Seniors’ Community Hub

The overarching goal of the Seniors’ Community Hub (SCH) program is to transform primary care into a central hub to better meet the health and social needs of older adults and their caregivers.

The SCH model of care was co-created by a geriatrician and a primary care doctor working in Alberta. The SCH program was implemented in partnership with the Edmonton Oliver Primary Care Network (EOPCN) in July 2016, and originally launched as a pilot program at the Misericordia Family Medicine Centre – one of EOPCN’s partner community-based family medicine clinics. Beginning in January 2019, the program expanded to serve patients within EOPCN’s larger network.

SCH’s target group is patients 65 years of age and over in the primary care provider’s patient roster or panel. Patients are invited to participate in the program if they have an electronic frailty index score of “mild to moderate” frailty.

The program encompasses a structured process for identifying, assessing and managing frailty. It encourages effective information-sharing between patients, care providers and healthcare settings, as well as provides community-based support to patients and their caregivers to help prevent or alleviate caregiver burden.

Participating SCH patients have experienced improvements in several areas of health, including: functional status; frailty score; walk test score; quality of life; and self-reported domains of pain, mood, mobility and usual activities (EQ-5D). Reduced caregiver burden and appropriateness of patient medications are other benefits of the program.

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

Download the Seniors' Community Hub innovation profile