Support is available to emergency departments and primary care teams interested in implementing the RCA’s post-fall rehabilitative care pathways for frail seniors.

The pathways for emergency departments and primary care are designed to connect older adults with frailty who fall with rehabilitative care to reduce functional decline and prevent additional falls.

Prior to the pandemic, the pathways were piloted in several locations across Ontario and are now ready for widespread adoption. Tracking tools, patient/clinician education materials and quality improvement processes have been developed and tested. In addition, the RCA is providing the following support to organizations and OHTs who want to introduce the pathways:

  • Implementation tool kit: Includes data collection surveys, clinician and patient information and tracking tools
  • Project management support for the first year of implementation: Includes facilitating adaptation of the pathways to include local referral pathways, supporting clinician orientation, conducting quarterly reviews of data, helping sites to develop quality improvement plans and providing ongoing implementation support
  • Data analysis and reporting: Includes collating and analyzing data collected; and facilitating a quality improvement process based on data analysis, patient journeys and clinical learnings

The RCA applies a PDSA approach using a three-month cycle, so that organizations can integrate learnings as they go. Several organizations are already implementing the pathways:

  • The North West Regional Seniors’ Care Program & Rehabilitative Care Program are supporting implementation in the Thunder Bay Regional Health Sciences Centre Emergency Department (an original pilot site) and a Nurse-Led Outreach Team
  • The North East Specialized Geriatric Centre is working with the Algoma Ontario Health Team, Timmins Academic Family Health Team and the Timmins and District Hospital Emergency Department to implement the pathways in those organizations.

Quality improvement funding may also be available through Ontario Health.

Interested organizations are encouraged to review the quick reference guide to the pathways and contact Gabrielle Sadler, Project Manager.