Frail seniors to benefit from more in-home support

Frail Island seniors living in Queens County can now receive in-home support for their complex health needs.

A nurse practitioner has been hired to support the expansion to Queens County of the Caring for Older Adults in Community and at Home (COACH) program. The expansion is possible thanks to a $140,000 investment in government’s balanced 2018-19 operating budget.

“Last week I was pleased to release our government’s action plan for seniors, near seniors, and caregivers – Promoting Wellness, Preserving Health,” Health and Wellness Minister Robert Mitchell said. “Today’s announcement shows our commitment to the recommendations from that strategy, including the development and implementation of home first, age-in-place initiatives. By expanding the COACH program, we are helping to improve access to care for frail seniors with complex needs and support individuals to remain in their communities.” 

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 to support frail seniors living in community. The program has since expanded to the Souris, Summerside, and O’Leary areas, and now supports a total of 60 Island seniors. 

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.

With the frail senior and their family at the center, COACH is delivered by an integrated, interdisciplinary expert team of health care professionals who collaborate with existing resources in the three partner programs – home care, primary care and the provincial geriatric programs. The nurse practitioner plays a key role on the team, acting as the interconnecting ’glue” between various sectors of the healthcare system. The nurse practitioner: 

•    provides direct patient care in the homes of frail seniors;
•    treats seniors on a timely basis to prevent further complications and the need for emergency services and hospital admissions; and 
•    encourages advanced care planning and access to community support, with the goal of improved crisis management and enhancement of quality patient care for the frail senior population.

“Island seniors are an important part of the fabric of our communities,” said Mary Sullivan, director of home and geriatric care. “Through the COACH program we are working collaboratively with other programs, services and health care providers to support frail seniors who wish to remain in their homes and enjoy a quality of life that they deserve. To now be able to offer that level of support to frail seniors across the province is incredibly exciting for our staff and life-changing for our clients.”

Promoting Wellness, Preserving Health is PEI’s first ever provincial action plan for seniors, near seniors, and caregivers. It has been designed to improve the lives of Islanders and support the enhancement and sustainability of the overall health and wellness system.  

The priority areas of the action plan build on existing strengths and partnerships. They provide direction in increasing system capacity through innovation and expanding services to better meet the needs of individuals, and address the social determinants of health through both community and government endeavors. The result will be a better, more efficient continuum of programs and services to meet the needs of Island seniors, present and future. 

The full strategy is available at

Media contact:
Amanda Hamel  


About the COACH program: 

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. 

The COACH program does not replace referrals by family physicians to the geriatric program. This initiative is a separate program for frail seniors with complex needs who require access to a collaborative expert team.

COACH program success:

An evaluation of the initial pilot program revealed that the COACH program was successful keeping frail seniors at home safely. Clients were better able to self-manage and make informed decisions which positively impacted their quality of care and quality of life, and when necessary, supported a smoother transition to and from acute or long-term care. More specifically, there were: 
•    66 per cent fewer hospital admissions; 
•    33 per cent fewer emergency department visits; and, 
•    50 per cent fewer primary care appointments.

COACH program eligibility:

Admission is based on assessed need, prioritized by available resources, and approved by a panel that includes health care professionals from Home Care and the Geriatric Programs.

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; or
•    they are living at home or in a Community Care Facilities (long-term care residents are not eligible).

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Phone: 902-368-6130
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