The Frailty and Elder Care Network was established to strengthen care for Nova Scotia’s aging population, with a focus on individuals living with frailty—a medical condition marked by reduced physical and functional capacity that increases vulnerability to adverse health outcomes. The Network’s mission aligns with Nova Scotia Health’s priorities to improve access, quality and sustainability by advancing healthcare innovations that enhance the well-being and outcomes of older adults with complex medical needs. Through improved recognition and assessment of frailty and the promotion of evidence-informed care, the Network supports clinical excellence and system-wide integration in the delivery of person-centered care.
Our Mandate
- Frailty Identification and Assessment
Implement the Clinical Frailty Scale risk stratification tool to support healthcare providers to identify, assess and care plan for patients living with frailty, especially in acute care settings.
- Education and Engagement
Engage healthcare providers, patients, families and essential care partners in understanding the unique needs of older adults, and provide resources and training to support best practices, including support for shared decision-making that respects the autonomy of older adults living with frailty.
- System Integration
Align, coordinate and support frailty-focused initiatives across the health system and community sectors to promote connected, person-centred care for older adults living with or at risk of frailty.
- Research and Knowledge Translation
Support research, evaluation and the implementation of evidence-based practices to improve outcomes for older adults and inform policy and practice across Nova Scotia.
Key Initiatives and Programs
- Identifying, Staging and Managing Frailty
Identifying, staging and managing frailty enables healthcare teams across all care settings to assess frailty and integrate frailty-informed care planning. This supports targeted interventions to halt, slow or reverse health decline and promotes individualized, goal-oriented, patient-centered care.
- Early Mobility Program
A provincial initiative ensuring that older adults living with frailty—particularly those most at risk of functional decline due to immobility during hospitalization—receive timely, targeted and purposeful mobility interventions. Promoting mobility is a core element of the frailty-informed care pathway. Patients who are 65+ and require minimal assist of one or less can be referred to the Early Mobility Program at all Nova Scotia Health regional sites.
- Dignity of Risk (DoR) Program
The DoR Program aims to shift the attitudes and approach of direct care staff and essential care partners to enhance how we care for older adults living with frailty or dementia to better uphold their autonomy and preferences and optimize their health outcomes in hospitals and the community. We recognize the culture shift required to acknowledge gaps in the care of older adults experiencing these challenges.
We offer workshops to help staff challenge ageism, overprotective attitudes and fear of liability while balancing safety with independence. Participants learn to assess frailty, identify related functional risks, apply evidence-based risk management in care planning and coach essential care partners to strengthen their ability to support informed decision-making that respects individuals’ right to reasonable risk—enhancing dignity, well-being and quality of life.
- Enhancing emergency care for older adults with Seniors Care Teams
With older adults (65+) now making up nearly 40 per cent of emergency department visits in Nova Scotia, many living with frailty, there's an important need for tailored, coordinated care. To meet this challenge, the Frailty and Elder Care Network is testing a more collaborative approach to caring for seniors through the placement of Seniors’ Care Teams (SCT) in the emergency departments at Cape Breton Regional, Yarmouth Regional, Colchester East Hants Health Centre and Dartmouth General with follow-through in the community, as appropriate.
SCTs are interdisciplinary teams—nurses, pharmacists, social workers, care coordinators, rehab professionals and more—working together to identify frailty early, reduce complications and support transitions home. Their person-centred approach includes supporting the emergency team to conduct comprehensive assessments, medication reviews and care planning that reflect each patient’s goals and values.
Patients discharged home from emergency departments will receive follow-up and help accessing community supports, equipment and services—ensuring continuity of care and reducing readmissions.
This model strengthens emergency care for older adults, aligns with Nova Scotia Health priorities like SAFER-f, Health Beyond Hospital, Home First and promotes aging in place. By introducing SCTs in Emergency Departments and in the community, we’re improving outcomes, enhancing the patient experience and supporting long-term wellness.
- Delirium Recognition
The Frailty and Elder Care Network provides education for direct care staff to improve delirium recognition, understand its connection to frailty and support appropriate management in acute care settings.
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