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Integrating Frailty into Chronic Disease Management: Enhancing Care for Older Adults living with Complexity

Unrecognized or unmanaged frailty can impact the achievement of desired outcomes for individuals living with chronic conditions such as Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Diabetes Mellitus (DM), etc. The Guidance Document details a practical, 4-step approach for integrating frailty-informed care into Chronic Disease Management for older adults. Frailty is a dynamic condition that influences clinical outcomes, self-management capacity, and risk of harm. Identifying and addressing frailty early allows primary care providers and specialty care teams to tailor care plans, mobilize appropriate supports, and improve quality of life.


Related Resources:

Related Resources

Related Resources

2026 Age-Well Annual Conference Presentation: Evaluating a Centralized Data Reporting and Visualization System for a Regional Geriatric Program

AFHTO 2026 Presentation: Designing a Regional Cognition Referral Pathway: Integrating Primary Care, Specialist, and Community Supports for Older Adults

Community Paramedicine Frailty Pathway

Canadian Association on Gerontology (CAG) 2026 Presentation: Integrated Care for Vulnerably Housed Older Adults: Barriers and Enablers to Implementation and Sustainability

HPCO 2026 Presentation: Understanding barriers and facilitators to goal-setting and shared decision-
making with persons with dementia in specialized geriatric services

AGS 2026 Presentation: Strengthening Geriatric Capacity in Ontario’s Health Workforce: Results of a Provincial Training Needs Assessment to Support Specialized Geriatric Services

Canadian Association on Gerontology (CAG) 2026 Presentation: Optimizing Regional Cognition Referral Pathways: Evaluating Standardized Referral Redistribution Criteria Across Specialized Geriatric Services (SGS)

Central East Cognition Referral Pathway Guidance Document

ICIC 2026 Presentations: Building Ontario's Workforce Capacity for Integrated Geriatric Services: Findings from a Provincial Training Needs Assessment

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