Better Health Outcomes for Seniors with Frailty

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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.

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  • Person- and
    family-centred care
  • Equity
  • Collaboration
  • Excellence
  • Integrity

Executive Director and Board Chair’s Message

Barbara Liu

Barbara Liu
Executive Director

Karim Mamdani

Karim Mamdani
Chair, Board of Directors

A man.

The 2020–21 year was abundant with challenge, and the Regional Geriatric Program of Toronto (RGP) rose to meet the needs of our network members and the people they serve – older adults living with frailty. Through uncertainty, we focused our work on mitigating the impact of COVID-19 by providing guidance and expert advice to advance care for seniors.

Where evidence did not exist, we nimbly assembled teams of respected clinicians, researchers, and leaders to provide expert guidance. Our knowledge translation products served as practical resources for many healthcare providers around the globe.

We leveraged the skills within our interprofessional teams of specialists – Geriatric Emergency Management Nursing, Psychogeriatric Resource Consultants, Nurse-Led Outreach Teams, and Specialized Geriatric Services – to address higher acuity and surging rates of deconditioning, delirium, responsive behaviours, and caregiver stress.

The challenges and changes of providing care during a pandemic necessitated a more critical focus on health equity. We promoted diversity, equity and inclusion, and we used this lens to improve access to care and provide much-needed guidance on optimizing the experience of virtual care for seniors. This annual report highlights the valuable contributions the RGP and our clinical partners made to the healthcare system.

We are committed to remembering the lessons learned through the tragedies of COVID-19 – the magnification of health inequity in our communities and devastation in long-term care homes. The pandemic accelerated positive intersectoral collaboration, but it also set back some of the hard-earned progress in person-centred care and the integration of family members as care partners. During the pandemic recovery, it is critical that we restore a focus on best practices in senior friendly care in all sectors of the healthcare system.

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We respect diversity. We condemn racism and discrimination. We are taking action to make a difference.

The RGP respects the diversity of older adults and caregivers in Ontario.

The Senior Friendly Care Framework describes what respect for diversity looks like: “Care providers respect each individual’s breadth of lived experience, relationships, unique values, preferences, and capabilities,” and “Care providers demonstrate competency providing care to an older population with diversity in all its many forms.”

We condemn racism and the discrimination that older adults and their caregivers experience because of ethnicity, age, gender, sexual identity, physical or mental ability, religious or spiritual beliefs, socio-economic status, and other identities or qualities that make them who they are. We are mindful of the injustices that are rooted in the history and ongoing legacy of colonialism and systemic racism, which have disproportionately impacted Indigenous Peoples and Black communities. We acknowledge that these issues are pervasive in our society, including in healthcare, and that they impact access to care, quality of care, and health outcomes. We recognize that we have much work to do.

We are taking action to make a difference. Equity is one of our core values and is embedded in our strategic plan. We are examining our work with a robust commitment to our equity goals. We are reflecting on our individual behaviours and decision-making processes to identify and mitigate bias. We are embracing continuous learning to educate ourselves and our colleagues to promote equity, diversity, and inclusion.

Health equity – we ask because we care

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To provide more equitable patient access and care, we need to better understand the diversity of our older adult patients. This starts with asking older adults about the identities or qualities that make them who they are.

“We need to ask who we are not seeing and why.”

Health Equity Leadership Coalition member

100% of participants foundthe webinars useful ingenerating new ideasfor their practice or work settings.

Building on Ontario Health Toronto’s health equity data initiative “We Ask Because We Care”, we have provided training to our network of Specialized Geriatric Services healthcare providers to support the collection of patients’ demographic data to promote health equity. By enhancing our understanding of the people we serve, including their gender identity, sexual orientation and household income, we can better tailor our services and care plans to meet the diverse needs of older adults with frailty.

Asking health equity questions is only the beginning. Healthcare providers must be competent in delivering equitable and culturally safe care. To build this competency, we are hosting webinars on topics such as “Ageism and Cultural Humility” and “Safety when Caring for 2SLGBTQ Older Adults.” We have also convened a Health Equity Leadership Coalition, where healthcare providers who work with older adults can advance their skills and knowledge and put their learnings into action.

“This webinar gave me the background information necessary to better understand the complex feelings of members of the 2SLGBTQ community regarding how lived experience during changes in legislation can continue to affect their care decisions.”

“Safety when Caring for 2SLGBTQ Older Adults” webinar attendee

Embracing virtual care

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COVID-19 not only disrupted the delivery of healthcare; it also created a new reality where healthcare providers needed to adopt virtual technology into their practice.

“I benefited from everything. I feel different – good. I feel stronger, I walk better, I feel happier. I have less pain. The staff are the best, very friendly, very good program. I wish there were more programs like this.”

Geriatric Day Hospital client

Although using technology to deliver healthcare has many benefits, it can also pose challenges for older adults with frailty, especially for those with cognitive, hearing, or visual impairments, or who may have limited access to or comfort using technology.

As virtual care toolkits emerged during the pandemic, we filled the gap of virtual care tools that support healthcare providers in meeting the unique needs of older adults with frailty and their caregivers. In addition to reviewing the existing evidence on virtual care, we gathered advice on practical approaches and emerging best practices from older adults, caregivers, Specialized Geriatric Services (SGS) providers and Nurse-Led Outreach Teams (in long-term care homes). As a result, we developed toolkits, tip sheets, and webinars and introduced the “Virtual First Model of Care” for SGS. This new model of care provides a stepwise process that outlines interprofessional intake and a prioritization and assessment system to help older adults access the care that best meets their needs – virtually or in person.

To support the implementation of this new way of delivering care, we facilitated ongoing knowledge exchange across our network of SGS programs. Through town hall meetings that we continue to hold regularly, healthcare providers gather to keep abreast of changes in the system, identify gaps where resources are needed, share virtual care (and other) innovations, and support each other through the ebbs and flows of COVID-19.

“Thank you very much for the learning opportunity. It is a great help and support to sustain me while working during this challenging time. As virtual care is our new tool to reach out to our clients in providing care, the webinar that you provided is helping me to see and to think creatively for the people we care for.”

“How to Make Virtual Visits Senior Friendly” webinar attendee

A new community role with a senior friendly focus

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The Community Paramedic is an emerging role that focuses on preventing unnecessary emergency department visits by providing proactive care in collaboration with a primary care provider, such as remote monitoring and referrals to services.

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With this new role comes the need for new knowledge. A critical factor in improving outcomes for older adults living with complex health concerns is ensuring that all healthcare providers are knowledgeable and skilled in addressing the unique needs of older adults. This is senior friendly care (sfCare). As part of Fanshawe’s Community Paramedicine orientation course, the South West Frail Senior Strategy partnered with Fanshawe College and the RGP. Allied health clinicians from Specialized Geriatric Services at St. Joseph’s Health Care, London facilitated a Q&A session to launch the sfCare e-Learning Series.

The curriculum included delirium, mobilization, pain, loneliness, nutrition, polypharmacy, and urinary incontinence. While most paramedics (85%) identified their pre-knowledge of pain as good or very good, very few (15%) said the same about incontinence – an issue that can have far-reaching impacts such as decreased mobilization and social engagement. Post-knowledge scores increased for all topics, and 95% of learners felt the education provided new knowledge to meet the challenges in their roles as community paramedics.

“As I was doing the delirium module I realized – I’ve seen this so many times, and now I know what it is.”

Community Paramedicine learner

Caring for long-term care

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COVID-19 had a serious impact on many residents and staff in long-term care homes (LTCHs), as well as residents’ caregivers and families.

As many organizations prepared to redeploy staff to homes in need, our network of Psychogeriatric Resource Consultants (PRCs) and Nurse-Led Outreach Teams (NLOTs) leveraged their expertise working with LTCH staff and residents to support a system-wide response to the pandemic while meeting the dynamic needs of LTCHs.

PRCs provide coaching, knowledge products, and training to healthcare providers across the care continuum on evidence-based care for dementia and geriatric mental health. During the pandemic, they added extra support for LTCHs by developing a training program for redeployed staff focused on caring for residents with responsive behaviours. During PRC-led webinars, healthcare providers learned that all behaviours have meaning and are responses to unmet needs.

PRCs also collaborated with Behavioural Support Leads from Ontario Health Toronto to develop tip sheets with practical suggestions for redeployed staff when knowledge needs were identified, such as communication tips to assist in de-escalating responsive behaviours.

NLOTs provide clinical care and guidance to staff when LTCH residents experience an acute change of condition that puts them at risk of a transfer to hospital. During the pandemic, NLOTs quickly expanded their role by providing:

  • Leadership and crisis management – prioritizing homes with no attending physician on site, brokering and supporting relationships across sectors
  • Additional support with infection prevention and control education and audits
  • Vaccine rollout support – vaccinating newly admitted or repatriated residents and disseminating resources to mitigate vaccine hesitancy
  • Increased collaboration with the Hospice Palliative Care Team to support LTCH staff in providing palliative and end-of-life care
  • Expanded service to additional congregate care settings (retirement homes, group homes).

“TERRIFIC!!! I normally work in LTC as a sideline and not as my full-time practice, so I need refreshers on these types of approaches. During COVID, it’s even tougher for all of us. THANK YOU!”

“COVID-19 LTC Orientation for Redeployed Healthcare Workers – Wandering” webinar attendee

What we did about a pandemic within the pandemic

Early in the pandemic, clinicians around the globe reported a rise in delirium of up to 70%. Delirium, a preventable medical emergency that leads to increased risk of morbidity and mortality, quickly became known as “a pandemic within the pandemic.” COVID-19 precautions made managing delirium challenging, so we jumped into action to support the front line.

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We started the conversation about the urgent need for delirium care during COVID-19. Our senior friendly care (sfCare) policy briefs for hospitals and Ontario Health Teams built a case for change, highlighted delirium as a preventable harm and provided recommendations on how to start making immediate change. These briefs served as conversation starters with system leaders at COVID-19 tables.

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We developed ready-to-use delirium resources with special considerations for the pandemic context. This included four short practical tip sheets on preventing and managing delirium and communication tips and techniques.

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We made one of our most popular delirium resources – the delirium prevention poster – more accessible by translating it into 14 languages commonly spoken in Ontario, including three Indigenous languages.

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We helped set the standard of delirium care in Ontario by co-chairing Ontario Health’s Quality Standard Advisory Committee for the Delirium Standard, and we are supporting organizations in implementing this standard with a practical guide focused on quick wins.

Circle one: 53 % of searches on our website during the pandemic were related to delirium. Circle two: Our most downloaded sfCare resource this year was our sfCare Learning Series module for clinicians on Delirium in Dementia.
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Discovering the best innovative, integrated care for seniors

Building on the momentum gained in last year’s engagement with Ontario Health Teams (OHTs), we have commenced a Greater Toronto Area OHT Community of Practice (CoP) on senior friendly care (sfCare). The CoP includes representation from 10 OHTs whose priority population is seniors and those living with frailty.

There are more than 50 individual members in the CoP, including administrative leads, primary care leads, senior care project leads, and experts with experience in senior care service delivery. The CoP focuses on discovering the best of integrated care innovations for seniors. There are opportunities for members to network, brainstorm, and exchange successes.

The CoP has discussed point-of-practice topics such as infection prevention and control compliance for seniors with cognitive impairment and implementation of care-at-home service pathways. Implementation science frameworks and sfCare principles guide the content of each meeting. Members leave each meeting with a summary of practical messages and resources. Between meetings, our RGP coaches are available to connect with CoP members and continue the conversation about implementation at their respective OHT.

Understanding our reach and impact

We analyze data from a variety of sources to better understand our reach and impact. A few highlights from this pandemic year:

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Exceptional care continues in geriatric day hospitals

  • 9.3/10 overall experience rating
  • 93% would definitely recommend the service to friends or family

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More people are discovering our resources

  • 32,000 visitors to our website
  • 85% of website visitors were new
  • 5,165 people participated in 16 webinars

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Our most popular resources

  • COVID-19 web page
  • sfCare Learning Series
  • Webinar – “COVID-19 LTC Orientation for Redeployed Healthcare Workers: Supporting Clients with Dementia and Responsive Behaviours.”
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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, 2021, and the summary statement of operations and changes in fund balances for the year then ended and related note, are derived from the audited financial statements of the Regional Geriatric Program of Toronto (the “Organization”) for the year ended March 31, 2021.

In our opinion, the accompanying summary financial statements are a fair summary of the audited financial statements on the basis described in Note 1.

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 21, 2021.

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 1.

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
September 21, 2021

Note 1: 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, 2021, 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 and changes in fund balances. They do not include the summary statement of 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 presentation of expenses has been limited to the totals and the note referencing has been removed; and
  • Major subtotals, totals and comparative information from the audited financial statements are included.

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
    Healthcare Consultant
  • Anne Babcock
    President and CEO, Woodgreen Community Services
  • Gillian Bone
    Integration and Strategic Project Lead, The Four Villages Community Health Centre
  • Caroline Brereton
    CEO, Ontario Chiropractic Association
  • Irfan Dhalla
    Vice President, Care Experience and Equity, Unity Health Toronto
  • Geoff Fernie
    Creaghan Family Chair in Prevention and Healthcare Technologies, University Health Network
  • Linda Jackson (Vice Chair)
    Executive Director, Academic Family Health Team, Unity Health Toronto
  • Karim Mamdani (Chair)
    President and CEO, Ontario Shores Centre for Mental Health Sciences
  • Gary Newton
    President and CEO, Sinai Health System
  • Sundeep Sodhi
    Director, Strategy and Member Relations, Ontario Hospital Association
  • John Yip
    President and CEO, Kensington Health

Download a PDF of this report