offerings The Compendium of Educational Offerings Relevant to Interprofessional Comprehensive Geriatric Assessment (CGA) is a result of collaboration between the North East Specialized Geriatric Services (NESGC), Seniors Care Network, and Laurentian Research Institute for Aging (LRIA). This final result of this collaboration is an extensive compendium of educational offerings divided into 3 sections.	Screening and Assessment	Other
Frequently Asked Questions (FAQ) A summary of frequently asked questions that covers what is a comprehensive geriatric assessment, what are specialized geriatric services and what should be included in the ideal basket of specialized geriatric services. CGA performed by SGS can take place in a variety of settings. The RGPs advocate that CGA should be available across the continuum of health care services in community, emergency, inpatient, and longterm care settings, and delivered by an interprofessional, specialized geriatric team.	Screening and Assessment	FAQ
Why is Comprehensive Geriatric Assessment the Gold Standard? Covers the CGA process as a tool, not just assessment, includes management plan and implementation. Includes robust evidence in the hospital setting that it increases likelihood of living at home and in other settings – prevents functional decline.	Screening and Assessment	Presentation
Co-Creating a Position on the Coordination of Care for Older People Living with Frailty Objectives of this presentation are to provide a brief overview the competency framework for interprofessional CGA and demonstrate how a framework can be applied to advance practice locally and provincially through the example of coordination of care with older people living with frailty.	Professional Practice	Presentation
Organization Design for Geriatrics: An Evidence Based Approach This handbook is aimed at providing an evidence‐based approach to service delivery for the elderly patient in core specialized geriatric services. Core inpatient services include geriatric rehabilitation, assessment and consultation services. Core outpatient programs include geriatric outreach, outpatient clinics and geriatric day hospitals. In addition, there are a number of condition‐specific units, focused or innovative areas of care.	Professional Practice	Report
RGP Knowledge to Practice Framework This KTP framework has been used to guide two provincial initiatives – the geriatrics, interprofessional practice and interorganizational initiative designed to build geriatrics capacity in family health teams and community health center, and the senior friendly action program supporting teams to use continuous quality improvement projects in acute care geriatrics. The framework is also used to guide the KTP elements of a several research grant applications.	Professional Practice	Framework
An Overview of RGP Programs Regional Geriatric Programs (RGPs) provide a comprehensive network of specialized geriatric services which assess and treat functional, medical, and psychosocial aspects of illness and disability in older adults.	Screening and Assessment	Report
Patients First Position Paper We are concerned that older Ontarians were not a focus of this consultation process, nor included in any significant way in the Patient’s First discussion document. This is despite the Ministry’s commitment to a Seniors Strategy that prioritizes access for seniors to community based supports to enable them to live at home for as long as possible. Given that seniors consume almost 50% of the health care budget and more than 60% of acute care hospital days (including a significant proportion of ALC days), we contend that the priorities of the provincial Seniors’ Strategy should feature prominently in the subsequent plan, demonstrating health system planning reflective and proportional to the position seniors occupy as health care consumers.	Professional Practice	Position Paper
CGA Self-Assessment Tool (Interprofessional) The self assessment tool is a living document that is meant to support the clinician to adequately prepare themselves to deliver interprofessional comprehensive geriatric assessment and interventions by supporting the ongoing growth and development of the core competencies outlined in the “A Competency Framework for Interprofessional Comprehensive Geriatric Assessment”. Self assessment is integral to lifelong learning. It is beneficial to elicit feedback from a mentor and/or a supervisor when identifying learning needs and setting goals.	Professional Practice	Toolkit
Competency Framework for Interprofessional Comprehensive Geriatric Assessment The purpose of this competency framework is to describe detailed practice expectations of health professionals participating in the CGA. This Framework will help health professionals to adequately prepare themselves to deliver interprofessional comprehensive geriatric assessments and interventions and work effectively in a specialized geriatrics environment.	Screening and Assessment	Report
Caregiver Education and Training Sf7 Toolkit The SF7 Toolkit is a Senior Friendly Care (sfCare) resource that supports clinical best practices for healthcare providers in each sector and provides self management tools for older adults and their caregivers. The toolkit is available by individual topic, as well as by all topics together. All SF7 toolkit options are available on our website.	Screening and Assessment	Toolkit
13 Prescribing Tips for Older Adults	Core Geriatric Knowledge	Toolkit

Aging Care in Ontario Summit Reports

On February 21, 2024, Provincial Geriatrics Leadership Ontario and the Behavioural Supports Ontario Provincial Coordinating Office (BSO PCO) convened partners from across Ontario to co-design an answer to the important question of “how to design the health and social care system we all want to age in?". This resource includes two reports.

Report

Quick Reference Guide: Implementing Nurse Led Outreach Teams in Ontario

Nurse Led Outreach Teams (NLOTs) are one of Ontario’s specialized geriatric services. This Quick Reference Guide supports organizations who are implementing and operating NLOT Teams.

Program Implementation

Toolkit

Customizable Templates for Frailty Screening & Management in Primary Care

This document accompanies the resource guide "Frailty Screening & Management in Primary Care".

Program Implementation

Toolkit

Customizable Templates for Frailty Screening & Management in the Community

This document accompanies the resource guide "Frailty Screening & Management in the Community".

Program Implementation

Toolkit

Frailty Screening & Management in the Community

The "Frailty Screening & Management in the Community" resource is intended to guide the implementation of frailty screening and management in community settings.

Screening and Assessment

Toolkit

Frailty Screening & Management in Primary Care

The "Frailty Screening & Management in Primary Care" resource is intended to guide the implementation of frailty screening and management in primary care settings.

Screening and Assessment

Toolkit

Fracture Prevention in Long-Term Care (Toolkit)

The Ontario Osteoporosis Strategy for Long-Term Care (LTC) aims to increase awareness about fracture prevention specifically for older adults living with frailty in LTC and to support fracture risk-reduction. With a well-established bone health research program, the Geras Centre for Aging Research has been involved in leading the Osteoporosis Strategy in LTC and, in collaboration with key stakeholders has developed a variety of awareness raising and fracture prevention knowledge products and tools targeted to health professionals and LTC resident and their families.

Screening and Assessment

Toolkit

Developing & Implementing a Geriatric Emergency Management Program

Clinical Models

Presentation

Assessing Caregiver Needs

This presentation summarizes a rapid review of Caregiver Screening and Assessment tools conducted by members of the Ontario Collaborative for Aging Well, led by Ontario Caregiver Organization and Seniors Care Network.

Clinical Models

Presentation

ALC Leading Practices – Community Current State Assessment Tool

This implementation tool is intended to be used in conjunction with the Alternate Level of Care (ALC) Leading Practices to Prevent Hospitalization and Extended Stays for Older Adults (2021) and the Leading Practices in Community Based Early Identification, Assessment & Transition: Preventing Alternate Level of Care (2022)

Clinical Models

Presentation

Response Guide – Ontario Health 2023-2024 Expanding and Enhancing IPCs

This EOI Response Guide provides content to aid in the completion of the Ontario Health EOI for ICTs template. Teams that are interested in focusing on addressing the needs of older adults in their community may find the included information can support their application.

Clinical Models

Presentation

Provincial Common Orientation to Caring for Older Adults – Program Outline

The Provincial Common Orientation is a tiered approach to learning that enables health and social care providers interested in the care of older adults living with frailty to engage in relevant and progressive professional development. The Provincial Common Orientation is intended to support a holistic approach to geriatric care through learning activities that integrate the complex physical, cognitive, social and mental health concerns frequently experienced among older adults.

Clinical Models

Presentation

Leading in the Care of Older Adults Series: Capacity Planning

Clinical Models

Presentation

Holistic Approach to Frailty for Ontario Health Teams

Clinical Models

Presentation

2022-2023 PGLO Priorities

Downloadable version of PGLO's 2022-2023 priorities.

Clinical Models

Presentation

Frailty: A Primary Care Approach (Video Presentation)

In this video, Dr. Jo-Anne Clarke, Geriatrician and Medical Director of the North East Specialized Geriatric Centre, presents about frailty to the Project ECHO Primary Care participants.

Clinical Models

Presentation

Rehabilitative Care for Older Adults Living With or At Risk of Frailty

Provincial Geriatrics Leadership Ontario and the Rehabilitative Care Alliance have released a new best practice framework to guide rehabilitative care for older adults living with/at risk of frailty.

Interprofessional Practice

Framework

Consensus Statement: Care for the Older Adult with Complex Health Conditions – Reframing ‘Frailty’ in an Ontario Context

This statement is intended to provide clarity about concepts related to complexity and frailty as they relate to the planning and delivery of care required by older adults in Ontario.

Interprofessional Practice

Framework

Geriatric Continuing Professional Education Links

Interprofessional Practice

Framework

Sample Chart Review Tool

Interprofessional Practice

Framework

NEW – 2019-2022 Specialized and Focused Geriatric Services Asset Inventory

The Provincial SGS Asset Mapping Initiative informs a current state view of the supply and utilization of health services designed for older people living with complex health conditions.

Interprofessional Practice

Framework

ALC Leading Practices: Supporting Ontario Health Teams to Influence Alternate Level of Care

In concert with colleagues leading Senior Friendly Care initiatives across Ontario, Provincial Geriatrics Leadership Ontario is pleased to share information to support OHTs in their efforts to help individuals at risk for protracted hospital stays (e.g. ALC designation).

Interprofessional Practice

Framework

An Implementation Rubric for Operationalizing Integrated Care for Older Adults

An implementation rubric can be used by health authorities and organizations to strengthen consistency in the operationalization of integrated care for older persons living with complex health and social care requirements and their care partners.

Interprofessional Practice

Framework

A Conceptual Model for Integrated Older Persons Care

This conceptual model illustrates the interconnected relationships between abstract concepts, organizing structures, and desired courses of action at macro, meso and micro levels of support that bring about quality integrated care across the continuum of care for older persons living with complex health conditions and care partners.

Interprofessional Practice

Framework

A Systems Level Logic Model for Integrated Older Persons Care

A systems level logic model was developed to provide a road map of the theory-to-practice relationships important for implementing a sustainable integrated system of care for older persons and care partners living with complex health and social care requirements.

Interprofessional Practice

Framework

Performance, Implementation and Measurement Framework

PGLO undertook a multi-pronged initiative to develop a Performance Implementation and Measurement Framework to guide the design, implementation and measurement of a system of integrated care to support older persons living with complex health and social care requirements in Ontario and their care partners.

Interprofessional Practice

Framework

Alternate Level of Care Leading Practices Self Assessment Tool

The Self-Assessment Tool: Alternate Level of Care (ALC) Leading Practices to Prevent Hospitalization and Extended Stays for Older Adults is intended to be used in conjunction with the Leading Practices to Prevent Hospitalization and Extended Stays for Older Adults.

Interprofessional Practice

Framework

Alternate Level of Care Leading Practices Guide

The Alternate Level of Care Leading Practices guide was developed by the Ontario ALC Leading Practices Working Group and identifies evidence-based leading practices for the care and proactive management of hospitalized older adults at risk of delayed transition to an appropriate setting that can be implemented in the emergency department, acute care and post-acute care settings. While the focus of this guide is on ALC prevention and management in hospitalized older adults, many of these leading practices can be applied to other patient populations.

Care Planning and Intervention

Toolkit

Coordinating Access to Specialized Geriatric Services: A Review of Evidence and Current Practice

This report summarizes the results of a review of available literature, organizational processes and expert opinion and informs best practices in coordinated access mechanisms. The results can aid improved coordination between services and create scalable mechanisms for coordinating access to required services, optimizing care for older adults living with complexity in the community.

Care Planning and Intervention

Report

Delirium Awareness Resources

Delirium is a medical emergency. Delirium may be under-recognized in older adults. Learn more about what you can to to identify and help to manage delirium.

Core Geriatric Knowledge

Report

Pandemic Recovery Planning for Older Adults Infographic

An infographic describing key principles to guide pandemic recovery planning and system transformation in older adult care.

Core Geriatric Knowledge

Report

PGLO Annual Activity Report 2020-2021

A detailed report on the activities of PGLO and its network for the fiscal year 2020-2021

Core Geriatric Knowledge

Report

Looking Forward: Perspectives on Long Term Care of the Future

This report summarizes a consultation held with members of the Canadian Geriatric Society (CGS) and Provincial Geriatrics Leadership Ontario (PGLO) Long-Term Care (LTC) Interest Group to inform National Standards for Long-Term Care.

Core Geriatric Knowledge

Report

Find Specialized and Focused Geriatric Services in Ontario

Core Geriatric Knowledge

Report

Achieving Consensus on a Core Set of Indicators For Integrated Older Persons Care in Ontario – Study Information

Core Geriatric Knowledge

Report

An Integrated Approach to Preventing Fall-Related Injuries among Older Adults in Ontario

A framework describing key requirements for fall prevention in Ontario.

Core Geriatric Knowledge

Position Paper

An Environmental Scan of Older Adult Fall Prevention Indicators

Core Geriatric Knowledge

Position Paper

Screening and Assessment Tools for Falls in Older Adults in Ontario

Core Geriatric Knowledge

Toolkit

Fall Prevention Knowledge Products

Core Geriatric Knowledge

Toolkit

Prevention Research Initiatives – Fall Prevention in Older Adults with Cognitive Impairment

Core Geriatric Knowledge

Toolkit

Delirium Quality Standards – Knowledge Translation Resources

PGLO partnered in the development of the Ontario Health Delirium Standard. Find resources to support knowledge translation here.

Core Geriatric Knowledge

Toolkit

Segmenting the Population Fact Sheet – Older Adults Living with Complex Health Conditions

This fact sheet describes approaches to population segmentation in older adult living with complex health conditions. It is one of a series of resources intended to bring trusted and credible information and support to the efforts of Ontario Health Teams, specific to the needs of an older adult population living with complexity.

Population Health

Ontario Health Team Supports

First Nations Aging Study

This study, completed in 2019, through a partnership between the Chiefs of Ontario and university researchers was the first Ontario-wide profile of aging in First Nations populations.

Population Health

Report

Virtual Care Decision Tool for Older Persons’ Care

This Virtual Care Decision Tool is a resource that aims to provide a structured approach to critical decision making about determining the a best approach to a comprehensive geriatric assessment (e.g. virtual or in-person)

Screening and Assessment

Toolkit

Caregiving Strategies Handbook (All Languages)

The Caregiving Strategies Handbook is available in four languages.

Caregiver Assistance

Toolkit

Caregiving Strategies Handbook (Mandarin)

Mandarin translation of the Caregiving Strategies Handbook.

Caregiver Assistance

Toolkit

Caregiving Strategies Handbook (Cantonese)

Caregiver Assistance

Toolkit

Vaccine Myth Busting Resources for Clinicians

This resource includes responses to common myths, notes about vaccination in immunosuppressed older populations, ideas for having the conversation about vaccine hesitancy and several current clinical resources.

Core Geriatric Knowledge

Toolkit

Myth-busting: Addressing Vaccine Hesitancy (Video)

Core Geriatric Knowledge

Presentation

Cognitive Screening Toolkit

This new Toolkit can serve as a resource for clinicians to better understand cognitive screening tools, which have been validated in Primary Care settings and are available for free. This toolkit can help in selecting the appropriate cognitive screening tool to use with primary care patients.

Screening and Assessment

Toolkit

Frailty Estimates by Census Division and Ontario Health Region

The Provincial Geriatrics Leadership Office has estimated the prevalence of frailty by census division and projected these estimates to 2040 to facilitate planning for health services for older adults living with complex and chronic health concerns.

Screening and Assessment

Population Health

Designing Integrated Care for Older Adults Living with Complex and Chronic Health Needs: A Scoping Review

This scoping review , developed by the Provincial Geriatrics Leadership Office, examines the literature to highlight core design elements that can assist planners, policy makers, health leaders and clinicians in their health system design work. It is also relevant to older persons and family/friend caregivers who, with this information in hand, can contribute to design and evaluation of the services intended to support them.

Screening and Assessment

Report

Asset Mapping Data Entry Portal

Screening and Assessment

Report

Reflecting on the COVID-19 Pandemic: Themes from Long Term Care – An International Virtual Town Hall

Held September 25, 2020, this international event convened a wide range of experts and reviewed evidence briefs and experience from around the world to inform future planning in Long Term Care and Older Person’s Care.

Screening and Assessment

Presentation

Family Presence in Older Adult Care – A Statement Regarding Family Caregivers and the Provision of Essential Care

This statement been prepared to support the restoration of family presence, to aid the fulfilment of commitments to patient and family centred care across health organizations and to enable the integration of Family Caregivers across the health care system moving forward.

Screening and Assessment

Position Paper

Chronic Disease Management in Long-term Care: Diabetes

Dr. Ruth Ellen, BScH, MD, FRCP(C), brings her experience in geriatric and internal medicine, along with her past practice as an MRP in Long Term Care, to a practical discussion about optimizing diabetes management in LTC, at this challenging time. While taking a focus on times of high stress, Dr. Ellen's advice applies to overall management and will be of interest to primary care physicians, nurse practitioners, RN, RPNs, LTC pharmacists, and others.

Core Geriatric Knowledge

Presentation

Chronic Disease Management in Long-term Care: Heart Failure

This session provided specific information for the Long Term Care (LTC) environment with a focus on effective chronic disease management that can lessen care requirements and promote comfort and quality of life for those living with chronic disease in any setting. This session may be particularly important for primary care physicians, nurse practitioners and others caring for individuals living with heart failure during COVID-19 outbreaks.

Core Geriatric Knowledge

Presentation

Virtual Approaches to Cognitive Screening During Pandemics

Published May 8, 2020 by the Canadian Geriatrics Society (CGS) by authors Dr. Kristen Clark and Dr. Philip St John, “Virtual Approaches to Cognitive Screening During Pandemics” reviews the evidence and approach for eight virtual screening tools for cognition and provides advice to clinicians at a time when many are increasingly using virtual means to reach their patients.

Core Geriatric Knowledge

Toolkit

Guide de stratégies pour les aidants naturels

Le Guide de stratégies pour les aidants naturels : offrir soins et soutien à un aîné fragilisé a été préparé pour vous, parents et amis qui soutiennent un aîné. Créé en consultation avec des aidants dans tout l’Ontario, il a été révisé par des professionnels de la santé.

Caregiver Assistance

Toolkit

Social Distancing Yes – Social Isolation No – Key Messages

Social Distancing Yes -Social Isolation No - Key Messages

Caregiver Assistance

Toolkit

Clinical Pathway for Community Care of Older Adults screening COVID-19+

Screening and Assessment

Toolkit

Managing Respiratory and End-of-life Symptoms for Frail Elderly Patients with COVID-19

Screening and Assessment

Toolkit

Goals of Care Script – Long Term Care

Screening and Assessment

Toolkit

Virtual CGA – Practical Advice

Screening and Assessment

Toolkit

Patient Poster – Notice to Home Care Workers

Screening and Assessment

Toolkit

Searchable COVID-19 Specific Resource List (Geriatric Care)

Screening and Assessment

Toolkit

Sample Telephone Script

Sample script for teams making calls to patients/families.

Screening and Assessment

Resource

SGS In-Home Screening Tool/Guide

This tool may assist teams who are calling and screening patients for urgent geriatric care.

Screening and Assessment

Resource

General Guidance – Pandemic Planning and Specialized Geriatric Services

This document summarizes emerging advice and experience from the field, including guidance for community based care of older adults living with frailty.

Screening and Assessment

Resource

Pandemic Clinical Resources and Supports – Older Adults Living With Complexity

This information has been compiled to support the continued delivery of care to older adults living with complex health conditions (e.g. frailty), during the current COVID-19 pandemic.

Screening and Assessment

Resource

Seniors Services – Trillium Health Partners Referral Form

Seniors Health Services at Trillium Health Partners include a variety of hospital and community based services that specializes in the care of older adults with complex health care needs. For more information, visit

Screening and Assessment

Resource

Caregiving Strategies Handbook

Caregiving Strategies are a collection of educational resources that have been developed and/or curated for family and friend caregivers who provide care and support for seniors experiencing frailty.

Caregiver Assistance

Toolkit

PGLO Older Adult Experience Survey – Implementation Guide

The Older Adult Experience Survey (OAES) is an evidence-informed, collaboratively developed experience survey designed specifically for appointment-based SGS programs/clinics. Current findings support the survey being valid and reliable, and consistent from individual to individual, across settings and at different points of time in care. The survey is designed to support SGS programs regionally and provincially as well as to identify quality improvement initiatives. This Implementation Guide supports consistent use of the OAES in practice and is recommended reading prior to initiating use of the OAES.

Caregiver Assistance

Toolkit

PGLO Older Adult Experience Survey

The Older Adult Experience Survey (OAES) is a measure to better understand the experience of older adults accessing specialized geriatric services.

Caregiver Assistance

Toolkit

Pictorial Fit-Frail Scale (PFFS)

Screening and Assessment

Resource

Submission – Ontario’s Seniors Strategy (July 2019)

In May 2019, in anticipation of the Ministry of Seniors and Accessibility’s consultation, the Regional Geriatric Programs of Ontario canvassed clinical leaders from across the field of geriatrics. The purpose was to gather expert insights pertinent to the needs of seniors living with frailty, in order to inform the anticipated Ontario Seniors Strategy. This report summarizes the input received from 65 clinical experts from across Ontario, whose daily work focuses on the unique needs of older people living with frailty, and their caregivers.

Screening and Assessment

Report

A Population-Based Study of Older Adults in Ontario: Dementia, Frailty and Utilization of Physician Specialist Services

This current report provides information on the number of older adults in Ontario, and by local health integration network (LHIN) to identify potential needs related to health services for these populations in Ontario.

Screening and Assessment

Report

iGeriCare

iGeriCare is a free, online dementia education program developed by experts in geriatrics, mental health and online learning at McMaster University

Screening and Assessment

Other

Caregiver Conversations- Progress Report 3

Screening and Assessment

Other

Support for Ontario Health Teams in Caring for Older Adults OHTs – Senior Friendly Care

The need for an authentic focus on the goals and aspirations of older people living with frailty (or at risk of frailty) is especially important as health service providers work towards a new model of service delivery as part of an Ontario Health Team (OHT). Older adults living with frailty or at risk of frailty require a specialized, senior-friendly approach to care across the healthcare continuum in order to meet their unique needs. The Regional Geriatric Programs of Ontario are pleased to offer their support as a strategic partner in achieving this goal.

Screening and Assessment

Position Paper

What We Heard Report

To understand and respond to the learning needs of family and friend caregivers of seniors living with frailty, the Regional Geriatric Programs of Ontario (RGPO) initiated the Caregiver Education and Training Project. Based on a co-design process to develop educational resources for caregivers of seniors living with frailty, we hosted 10 focus groups in communities across Ontario. Connecting with 133 caregivers and 78 interprofessionals, this report highlights what we heard.

Screening and Assessment

Report

Position Statement on The Need for Expert Clinical Care for Older People Living with Complex Health Conditions

If we are to end hallway medicine, all Ontario Health Teams must demonstrate the necessary policy, clinical and funding focus on older people living with complex and multiple interacting health conditions (including dementia). Each Ontario Health Team must include specific services that focus on this population and engage the appropriate clinical leadership necessary to carry out this work.

Professional Practice

Position Paper

Specialized Geriatric Services in Ontario RGPO – Physician Human Resources Report

This project is intended to produce a partial current state view of specialized geriatric services across the province of Ontario, with a focus on the supply and utilization of health services designed for older people living with frailty

Professional Practice

Report

Planning for Older Adults Living with Frailty – SGS Asset Mapping Report

This exercise was envisioned as a first step in capacity planning, with a primary goal of informing a current state view of the supply and utilization of health services designed for older people living with frailty (e.g. specialized geriatric services) to contribute to future capacity planning.

Professional Practice

Report

Caregiver Conversations – Progress Report 2

Progress as of March 2019. This newsletter shares insights into what we are hearing and lets you know about upcoming events and other ways to engage with the project.

Caregiver Assistance

Report

Caregiver Conversations – Progress Report 1

Progress as of December 2018. This newsletter shares insights into what we are hearing and lets you know about upcoming events and other ways to engage with the project.

Caregiver Assistance

Report

Compendium of Educational Offerings

The Compendium of Educational Offerings Relevant to Interprofessional Comprehensive Geriatric Assessment (CGA) is a result of collaboration between the North East Specialized Geriatric Services (NESGC), Seniors Care Network, and Laurentian Research Institute for Aging (LRIA). This final result of this collaboration is an extensive compendium of educational offerings divided into 3 sections.

Screening and Assessment

Other

Frequently Asked Questions (FAQ)

A summary of frequently asked questions that covers what is a comprehensive geriatric assessment, what are specialized geriatric services and what should be included in the ideal basket of specialized geriatric services. CGA performed by SGS can take place in a variety of settings. The RGPs advocate that CGA should be available across the continuum of health care services in community, emergency, inpatient, and longterm care settings, and delivered by an interprofessional, specialized geriatric team.

Screening and Assessment

FAQ

Why is Comprehensive Geriatric Assessment the Gold Standard?

Covers the CGA process as a tool, not just assessment, includes management plan and implementation. Includes robust evidence in the hospital setting that it increases likelihood of living at home and in other settings – prevents functional decline.

Screening and Assessment

Presentation

Co-Creating a Position on the Coordination of Care for Older People Living with Frailty

Objectives of this presentation are to provide a brief overview the competency framework for interprofessional CGA and demonstrate how a framework can be applied to advance practice locally and provincially through the example of coordination of care with older people living with frailty.

Professional Practice

Presentation

Organization Design for Geriatrics: An Evidence Based Approach

This handbook is aimed at providing an evidence‐based approach to service delivery for the elderly patient in core specialized geriatric services. Core inpatient services include geriatric rehabilitation, assessment and consultation services. Core outpatient programs include geriatric outreach, outpatient clinics and geriatric day hospitals. In addition, there are a number of condition‐specific units, focused or innovative areas of care.

Professional Practice

Report

RGP Knowledge to Practice Framework

This KTP framework has been used to guide two provincial initiatives – the geriatrics, interprofessional practice and interorganizational initiative designed to build geriatrics capacity in family health teams and community health center, and the senior friendly action program supporting teams to use continuous quality improvement projects in acute care geriatrics. The framework is also used to guide the KTP elements of a several research grant applications.

Professional Practice

Framework

An Overview of RGP Programs

Regional Geriatric Programs (RGPs) provide a comprehensive network of specialized geriatric services which assess and treat functional, medical, and psychosocial aspects of illness and disability in older adults.

Screening and Assessment

Report

Patients First Position Paper

We are concerned that older Ontarians were not a focus of this consultation process, nor included in any significant way in the Patient’s First discussion document. This is despite the Ministry’s commitment to a Seniors Strategy that prioritizes access for seniors to community based supports to enable them to live at home for as long as possible. Given that seniors consume almost 50% of the health care budget and more than 60% of acute care hospital days (including a significant proportion of ALC days), we contend that the priorities of the provincial Seniors’ Strategy should feature prominently in the subsequent plan, demonstrating health system planning reflective and proportional to the position seniors occupy as health care consumers.

Professional Practice

Position Paper

CGA Self-Assessment Tool (Interprofessional)

The self assessment tool is a living document that is meant to support the clinician to adequately prepare themselves to deliver interprofessional comprehensive geriatric assessment and interventions by supporting the ongoing growth and development of the core competencies outlined in the “A Competency Framework for Interprofessional Comprehensive Geriatric Assessment”. Self assessment is integral to lifelong learning. It is beneficial to elicit feedback from a mentor and/or a supervisor when identifying learning needs and setting goals.

Professional Practice

Toolkit

Competency Framework for Interprofessional Comprehensive Geriatric Assessment

The purpose of this competency framework is to describe detailed practice expectations of health professionals participating in the CGA. This Framework will help health professionals to adequately prepare themselves to deliver interprofessional comprehensive geriatric assessments and interventions and work effectively in a specialized geriatrics environment.

Screening and Assessment

Report

Caregiver Education and Training Sf7 Toolkit

The SF7 Toolkit is a Senior Friendly Care (sfCare) resource that supports clinical best practices for healthcare providers in each sector and provides self management tools for older adults and their caregivers. The toolkit is available by individual topic, as well as by all topics together. All SF7 toolkit options are available on our website.

Screening and Assessment

Toolkit

13 Prescribing Tips for Older Adults

Core Geriatric Knowledge

Toolkit

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