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Reading: Identifying Older Adults with Changing Care Needs: A Co-designed Community-Based Screening Tool


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Poster Abstracts

Identifying Older Adults with Changing Care Needs: A Co-designed Community-Based Screening Tool


Kaitlin Siou ,

University of Toronto, CA
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Jocelyn Charles,

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Catherine Convery,

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Teri Henderson

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Older adults 65 years and older are the fasting-growing age group in Ontario. Older age increases the likelihood of living with a chronic illness or disability, which are key demographic drivers of healthcare utilization. There is a need for more integrated care pathways in the community for older Ontarians to receive timely access to care earlier in an illness and/or disability trajectory to reduce dependence on hospital visits for acute care and improve quality of life. Importantly, this means novel collaborative approaches to help with early identification of new or changing care needs.

Aims Objectives Theory or Methods

The aim of our quality improvement project is to improve early identification of changing care needs in older adults in the North Toronto Ontario Health Team region. The development of a community screening tool was based on a review of the literature, clinical experience, and co-design with patients and families, community organizations and agencies, and interprofessional healthcare providers. Planning also included identifying pathways for communicating results of the screening tool within a patient's circle of care. The screening tool was then piloted in quality improvement cycles from April 2020 to January 2021 in two community settings.

Highlights or Results or Key Findings

Early identification of changing needs is enabled by a novel screening tool made up of three screening questions about acute changes in health, functional decline, and social isolation, with the goal of considering different dimensions of health to help identify older adults who may benefit from earlier care assessments. The questions are written in non-clinical language, with the view that they could be asked by anyone in the community. This could include building superintendents, meal deliverers, community volunteers, outpatient pharmacists, etc. The screening questions are designed for community members, recognizing that they may have different relationships and that their interactions may also be more frequent, which may help ensure that changing needs are recognized earlier. In our pilot study, 14% of 109 screening tools completed identified older adults requiring follow-up by the healthcare team. Of these identified adults, 64% required virtual or in-person follow up.


This simple, co-designed three-question screening tool to identify older adults in the community with changing care needs represents a valuable step in geriatrics and palliative care pathways. It highlights opportunities for further partnerships between interprofessional clinicians and non-clinician community members to improve the health of their community.

Implications for applicability/transferability sustainability and limitations

There are ongoing plans for the scale-up of this screening tool. This project was piloted in environments where some level of healthcare connectedness was already established. Maximum efficacy of this tool would likely occur with identification of older adults with care needs who do not have such existing contact.

How to Cite: Siou K, Charles J, Convery C, Henderson T. Identifying Older Adults with Changing Care Needs: A Co-designed Community-Based Screening Tool. International Journal of Integrated Care. 2022;22(S2):155. DOI:
Published on 16 May 2022.


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