As Vancouver’s population ages, the demands placed on the health care system are becoming more complex and more urgent. The number of adults aged 75 and older is projected to rise significantly over the coming decade, bringing with it an increase in multi-morbidity, frailty, and the need for coordinated, longitudinal care. These shifts are not simply demographic; they are structural, requiring a rethinking of how care is organized, delivered, and experienced across settings.
Within the Vancouver Division of Family Practice, this reality is shaping a growing body of work focused on strengthening care for older adults across primary care, long-term care, and community-based supports. Led by Jaimie Ashton, Director of Special Projects with a focus on seniors across care settings, this work is grounded in a clear premise: that better outcomes for older adults depend not only on clinical excellence, but on how well the system connects.
Fragmentation remains one of the most persistent challenges in care of the elderly. Older adults and their families often navigate multiple providers, services, and settings; frequently without clear pathways or shared understanding. The result is not only inefficiency, but uncertainty, delayed decision-making, and care that may not align with patient goals.
Addressing this requires more than incremental change. It calls for deliberate efforts to strengthen communication, clarify roles, and align partners across the system. The Seniors Across Care Settings team is positioned at this intersection, working across policy, clinical practice, and community partnerships to reduce gaps and support more integrated, person-centred care.
A key area of focus has been the development of initiatives that bridge traditionally siloed domains of care. One such initiative is the introduction of community-anchored cognitive behavioural therapy (CBT) for older adults. By situating evidence-based mental health care within familiar community settings, this model reduces barriers to access and stigma, while strengthening connections between clinical services and the broader community based social supports that shape health outcomes. This initiative was piloted in PCN 1 and will be scaled to other PCN’s this year.
This approach reflects a broader shift toward care that is not only clinically appropriate, but contextually relevant, embedded within the environments where older adults live, socialize, and seek support. In doing so, it supports aging in place while helping to alleviate pressure on acute care services.
Complementing this work is the Frailty Roadmap for Families, a tool spearheaded by the Senior and Frail Elder Care Committee. The Roadmap provides a structured framework that helps patients and families anticipate and navigate the progression of frailty. By outlining what to expect, identifying key transition points, and prompting meaningful conversations with care teams, it shifts the experience of care from reactive to proactive.
The impact of this shift is significant. Families are better prepared. Conversations about goals of care happen earlier and decision-making becomes more aligned with patient values. Physicians have noted that additional supports linking the Roadmap to concrete services and resources would further strengthen its utility, and work is underway to develop a companion guide to address this need.
In long-term care, efforts are similarly focused on improving clarity, coordination, and clinical insight. The Integrated Frailty and Function Assessment (IFFA) tool brings together validated assessment scales into a single, streamlined approach that supports more accurate identification of residents with advanced disease and palliative care needs. By reducing administrative burden and enhancing documentation, the tool enables clearer communication across care teams and supports more meaningful goals-of-care discussions.
Plans to integrate the IFFA into electronic medical records across Vancouver’s long-term care homes represent an important step toward embedding this work within routine practice ensuring that improvements are not only conceptual, but operational.
Underlying these initiatives is a governance approach that prioritizes alignment across partners. Seniors care, by its nature, is interdisciplinary, requiring coordinated input from physicians, nursing teams, community organizations, and health system leaders. The Division’s role is not to duplicate this work, but to convene it, to identify where fragmentation exists, clarify shared priorities, and support system-level changes that improve continuity of care.
This collective approach is essential in a context where older adults account for a disproportionate share of health care utilization. Small improvements in how care is delivered in the community can have significant downstream impacts, reducing reliance on high-cost acute services while improving patient experience.
For family physicians, this work represents both a challenge and an opportunity. Caring for older adults, particularly those who are frail or medically complex, requires a holistic approach that extends beyond episodic care. It also offers the opportunity to engage in a model of practice that is deeply relational, team-based, and aligned with principles of continuity and patient-centred care.
Across Vancouver, long-term care homes continue to seek physicians interested in contributing to this work. Those who choose to engage become part of a connected community of practice, with access to mentorship, quality improvement initiatives, continuing medical education, and a shared after-hours care system designed to support sustainability.
As the system continues to evolve, the direction is clear: improving seniors care will depend on the strength of the connections between people, services, and settings. By focusing on integration, communication, and proactive planning, there is an opportunity to not only respond to the needs of an aging population but to reshape how care is experienced in later life.