Frail seniors program receives national recognition

An innovative provincial government program intended to help seniors with complex health needs stay in their own homes longer has earned a national award.

The Caring for Older Adults at Home or in Community (COACH) Program was recognized with the Canadian Frailty Network’s Conference Choice Frailty Innovation Award last week. It was chosen by conference attendees from among the top 30 programs dedicated to frailty in older adults from across the country. As part of its presentation, the COACH Program debuted a video about its service and how it helps frail Island seniors.    

“I extend my congratulations to COACH Program staff on their national accolade recognizing their innovative approach to supporting frail seniors with complex needs, helping them to remain in their communities,” Health and Wellness Minister Robert Mitchell said. “This program is a wonderful example of our commitment to developing and implementing home-first, age-in-place initiatives for seniors, near seniors, and caregivers.”

The COACH program currently supports more than 60 Island seniors in Kings and Prince counties. 

First launched in 2015 as a pilot program in Montague, COACH was developed in partnership with home care, primary care and the provincial geriatric programs as a means to support frail seniors living in community. Also based in Souris, Summerside, and O’Leary, the program is expanding to Queens County following a $140,000 government investment to hire a nurse practitioner to support the program in the region.  

“To be nationally recognized for the innovative approach and support the COACH Program provides frail Island seniors who wish to remain in their homes is validating,” said Mary Sullivan, director of Home and Geriatric Care. “The program is life-changing for our clients, and we are fortunate to have an incredible team of health care providers who collaborate with other programs, services and health care professionals to support frail seniors enjoy a quality of life that they deserve while living in their own home.” 

The COACH Program’s geriatric nurse practitioner plays a key role on the multi-faceted team of experts, acting as the interconnecting ‘glue’ between various sectors of the health care system.

“My job is to support older adults living at home,” said Souris-based COACH geriatric nurse practitioner Kirsten Mallard, who is featured in the program’s video and was part of the team that presented at the Canadian Frailty Network Conference. “I’ll do the assessment; identify a number of things that we could do to help them to stay at home. I follow up with the rest of the team and we implement those changes step by step. We’re empowering people to be in control of their own lives with the ability to make decisions. It matters because they’re in their own home.” 

For more information about the COACH Program, visit


Media contact:
Amanda Hamel  


COACH Program Overview: 
The goals of the COACH Program are to improve access to care for frail seniors with complex needs by: 
•    supporting seniors to remain in their home longer or return home sooner by collaborating with  partner programs;
•    reducing duplication and repetition for seniors through sharing of information between partner programs; and,
•    increasing awareness of and expertise in caring for complex geriatric syndromes. 

COACH Program eligibility:
Island seniors must be referred to the COACH Program by their primary care provider, a geriatrician or geriatric program nurse practitioner or a home care coordinator. Frail Island seniors may be eligible for the COACH Program if:
•    they are an older adult (65 years and over) with complex needs, including physical and psycho-social needs
•    they have had a clinical frailty assessment that indicates the need for support (Rockwood Assessment score of 6 or greater)
•    they are primarily home bound due to cognitive or functional limitations
•    they are experiencing one or more geriatric syndromes (i.e. dementia, falls, incontinence, depression, delirium, immobility, sleep disturbance, etc.)
•    they have a referral from a primary care physician in support of receiving care from the COACH team
•    they or their caregiver would benefit from care coordination support, on an ongoing basis
•    they or their family/caregiver are agreeable to receive care from the COACH team
•    they are living at home or in a Community Care Facilities (long-term care residents are not eligible)

The COACH Program does not replace referrals by family physicians to the Geriatric Program. 

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