South West Frail Senior Strategy

South West Frail Senior Strategy logo

Through the South West Frail Senior Strategy, St. Joseph’s is working with health care partners, patients, and family caregivers to evaluate, identify and improve services for frail seniors in the region. This includes ensuring care meets the needs of the elderly and services are integrated and coordinated.

What we’ve heard – opportunities and priorities:

We have asked for feedback from stakeholders across the region, to help us identify opportunities to improve care for frail seniors.

Patient and family centered care is important: Care needs to be flexible to meet the varied needs of frail seniors. Family caregivers need to be intentionally involved in the planning and delivery of care for frail seniors.

The health care system should be integrated: In some regions, healthcare providers and services are collaborating well, however, there are opportunities to strengthen information sharing, optimize the use of technology and improve system navigation.

There are issues accessing specialized care for frail seniors: Community-based specialized services could be better used to improve access and decrease wait times. Access to specialized care is not consistent across the LHIN. There are opportunities to build on efforts to connect care across the region and leverage technology to improve access.

We need to build capacity in the system: There are opportunities to increase the capacity of existing providers and services through education and training. In addition, flexible and collaborative use of funding may support models of care that can meet the varied needs of frail seniors.

Get involved

Fill out a survey – share your experience with services for frail seniors in your community.

Stay informed

Sign-up for the South West Frail Senior Strategy newsletter.

Personal information is collected under the authority of the Public Hospitals Act R.S.O. 1990, CHAPTER P.40 for the purpose of contacting the sender in response to an inquiry. If you have questions about the collection of this information, please contact a Privacy and Freedom of Information Consultant, Mount Hope Centre for Long Term Care, 21 Grosvenor Street, Room WB31, London Ontario, N6A 1Y6. Phone: 519-646-6100 ext. 61418.


The current state of health care for frail seniors in the South West Local Health Integration Network

SouthWest LHIN region map

Research and consultation

The Geriatric Health Systems Research (GHSR) Group from the University of Waterloo has completed a current state analysis of care access and delivery for frail seniors in the South West Local Health Integration Network (South West LHIN).  More than 300 health care providers, patients and family caregivers in communities across the region have provided feedback that has validated these current state findings.

Findings identified through the research and consultation:

  • It’s difficult for seniors to navigate the system; there are too many  numbers to call
  • There are multiple intake and access processes
  • Seniors have to tell their story over and over again – to different health care providers
  • There are opportunities to replicate existing models of collaboration across programs and services

The South West Frail Senior Strategy (SWFSS) team continues to engage stakeholders to better understand sub-regional needs, priorities and opportunities.

Planning the future state of care 

The GHSR research and stakeholder consultation has also informed key recommendations for the SWFSS to improve care across the region.

Some of these recommendations include:

  • Proactive identification of at-risk or frail older adults
  • Coordinated intake and access
  • Cross-sectoral collaborative care planning
  • Increased navigation and case management support

What’s next?

Between October 2018 and March 2019, the SWFSS team is hosting events for all stakeholders including health care providers, patients, family caregivers and organizations to co-design the future state of health care for frail seniors in each sub-region.

Senior friendly care tools and resources for organizations

Senior friendly framework

In October 2017, the Regional Geriatric Program (RGP) of Toronto released the Senior Friendly Care (sfCare) Framework. This framework was developed by the RGP of Toronto in collaboration with provincial stakeholders, including older adults, caregivers and health care providers. It provides a foundation for achieving the best possible outcomes for older adults across the healthcare continuum. The Framework is an evolution of the Senior Friendly Hospital Framework, released in 2011, and includes guiding principles and defining statements that collectively describe what senior friendly care looks like across the continuum of care. The Framework can be accessed online at:

Senior friendly getting started toolkit

To support implementation of the sfCare Framework, a Getting Started Toolkit was developed that includes:

  • An online self-assessment tool – to identify strengths and opportunities for the organization implementing the Framework. The results will generate a report card, and the ability to compare results against a sector or all sectors.
  • Implementation resources – a curated package of tips and practical tools which can be used to inform action plans.
  • Introduction to sfCare training modules – five minute videos for executives and staff with basic information such as what senior friendly care is, why it’s important, the needs of older adults, and what staff and executives can do to make a difference.

Senior friendly self-assessment

  • The senior friendly self-assessment included in the toolkit was designed to identify your organization's strengths and opportunities related to senior friendly care.
  • As part of the SWFSS, organizations across the continuum of care in the region are being encouraged to complete this self-assessment.
  • Completed assessments will be reviewed by the South West LHIN and the RGP of Toronto. Organizations will receive a report card that indicates their strengths and opportunities and recommended resources to support the implementation of senior friendly care.
  • Completion of the self-assessment will provide valuable base-line data to inform the planning for the SWFSS.
  • The self-assessment can be completed online at:

Improving access to care for frail seniors

With many of the geriatric health care providers in the South West region located in London, accessing care can be difficult for some frail seniors. A team of specially trained registered nurses is bringing care into communities across the region and even into people’s homes. St. Joseph’s Geriatric Resource Nurse (GRN) Outreach Team includes seven nurses who provide comprehensive geriatric assessments for patients in Huron, Perth, Grey, Bruce, Elgin and Oxford counties. “The GRN assessments evaluate the patient for geriatric syndromes, review their mobility, mood, cognition and overall health,” says Kelly McIntyre-Muddle, coordinator with St. Joseph’s Specialized Geriatric Services. “They also gauge how well patients can function and do tasks such as driving, cooking and banking.”

The GRN’s then provide recommendations to improve the health and well-being of their patients to the patient, their family caregivers and their family physician. They also connect them to resources in their community.  

Part of the GRN’s role is to help patients access specialized geriatric care, without having to navigate the system on their own. The GRN’s often consult with the geriatricians and geriatric psychiatrists in St. Joseph’s specialty programs.

Patients do require a referral from a family physician to access the services of a GRN. Referrals can be made through the Geriatric Ambulatory Access Team online.

Who is leading this work?

The South West Frail Senior Strategy Regional Steering Committee Members:

  • Roy Butler Committee Chair, Vice President Patient Care and Risk Management, St. Joseph’s Health Care London
  • Adrienne Vanderweg, Senior Manager, Community Supports, VON – South West – North
  • Amber Alpaugh-Bishop,Program Manager, South West Health Links
  • Andrew Kroeker, Executive Director, West Elgin Community Health Centre
  • Andrew Underwood, Executive Director, Home & Community Services Grey/Bruce
  • Anne Campbell, Vice President Partnerships & CNE, Huron Perth Health Care Alliance
  • Bonnie Kotnik, Patient/Family Advisor
  • Carol Walters, CEO, Alzheimer Society London/Middlesex
  • Christine Thompson, Clinical Manager CCC, Rehabilitation and Integrated Stroke Unit, St. Thomas Elgin General Hospital
  • Dr. Lisa VanBussel, Psychiatrist, St. Joseph’s Health Care London
  • Dr. Michael Borrie, Geriatrician, St. Joseph’s Health Care London
  • Dr. Mulroy, Family Physician,Grey Bruce Health Services
  • Douglas Adams, Patient/Family Advisor
  • Elizabeth McCarthy, Director, Specialized Geriatric Services, St. Joseph’s Health Care London
  • Jennifer Row, Director, Complex/Direct Nursing, South West Local Health Integration Network
  • Lynne Johnson, Director of Long Term Care, Grey County
  • Lynn Hinds, Director, Sub-Region Planning & Integration (Oxford), South West Local Health Integration Network
  • Patricia Potter, Coordinator,  Regional Development & Ed SMH
  • Sandy Jansen,  President & CEO, Tillsonburg Memorial Hospital and Alexandra Hospital South West Frail Senior Strategy lead
  • Kelly McIntyre Muddle, Coordinator Specialized Geriatric Services, St. Joseph’s Health Care London
Last updated: Thu, 2019-05-16 09:22