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Helping seniors stay safe, healthy, and independent for longer

Coordinating our lives when we're young, mobile, and healthy can be a challenge. Now imagine you're a senior who can’t drive, you've got chronic health problems, and a busy family with limited time to take you to the appointments and tests you need to keep your health on track. It can be overwhelming, and chances are your health will suffer.

A Shared Care Delta Division of Family Practice project aimed to address the needs of this vulnerable population, recognizing that increased support and access to services during a crucial period could keep seniors living safe, healthy, independent lives for longer.

Specifically, previous Division initiatives had highlighted a growing trend of ER visits and long hospital stays for seniors in Assisted and Independent Living (A/IL), where a person’s increasing frailty may not easily be identified. Without mitigating the risks for these frail seniors, residential care can become a necessity sooner rather than later.    

Collaborative Solutions

Looking to coordinate solutions focused on Assisted Living, Delta Division convened a steering committee of all relevant partners; family physician and specialist leads, Fraser Health administration, Home Health Services, and Delta’s community services. After some discussions of issues and potential solutions, Augustine House, a local AL facility also came on board. Together the Committee developed a funding proposal for a ‘Delta Health Hub’ to be piloted at Augustine House. Goals of the project centred on detecting health risks early, providing fast and easy access to Primary Care services in one location, and facilitating smooth transitions between available services. Their proposal was approved by the Shared Care Committee (a partnership of Doctors of BC and the BC government) and work started November 2017. The Delta Health Hub opened in June 2018.

How it works

An onsite Health Hub is now available for Augustine House residents, offering a centralized service to manage their care. Residents are encouraged to sign up for the hub, starting with the completion of a self-health assessment form. This helps to bring to light health issues where extra support might be needed. This could include increased frailty, risks of falls, problems with cognition, polypharmacy, and other indications of health problems.

A Geriatric Nurse and Geriatrician Dr Katalin Balogh review the self-assessments during their weekly hub visit to Augustine House. “If there is anything abnormal, we communicate with the GP right away with a special form. It also allows the GP to communicate back to us to organize a GP visit or onsite services for the patient,” explains Dr Balogh.

Medication reviews with community pharmacists are also part of the assessment process. “We have expedited multiple medication reviews on site for patients,” states Balogh. “If the pharmacist has concerns, they communicate their concerns to the GP. Everything goes back to the GP.” Balogh also talks about how she and the geriatric nurse can access and document care in the patient’s EMR. “All providers can access the record, including GPs and providers in the ER. This communication has been key,” she states. Referrals are all managed by the Hub MOA.

Communication & Knowledge Sharing

The increased communication doesn’t just extend to the care team, but to the resident and their family. Each Hub member has their own binder that they keep in their suites with a record of their assessments, who they’ve seen and any recommendations for referrals. The binder has proved to be a valuable resource for the resident, their loved ones and the care team.

The Health Hub also holds regular education sessions for residents. Presentations have included Fraser Health’s Mobile Falls Clinic, Healthy Aging, and Advance Care planning. Cecile French, a resident of Augustine House appreciates the sessions “Next week a pharmacist is coming to talk to us. When we learn to take care of ourselves, we don’t take chances, and that reduces the number of emergencies”, she states.

Challenges and Aha moments

Dr Balogh shared her surprise at what she’s learned from her work on the project “It’s been very eye opening, and I now have a better understanding of how difficult it is for people to accommodate their increasing medical needs,” she comments. If we don’t bring care to them, many will choose not to seek attention until a crisis.  We also realize we need to develop more strategies to reach our most frail residents, but we’re working on that, she adds. A Welcome package is now available for the resident and family with information about the Hub.

Next steps

Work will continue to improve the Hub and connect with other services that could be involved, such as older adult mental health. The Division and Steering Committee would also like to see the model expanded to other assisted living communities in the area, recognizing that each one will require their own partnerships, and adjustments to the model to fit their own unique needs. For the Steering Committee, the strength of the partnerships was crucial to the success of the project: “The biggest accomplishment was that we all have one clear vision. We are able to see the vision. Everything has come into place very nicely.”


View this storyboard for an overiew and data from the project. A resident pamphlet is also available here. Other resources, including self-health assessment forms are available upon request.


Geri McGrath, Executive Director, Delta Division of Family Practice



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