Seniors Community Hub: Integrated Care for Frail Seniors

Project Leads

Dr. Sheny Khera

Dr. Marjan Abbasi

Dr. Marjan Abbasi, Edmonton Oliver Primary Care Network (PCN) and the Misericordia Hospital
Dr. Sheny Khera, Edmonton Oliver Primary Care Network (PCN)


Frailty and chronic complex conditions in seniors have a huge financial impact on the health care system. Seniors can be better supported and costs avoided if interventions to improve services for frail seniors are integrated and sustained in primary care, their first point of contact.

Project Summary

The goal of this project is to develop and implement a holistic, interdisciplinary integrated geriatric program within a primary care network.  The hope is that this will improve quality, efficiency and coordination of care for frail seniors living in the community. Primary care physicians, specialists, interdisciplinary teams, patients and family/caregivers will collaborate, and work together on care planning and assessment of care needs. Case managers will serve as system navigators, and clinical records will be shared with interdisciplinary teams.

The Seniors’ Community Hub (SCH) model of care builds a “hub” within each primary care practice to deliver person-centered, evidence-informed, coordinated and integrated care services to older adults living with frailty.

The SCH is designed to maintain and enhance seniors’ health and wellness. It will build integrated primary health care, centered on the needs and priorities of older adults living with frailty, and allows effective information sharing between patients, care providers and settings.  The SCH will provide community-based support to family caregivers to prevent or alleviate caregiver burden.

This approach mobilizes available resources of the primary care networks (PCNs) and community partnerships to deliver this care using a team based approach within the patients’ medical home. The key elements of the SCH are related to: 1) Structured Process of Care; 2) Education of Healthcare Workforce Patient and caregiver empowerment; and 3) Partnership in care.


  1. Development of a structured care process for seniors living with frailty in primary care.
  2. SCH training workshops for primary health care nurses, family physicians and allied health members working in PCN clinics.
  3. Implementation of the SCH program in the Edmonton Oliver PCN.

impact and Ultimate Success

Our evaluation is ongoing, however we have seen improvement in patient-oriented outcomes such as an improvement in gait speed, functional status (as measured by SMAF tool), and caregiver burden. There are also positive changes in the level of frailty, and quality of life (as measured by EQ-5D), with noticed improvement in the domains of usual activities, pain/discomfort, anxiety/depression, and mobility, as well as the EQ-VAS score. Medication reviews significantly decreased the number of inappropriately prescribed medications.

Patients reported that the SCH has been helpful in providing knowledge, facilitating planning, and managing chronic diseases.  This is occurring while seniors also feel listened to, and that their goals, priorities and opinions have been considered. Health care providers report improved efficiency and quality of care, as well as improved team communication and collaboration.

The SCH is a grassroots initiative highlighting a path towards integration and value based care. Success would be every primary care practice becoming a “hub” inspiring healthy aging, and optimally supporting those living with frailty.