Better Health Outcomes for Seniors with Frailty


Better health outcomes for seniors with frailty.

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We share our geriatric expertise to support all care team members in the delivery of senior friendly and evidence-informed care that optimizes the function and independence of seniors and supports aging in place.


Person and family-centred care

Executive Director and Board Chair’s Message

When reflecting on 2019–20, the phrase “unprecedented times” is one that often comes to mind.

Barbara Liu

Barbara Liu
Executive Director

Scott Dudgeon

Scott Dudgeon
Chair, Board of Directors

A pandemic disrupted our existence, and a series of world events shone a spotlight on the inequities experienced by citizens in our society and patients in our healthcare system.

The demand for change has been ignited, and with it comes an opportunity for healthcare services to reimagine how we operate. This moment in time is more than an inflection point. It is imperative that we consider what we must do and also create feasible plans for implementation that will have enduring impacts.

Prior to the onset of the COVID-19 pandemic, the Regional Geriatric Program of Toronto (RGP) board refreshed our strategic plan.

The relevance of our strategic priorities, transforming Specialized Geriatric Services (SGS) and fostering excellence in senior friendly care (sfCare), continues to resonate in the healthcare system’s new normal. These strategic priorities are critical elements of a reimagined healthcare system, a revitalized system designed to address what matters most to older adults and their families, and an integrated continuum of care that must reduce inequities in healthcare and deliver improved outcomes for all seniors with frailty.

A special note of thanks to Scott Dudgeon

Scott Dudgeon has served on the RGP board of directors for nine years, the last three years as the board chair. He has built a board of respected healthcare leaders, attracted by the opportunity to make a difference for older adults with frailty and to work with a dynamic group of thought leaders. He has shared an inspiring vision for system integration, along with a wealth of experience in healthcare leadership and governance. We are grateful for his active and eloquent advocacy for the RGP’s goals and the needs of seniors with frailty.

Responding to the pandemic

The RGP is a system resource dedicated to the care of older adults with frailty. During the past year, the RGP team demonstrated its added value to the healthcare system, pivoting swiftly in the early days of the COVID-19 pandemic.

The impact of COVID-19 was most devastating among the oldest members of our society. Yet, information on how to meet the needs of older adults with frailty while adhering to infection control measures was lacking or difficult to access.

Challenges on the frontline

How do I perform a COVID-19 test swab on an older adult with dementia?
I need educational tools to help families communicate well during a virtual visit.
How can I communicate with an older adult who is experiencing delirium while I am wearing a mask?
Staff being redeployed to long-term care need to know about responsive behaviours.
COVID-19 can present as delirium in older adults, and they could have COVID-19, delirium or both! What do I need to know about delirium in this context?

The RGP team quickly synthesized available evidence, gathered expert opinions, and created concise and practical knowledge translation tools to support clinical practice.

The RGP COVID-19 webpage became a go-to knowledge library nationally and internationally for resources related to caring for older adults with frailty during the pandemic, and this resulted in our resources being used to support training for Canadian Armed Forces staff who were deployed to long-term care.

Continuous Improvement and Innovation in Specialized Geriatric Services

We provide system-level leadership with our network of Specialized Geriatric Services (SGS) teams. Prioritizing continuous improvement and innovation is fundamental in optimizing the way services are delivered.

In 2019–20 we focused on the following strategic goals:

Building capacity for rapid access appointments

SGS teams developed, piloted and implemented new processes and pathways to provide rapid access to patients who needed to be seen urgently.

Implementing best practice integration of telehealth to increase access to SGS consultation and assessment

Our step-by-step guide for delivering virtual care with geriatric patients and our webinar series prepared SGS teams and supported the expedited uptake of virtual care across all sites with the onset of the pandemic.

Connecting ambulatory clinics in the Greater Toronto Area

Geriatric clinic sites are now connected through a committee that has created service standards and serves as a platform for quality improvement and service coordination

Scaling up performance-indicator data collection

Outcome indicators and service and system level utilization data are being collected and analyzed across all SGS to support regional planning and coordination.

Coordinating and integrating geriatric medicine and psychiatry outreach

A pilot site is in the process of integrating geriatric medicine and geriatric psychiatry outreach services to realize efficiencies in service and improve access.

woman sits on chair

The kindness, care and flexibility of people working in this program, mostly their willingness to help, was greatly appreciated. Thank you for caring for elders and not giving up on them.

– Geriatric Day Hospital Client

Fostering Excellence Through sfCare

sfCare is preventive and proactive care for the unique needs of older adults. It is not a destination, designation or add-on to care; it is the way care should be provided at all times, including during a pandemic. We develop practical supports to help organizations continuously improve the care they provide to older adults with frailty.

SF care ad: SF care - Senior Friendly Care - Optimizing care for the unique needs of older adults. we care about seniors care.

The launch of the sfCare Learning Series last year generated excitement among educators, as they now had ready-to-use training to support healthcare providers for whom geriatrics is not a speciality.

With this launch also came an outpouring of requests to expand the series to support even more learners. As a result of these requests, we have grown the series to include advanced clinical modules, French translations and an e-learning platform.

Building on the success of our Mobilization of Vulnerable Elders (MOVE) intervention that promotes mobilization in hospital, we are now developing a mobility intervention for older adults with frailty who are living in the community.

Promoting Movement in Older Adults (ProMO)* is unlike existing home-based exercise programs. It optimizes natural opportunities for mobilization during care by a personal support worker or family caregiver, and can be embedded in facilitated activities of daily living. Older adults, caregivers, and personal support workers are co-creating ProMO with us.

* Funding for this research was provided by the Canadian Frailty Network

Supporting Ontario Health Teams

Ontario Health Teams (OHTs) are using a new care delivery model to provide coordinated care across the continuum. For many of these teams, the priority population is older adults. We are leveraging our experience, expertise in frailty, relationships and human resources to support OHTs in advancing care for this priority population.

To support the application and planning processes, we have been sharing our clinical expertise with OHT working groups and translated senior friendly care for OHTs by co-creating tailored resources. As OHT planning progressed, we engaged seven OHTs focused on older adults with frailty by convening a knowledge exchange workshop to delve deeply into their shared challenges, including understanding population health approaches, inter-organizational collaboration and clinical best practices.

As OHTs evolve, so will our support. We have recently started collaborating with the Rapid-Improvement Support and Exchange (RISE) – part of the Ministry of Health’s Central Program of Supports for OHTs. As the subject matter experts on the care of older adults with frailty, we are offering our clinical expertise and resources to OHTs through RISE’s networks and online learning communities.

I am grateful for this resource. I have already started integrating some of it for a training session I am giving tomorrow.

Nursing Directorate, large teaching hospital
(in response to the launch of the sfCare Learning Series for Clinicians)


Looking Forward: A New Strategic Plan for 2020  2023

Plan Goal: Advance equitable access to integrated care for older adults with frailty.

Two strategic priorities


Transform SGS

The RGP will promote coordinated and equitable access to SGS. Through partnership and collaboration, we will help ensure these targeted services are offered in an integrated, high-quality, evidence-informed manner.
  1. Define and collect key metrics and indicators, including those relating to equitable access.
  2. Foster integration between SGS providers, including geriatric psychiatry, geriatric medicine and care of the elderly teams.
  3. Build partnerships, across the care continuum, to optimize referrals and integrated care pathways to SGS.
  4. Promote the use of technologies including virtual care to broaden access to specialized geriatric consultation and assessment.

Foster Excellence in sfCare

The RGP will leverage its expertise and influence to ensure optimal care for seniors with frailty. We will build capacity for sfCare across the health system by sharing and facilitating the use of evidence, information and best practices.
  1. Increase awareness of the work of the RGP and its network, and maximize the influence of our programs and initiatives.
  2. Identify, develop and disseminate resources that promote evidence-informed, innovative and person-centred practices among providers.
  3. Support implementation of best practices through coaching and quality improvement initiatives.
  4. Develop cross-sectoral indicators of sfCare, working with partners from across the continuum of care.

Measuring impact

We analyze data from a variety of sources, including from our network of SGS providers. A few highlights from this past year include:


Our average monthly number of Twitter impressions* from April 1, 2019, to March 31, 2020, was 9,474.

We started to share our COVID-19 resources in late March 2020, and our Twitter impressions in April increased to nearly six times the average, to an all-time monthly high of 54,700.

*Twitter impressions represent the total number of times a tweet has been seen.


From May 2019 to March 2020, we held nine webinars, with an average of 217 registrants per webinar.

Our most popular webinar, with 500 registrants, was “Reporting on fitness to drive in dementia in Ontario: what’s new since 2018.”

Patient Experience

Patient experience surveys revealed that in our network of Geriatric Day Hospitals, the overall experience rating was 9.5/10 (based on 252 surveys), and 95% would definitely recommend the service to friends or family.

Across our network of Geriatric Outreach Teams the overall experience rating was 9.2/10 (based on 104 surveys), and 87% would definitely recommend the service to friends or family.


The monthly average number of visits to our website from April 1, 2019, to March 31, 2020, was 7,264.

With the launch of our COVID-19 webpage in March 2020, we experienced a 72% increase in website visits (comparing the three weeks pre-launch to the three weeks post-launch).

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Report of the Independent Auditor on the Summary Financial Statements

To the Members of the Regional Geriatric Program of Toronto


The summary financial statements, which comprise the summary statement of financial position as at March 31, 2020, and the summary statements of operations for the year then ended, are derived from the audited financial statements of Regional Geriatric Program of Toronto (the “Organization”) for the year ended March 31, 2020.

In our opinion, the accompanying summary financial statements are a fair summary of the audited financial statements on the basis described in Note.

Other Matter

The summary financial statements of the Organization for the year ended March 31, 2020 were audited by another firm of licensed public accountants. The other firm expressed an unmodified opinion on those summary statements on October 15, 2019.

Summary Financial Statements

The summary financial statements do not contain all the disclosures required by Canadian public sector accounting standards. Reading the summary financial statements and the auditor’s report thereon, therefore, is not a substitute for reading the audited financial statements and the auditor’s report thereon.

The Audited Financial Statements and Our Report Thereon

We expressed an unmodified audit opinion on the audited financial statements in our report dated September 17, 2020.

Management’s Responsibility for the Summary Financial Statements

Management is responsible for the preparation of the summary financial statements on the basis described in Note.

Auditor’s Responsibility

Our responsibility is to express an opinion on whether the summary financial statements are a fair summary of the audited financial statements based on our procedures, which were conducted in accordance with Canadian Auditing Standards (CAS) 810, Engagements to Report on Summary Financial Statements.

MNP LLP, Chartered Professional Accountants
Licensed Public Accountants – Mississauga, Ontario

Note: Summary Financial Statements

The summary financial statements are derived from the audited financial statements, prepared in accordance with Canadian public sector accounting standards, as at March 31, 2020 and for the year then ended.

The preparation of these summary financial statements requires management to determine the information that needs to be reflected in them so that they are consistent in all material respects with, or represent a fair summary of, the audited financial statements.

Management prepared these summary financial statements using the following criteria:

  • The summary financial statements include the summary statement of financial position and the summary statement of operations. They do not include the summary statements of changes in fund balances and cash flows, summary of significant accounting policies, or notes to the financial statements and accompanying schedules;
  • Information in the summary statements agrees with the related information in the audited financial statements except the note referencing has been removed; and
  • Major subtotals, totals and comparative information from the audited financial statements.

Regional Geriatric Program of Toronto (RGP) Participating Organizations:

  • Baycrest
  • Humber River Hospital
  • Lakeridge Health
  • Mackenzie Health
  • Markham Stouffville Hospital
  • Michael Garron Hospital
  • North York General Hospital
  • Northumberland Hills Hospital
  • Ontario Shores Centre for Mental Health Sciences
  • Orillia Soldiers’ Memorial Hospital
  • Peterborough Regional Health Centre
  • Royal Victoria Regional Health Centre
  • Scarborough Health Network
  • Sinai Health System
  • Southlake Regional Health Centre
  • Sunnybrook Health Sciences Centre
  • The Salvation Army Toronto Grace Health Centre
  • Trillium Health Partners
  • Unity Health Toronto
  • University Health Network
  • West Park Healthcare Centre
  • William Osler Health System
  • Women’s College Hospital

Members of the RGP Board and Corporation:

  • Carol Anderson
  • Anne Babcock
  • Caroline Brereton
  • Gail Donner
  • Scott Dudgeon (Chair)
  • Geoff Fernie
  • Cathy Fooks
  • Linda Jackson
  • Karim Mamdani (Vice Chair)
  • Gary Newton
  • Ru Taggar

Download a PDF of this report