Caring for Older Adults in the Community and at Home (COACH)

Caring for Older Adults in the Community and at Home (COACH) is a province-wide program in Prince Edward Island that improves access and quality of care for frail older adults, and their families and caregivers. It supports patients to remain at home longer and return home from hospital sooner.

COACH is a partnership between Health PEI’s Home Care, Primary Care and Geriatric Programs. At the centre of the COACH program is a team of interdisciplinary, specialized healthcare professionals that includes a geriatric nurse practitioner, a primary care provider and home care coordinator.

The COACH team provides direct patient care at home to predict, prevent or proactively manage health crises – and decrease the need for emergency services or admission to hospital. The team does this by encouraging advance care planning and access to community support. The COACH program increases the awareness and expertise about complex geriatric syndromes of all healthcare providers who provide care to older adults, and teaches caregivers how to continue to care for, and support, their loved ones at home.

The COACH program was piloted in January 2015 in Montague, Prince Edward Island and has since rolled out across the province.

Outcomes of the COACH pilot program included a 66 percent decrease in in-patient admissions, a 33 percent decrease in emergency department visits and a 50 percent decrease in primary care visits (average appointments per month). There were also savings of $1.41 million related to 13 participating patients and families resulting from a reduction in the average length of stay for those who moved to long-term care and then passed away. There was also improved staff satisfaction and better quality of life at home for patients, families and caregivers through their increased ability to self-manage and make informed decisions.

This is one of the innovations being implemented as part of the Canadian Foundation for Healthcare Improvement’s Advancing Frailty Care in the Community Collaborative.

Download the COACH innovation profile