Team profiles :

Huron Shores Family Health Team

At a Glance   

Region: Ontario

Setting: Rural

EAIP program principle(s): 

• Access to specialized healthcare services
• Access to social and community supports 
• Access to system navigation and support 

Implementation (new, spread, and/or expand):   

• New 

Team Profile  

The organization leading this initiative is the Huron Shores Family Health Team (HSFHT). The collaborative team includes a variety of interdisciplinary staff (e.g., Nursing, Geriatric Assessor, Physiotherapist, System Navigator, and Quality Improvement Consultants) from Huron Shores Family Health Team, North Shore Health Network and Algoma Ontario Health Team. The team also includes a community member as a patient advisor.  

Community

• This initiative is located in the Algoma Region of Northern Ontario, where the Huron Shores FHT provides care to over 14,000 people, including three First Nations communities.  
• The Algoma region has a significantly higher proportion of older adults when compared with the rest of the province. The most recent census data (2021) shows that 26% of individuals are 65+ (30,090 of a population of 113,777) in the Algoma district, and this number is projected to increase significantly in the coming years.  
• Within the HSFHT's service area in East Algoma, over 30% of individuals are aged 65 and over. 
• As there is a large proportion of older adults in East Algoma, transportation has been identified as a primary barrier to accessing services far from individuals’ home communities. 

Program Focus 

Program Description  

• The team plans to implement the HSFHT Healthy Aging Program, aligning with the Algoma Ontario Health Team's "Healthy Aging Strategy”. This program is aimed at frailty prevention and management, which consists of two parts; early frailty identification and public education.  The Early Frailty Identification component includes embedding a frailty screening tool into the Electronic Medical Record (EMR) in primary care. Integrated within the EMR, the Interdisciplinary Healthcare Providers (IHPs) can efficiently identify frailty in patients aged 65 and older, as well as those with specific risk factors. The embedded tool guides the IHPs screening questions, offering resources to manage patients and facilitate referrals to appropriate services. Individuals identified as frail will be referred for a comprehensive assessment, during which providers will utilize evidence-based assessments to connect them with appropriate community supports and services, enhancing patient outcomes and experiences. 

Implementation Approach: 

• Integration of Frailty Assessments: Huron Shores FHT will implement a level 1 annual frailty screening for all individuals aged 65 and older, utilizing a modified version of the C5-75 screening tool and a fall screening tool. Based on these results, interventions such as referrals to community exercise classes or education may be recommended. Patients identified as frail through annual screening will undergo a multifactorial assessment to identify contributing factors. Following the assessment, a care plan, including appropriate referrals or interventions, will be developed to support the patient in achieving their care goals. 
• Healthy Aging Health Promotion: A series of educational sessions will be offered in various communities to provide education around healthy aging. These sessions will cover topics such as modifiable risk factors, the concept of frailty, and available services. Special guests will present on different topics and resources will be made available to community members.  As part of this program, the first annual Healthy Aging fair is being planned for the fall of 2024. The public education component is aimed at people of all ages, and not simply those 65 and older.