Older Adults with Frailty

Preventing functional decline and secondary falls among older adults living with frailty

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

  • Best practice framework for older adults living with frailty

    The RCA and Provincial Geriatrics Leadership Ontario have developed a new best practice framework to guide rehabilitative care for older adults living with/at risk of frailty. The document outlines best practices and the required components of rehabilitative care for older adults living with/at risk of frailty. It also provides guidance on how to implement these best practices within specific domains of care. An earlier RCA document provides guidance specific to the context of COVID-19.
  • Implementing post-fall rehabilitative care pathways

    Support is available to emergency departments and primary care teams interested in implementing the RCA's evidence-based care pathways for primary care and emergency departments. The pathways 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.  

  • 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

Frail Seniors Rehabilitative Care Best Practice Framework

Rehabilitative Care for Older Adults Living With/At Risk of Frailty: From Frailty to Resilience (December 2021)

Gap Analysis Tool


What to do next:

Sets out core elements and processes of care required when providing rehabilitative care to older adults living with/at risk of frailty, recommended best practices and how to implement them within specific domains of care.

See February 23, 2022 webinar here

Please note: This new document replaces the earlier Frail Seniors Rehabilitative Care Best Practice Framework: Bedded Levels of Care (June 2020) and the Frail Senior/Medically Complex Compendium (2015). 

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 in the pandemic context.
Pathways to Post-Fall Rehabilitative Care
Quick Reference to Post-Falls Pathways for Older Adults (November 2021) Overview of support available from RCA to help organizations implement pathways. 
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.
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 Shared Provincial Indicators (January 2018) Description and technical definitions of standardized indicators for Assess & Restore reporting.