Abstract
As in many regions, the Fraser Health Authority is providing health services to the expanding demographic of older adult population. With increase in chronic conditions and comorbidities with age, traditional health care delivery which focuses on reactive care to disease progression requires review. Supporting the aging journey requires supporting healthy lifestyles and proactive strategies to empower older adults to remain independent and prevent the progression of frailty. It requires understanding of the individuals’ functional status which can be measure in a comprehensive geriatric assessment with care planning to address the health and social deficits that lead to frailty. Preventing frailty also requires a holistic care strategy that integrates community social services with the traditional health service in community, hospital, assisted living and long term care facilities. In the Canadian health system where the community based social services are disconnected from the silo of health care delivery system, intentional integration of the two separate sectors was required to provide the full spectrum of care for the aging older adults. The Social Prescribing scheme was developed to network the community and health system services to ensure the appropriate level of care was available at each step of the aging journey. This was a co creation process partnering with the community based senior services sector represented by United Way BC with Fraser Health Home and Community Care portfolios. A change lead team led by a medical director, nursing educator, operations director, clinical nurse specialist, patient voices council supported by data analytics and communications consultants within Fraser Health worked to develop foundational education on frailty prevention and lifestyle management for all staff. Social prescribing was introduced to over 126 clinical service delivery areas within the region. Standardized referral forms were co created and embedded in the electronic health records system in the acute care settings and community health service offices. Primary Care providers were engaged to refer their older adults with pre to mild frailty to the social prescribing scheme where a community connector provided detailed interview intake to identify what matters most to the older adult and remove barriers to living a healthier lifestyle. Since the inception of social prescribing program in 2019, over 1000 referrals from the health authority and primary care providers have been provided. Community connectors have been able to remove barriers such as transportation, housing concerns, cultural and financial barriers to accessing appropriate community services to promote better nutrition and meals, activity and social connections.
With emphasis on providing seamless care for older adults, Fraser Health proceeded to develop the Frailty Pathway that integrates social prescribing with the health authority services such as home care for those further along the frailty progression. The frailty pathway is now being implemented in all communities in the region working in collaboration with the primary care providers as well as health authority staff. Evaluation is ongoing and as in the UK experience we hope to show reduction in health care utilization and improved quality of life that promotes independence and aging in place.