Frail Seniors

Preventing functional decline and secondary falls among frail older adults

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

  • Piloting 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 care pathways:

    • make it easier for primary care and emergency departments to connect older patients who have fallen with appropriate rehabilitative services
    • aim to reduce falls, one of the leading causes of preventable injuries among Ontario seniors that result in ED visits and hospitalizations.

The RCA is piloting the draft pathways in several regions of Ontario to finalize them before moving to broader implementation. 

  • 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.

  • 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.


Pathways to Post-Fall Rehabilitative Care
Post-Fall Pathway: Emergency Department  - DRAFT (October 2019 Clinical pathway for ED assessment and referrals.
Post-Fall Pathway: Primary Care - DRAFT (October 2019) 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) Includes the framework, referral decision tree, and process indicators for support performance monitoring and QBP-related outcomes. Additional resources are available here
A&R Evaluation
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.
Assess & Restore Review & Analysis (March 2017) Review and analysis of the provincial impact of A&R funding from 2014/15 to Q2 2016/17. 
Pan-LHIN A&R Logic Model (March 2017) Logic model to demonstrate the collective impact of all initiatives funded by A&R funding.