Partners In Care: Improving Seniors’ Care

On March 11th and, due to incredible demand, also on March 20th, 2025, the Vancouver Division’s Seniors and Frail Elder Care Committee hosted the “Improving Seniors’ Care: Interactive Case Discussions” events. These collaborative case study-focused sessions highlighted care pathway development, supporting physicians in caring for their frail seniors living in the community. These events were the third and fourth in the Partners in Care Series – the first was in March 2024 and concentrated on navigating resources for frail seniors, and the second was in October 2024 and focused on elder abuse, neglect and self-neglect. The resources from our previous sessions are available at

A PDF which lists the table cards detailed information and has links to all resources are available here.**

Case Studies & Care Pathways

March 11th Table 1 Audrey

March 11th Table 2 Audrey

March 11th Table 3 Audrey

March 11th Table 4 Audrey

March 11th Table 5 Audrey

March 11th Table 6 Audrey

March 11th Table 7 Audrey

March 11th Table 8 Audrey

March 20th Table 1 Audrey

March 20th Table 2 Audrey

March 20th Table 3 Audrey

March 20th Table 4 Audrey

March 20th Table 5 Audrey

March 20th Table 7 Audrey

March 20th Table 8 Audrey

March 11th Table 1 Herman

March 11th Table 2 Herman

March 11th Table 3 Herman

March 11th Table 4 Herman

March 11th Table 5 Herman

March 11th Table 6 Herman

March 11th Table 7 Herman

March 11th Table 8 Herman

March 20th Table 1 Herman

March 20th Table 2 Herman

March 20th Table 3 Herman

March 20th Table 4 Herman

March 20th Table 5 Herman

March 20th Table 6 Herman

March 20th Table 7 Herman

March 20th Table 8 Herman

Case Study – Audrey Philpot (Downloadable PDF)

Case Study – Herman Fung (Downloadable PDF)

Event Resources

Did you miss the event, or need a refresher? You can view helpful resources from the event below

Case Study Workflow

As part of the event, participants engaged in an interactive activity utilizing a series of issue cards designed to facilitate discussion and problem-solving around key challenges faced by individuals in need of support. These cards were instrumental in guiding conversations, encouraging critical thinking, and fostering collaboration among attendees. Participants then created their own care plans using the “Tools / Assessment Cards” and the “Support Service / Resources Cards” listed below.

Issue Cards

The following issue cards were used in the activity to help participants identify and address various concerns:

Dementia
Frailty
Depression
Goals of Care
Driving
Falls
ADLs/iADLs (Activities of Daily Living / Instrumental Activities of Daily Living)
Social Isolation
Polypharmacy
Caregiver Burnout
Declining Physical/Mental Capacity
Financial Instability
Capacity

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Resource Card List

Tools / Assessment Cards: Frailty Roadmap

A basic guide for families to help orient themselves as their loved ones go through the various stages of frailty Outlines the features of each stage, includes questions to clarify where they are and what’s to come, has links to other resources, and has suggestions about the things they can do as a family and care team to give the patient the best quality of life https://tinyurl.com/Frailty-roadmap

Tools / Assessment Cards: MMSE

AKA – Mini Mental State Examination A brief, quantitative measure of cognitive status in adults Tests five areas of cognitive function: orientation, registration, attention and calculation, recall, and language 5-10 minute assessment time https://tinyurl.com/MMSE-assessment

Tools / Assessment Cards: SDM Serious Illness Conversation Guide

A guide to talk to substitute decision makers about; setting up a conversation, assessing understanding, sharing prognosis, exploring key topics, closing and documenting the conversation, and communicating with key care team members

Tools / Assessment Cards: Dementia Roadmap

A basic guide for families to help orient themselves as their loved ones go through the various stages of dementia Outlines the features of each stage, includes questions to clarify where they are and what’s to come, has links to other resources, and has suggestions about the things they can do as a family and care team to give the patient the best quality of life https://tinyurl.com/Dementia-roadmap

Tools / Assessment Cards: PHQ9

AKA – Patient Health Questionnaire-9 A multipurpose self report instrument for screening, diagnosing, monitoring and measuring the severity of depression Rates the frequency of the symptoms which factors into the scoring severity index 2-5 min assessment time https://tinyurl.com/PHQ9-assessment

Tools / Assessment Cards: Geriatric Depression Scale

A self-report measure of depression in older adults A questionnaire in which participants are asked to respond by answering yes or no in reference to how they felt over the past week Short form version: 15- items selected from the long form version which had the highest correlation with depressive symptom 5-7 min assessment time https://tinyurl.com/Geri-depression-scale

Tools / Assessment Cards: RoadSafe BC Reporting Unfit Drivers

RoadsafetyBC requires medical and nurse practitioners to report any patient who has a medical condition that makes it dangerous for them to drive, and continues to drive after you’ve warned them not to Reports may result from a condition causing persistent functional impairment or a condition that may cause episodic incapacitation https://tinyurl.com/RoadsafeBC

Tools / Assessment Cards: MOST Form

AKA – Medical Orders for Scope of Treatment An order completed by the adult’s Most Responsible Practitioner (MRP) Identifies one of six designations that provides direction on resuscitation status and scope of critical care and medical interventions https://tinyurl.com/MOST-forms

Tools / Assessment Cards: Falls Risk Questionnaire

A self-report measure to assess the risk of falling in older adults 2-5 min assessment time https://tinyurl.com/Fall-risk-questionnaire

Tools / Assessment Cards: Elder Abuse Suspicion Index (EASI) Assessment

AKA – Elder Abuse Suspicion Index A screening tool to detect those who are victims of elder abuse Aims to raise the level of suspicion about elder abuse to make an in-depth exploration about possible mistreatment, or ask patient permission to refer them for specialized evaluation by social service workers, adult protection workers, or specially trained police https://tinyurl.com/EASI-guide

Tools / Assessment Cards: SIMARD

AKA – Screen for the Identification of the cognitively Impaired Medically At-Risk Driver A screening tool for the identification of cognitively impaired medically at-risk drivers Developed and validated against actual driving performance using a driving evaluation https://tinyurl.com/SIMARD-assessment

Tools / Assessment Cards: TRAILS

Tests general cognitive function specifically assesses working memory, visual processing, visuospatial skills, selective and divided attention, processing speed, and psychomotor coordination Used in screening for driving fitness 2-5 min assessment time https://tinyurl.com/Trail-making-assessment

Tools / Assessment Cards: Canadian Frailty Network

Aims to improve the care of older adults living with frailty and support their families and caregivers by increasing recognition and assessment of frailty, increasing evidence for decision making, advancing evidence-based changes to care, educating the next generation of care providers, and by engaging with older adults and caregivers https://www.cfn-nce.ca/

Tools / Assessment Cards: Deprescribing Tools

Help to identify inappropriate or unnecessary medications to discontinue them through deprescribing guidelines and algorithms, patient decision aids, and an up-to-date resource list of evidence and research https://deprescribing.org/ https://medstopper.com/

Tools / Assessment Cards: Serious Illness Conversation Guide

A guide to talk to patients about; their goals and values, setting up a conversation, assessing the patient’s illness understanding and information preferences, sharing prognosis, exploring key topics, and closing and documenting the conversation

Tools / Assessment Cards: MOCA

AKA – Montreal Cognitive Assessment A highly sensitive tool for early detection of mild cognitive impairment Assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation 10 minute assessment time https://tinyurl.com/MOCA-assessment

Tools / Assessment Cards: Clinical Frailty Scale

A scale that measures the various stages of frailty and highlights the associated limitations to daily life as frailty progresses https://tinyurl.com/Clinical-frailty

Tools / Assessment Cards: Path Frailty App's

A user-friendly frailty assessment method that requires no training or instruction Based on the Frailty Assessment for Careplanning (FACT) tool and is designed to reliably assess frailty in as few questions as possible https://pathclinic.ca/app/

Tools / Assessment Cards: Comprehensive Geriatric Assessment Form

A multidimensional holistic assessment, which considers health and wellbeing and formulates a plan to address issues which are of concern to an older person and their family, arranges interventions according to the plan, and then reviews the impact https://tinyurl.com/Geriatric-assessment

Tools / Assessment Cards: Advanced Care Planning Conversation Guide

AKA – Advanced Care Planning A guide to prepare patients for future health care decisions by exploring their values, beliefs, goals, and preferences, help patients decide on a surrogate decision maker (SDM), and engage the SDM in the ACP process https://tinyurl.com/ACP-conversation-guide

Support Service / Resources Cards: VCH Older Adult Mental Health

Provides specialized community-based mental health and substance use services for older adults Typically for those 65 years and older enduring mental illness and/or substance use disorder and the coexistence of impairments in multiple domains related to the aging process https://tinyurl.com/VCH-Older-Adult

Support Service / Resources Cards: VCH IPT

VCH Allied Health Professionals and Community Primary Care Providers working together to support patients wholistically Free for attached patients who do not have access to extended health benefits or other means of access to funded health supports, one referral form for all services, care conferences with IPT Clinicians, internal referral to other IPT health providers, focus on mild to moderate health care needs https://tinyurl.com/VCH-IPT

Support Service / Resources Cards: Home Health/Case Manager

A referral form to arrange home and community care services Access line numbers cover various sectors throughout BC Home health services, case managers, orders, and treatment plans available through form Some home and community care services are provided free of charge, others include a fee determined by income https://tinyurl.com/VCH-Home-Health

Support Service / Resources Cards: PGT

AKA – Public Guardian and Trustee of BC Protects the legal, financial, personal, and health interests of adults who require assistance in decision making When a referral about a vulnerable adult in the community is received, PGT will research, ask many questions and help find the best solution to support the person that is vulnerable https://www.trustee.bc.ca/adults

Support Service / Resources Cards: Community Palliative Care Nursing

A range of palliative and end-of-life support and services offered by VCH for people living with serious illness, including their families, loved ones, and caregivers The palliative or end-of-life services include options for, in home, in hospital, in long term care, in hospices, and through outpatient clinics and programs https://tinyurl.com/VCH-Palliative-Care-Nursing

Support Service / Resources Cards: Family Caregivers of BC

A provincial, not-for-profit that provides physical and/or emotional care to those who support a family member, friend, or neighbor Supports caregivers by providing access to information, education and supports Provides direct support to caregivers through one-on-one emotional support, caregiver support groups, health care system navigation, and free educational resources https://www.familycaregiversbc.ca/refer

Support Service / Resources Cards: Seniors Services Society of BC

A non-profit agency providing local and provincial programs and services to support vulnerable older adults to live as independently as possible Connects adults 60+ with individual supports, social, meal, transport, community education and housing navigation services to enhance their lives https://www.seniorsservicessociety.ca/

Support Service / Resources Cards: NIDUS

A non-profit, charitable organization that provides education on personal planning Operates a centralized Registry for personal planning documents, including Representation Agreements, Enduring Powers of Attorney, Advance Directives, My Voice Expression of Wishes, Nominations of Committee and Notices of Revocations. https://nidus.ca/

Support Service / Resources Cards: Better at Home

A program that helps older adults with simple non-medical, day-to-day tasks so that they can continue to live independently in their own homes and remain connected to their communities Services vary from community to community but could include friendly visiting, transportation, light yard work, minor home repairs, light housekeeping, grocery shopping, and snow shoveling https://betterathome.ca/

Support Service / Resources Cards: VCH ReAct

Receives reports, provides consultation and coordinates responses to abused, neglected and self-neglected adults who cannot seek support and assistance on their own Referrals are responded to in accordance with the Adult Guardianship Act which gives VCH enhanced powers to intervene in emergencies and investigate situations where vulnerable adults are living at risk https://tinyurl.com/VCH-ReAct

Support Service / Resources Cards: Seniors First BC - SAIL Line

AKA – Seniors Abuse & Information Line A province-wide helpline for older adults and those concerned about older adults Provides general information and referral to community and/or government supports Provides information about abuse and neglect, including identifying potential risk and escalation Conducts intake into Seniors First BC programs https://seniorsfirstbc.ca/get-help/

Support Service / Resources Cards: Adult Day Programs

VCH provided specialized service for frail seniors and adults with physical or cognitive challenges who live independently in the community by themselves or with a caregiver Participants are provided with transportation, medical supervision, outings, activities, breakfast, lunch, snacks, and take-home meals Participants must be referred by a VCH case manager https://tinyurl.com/VCH-Adult-Day-Program

Support Service / Resources Cards: 211 BC

A free and confidential service that connects people to non-emergency helpful and vital resources in their community Provides information and referral to a broad range of community, government, and social services that assist with; basic needs like food and shelter, mental health and addictions support, legal and financial assistance, and support for seniors and newcomers https://bc.211.ca/

Support Service / Resources Cards: Provincial Language Services

Supports organizations to provide services to their diverse clients, including immigrants, refugees, official minority language speakers and members of the Deaf, Deaf-Blind and Hard of Hearing community through addressing language and communication access issues and barriers Services provided include; interpreting, deaf, deaf-blind & hard of hearing, francophone, translation https://plscustomer.phsa.ca/

Support Service / Resources Cards: PCN Pharmacists

Work alongside a multidisciplinary diverse team of health care professionals in general practice and within the primary care network, providing primary support for prescription and medication queries Reviews and make recommendations for the ongoing needs of patients Manages the use of medications with unplanned hospital admissions and with high-risk patient groups https://tinyurl.com/PCN-Pharmacists

Support Service / Resources Cards: HandyDART

A door-to-door, shared-ride service for persons who have either a temporary or permanent, physical or cognitive disability that is sufficiently severe that they are unable, without assistance, to use conventional transit for part or all of their travel https://tinyurl.com/HandyDART-info

Related Resources

Partners In Care: Improving Seniors’ Care

Case Studies & Care Pathways

Event Resources

Case Study Workflow

Issue Cards

Resource Card List

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